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North Carolina Consortium for Clinical Education and Practice

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North Carolina Consortium for Clinical Education and
Practice PASSPORT
Student Annual Orientation Checklist
Updated January 27, 2021
Name:
Email:
School Program:
School Faculty/Clinical Director Name & Email:
School Contracted Vendor:
Agency/Unit/Preceptor/Supervisor:
Start/End Dates of Rotation:
Graduation Date:
I. Universal Credentialing Requirements (for the Passport)
1. AHA BLS- Provider- CPR Training
Expiration Date:
2. Professional Liability Insurance
By school: Individual:
3. Criminal Background Check
Date Completed:
4. Drug Screen (urine)
Date Completed:
5. Required Immunizations:
See attached guidelines (per CDC recommendations)
Measles (2 doses or positive titer)
Date(s) Completed:
Mumps (2 doses or positive titer)
Date(s) Completed:
Rubella (2 doses or positive titer)
Date(s) Completed:
Varicella (2 doses or positive titer)
Date(s) Completed:
Tetanus/Diphtheria (Td/Tdap)
Date(s) Completed:
Hepatitis B (HBV) Series or Heplisav-B 2 doses 4 weeks
apart
Date(s) Completed or Signed Declination:
Influenza (annual, Fall)
Date Completed:
Tuberculosis Screening Preplacement
https://www.cdc.gov/tb/topic/testing/healthcareworkers.htm
Date TB Risk Assessment Completed:
Dates TB Skin Test or Blood Test
Completed & Read/Result:
II. Additional Credentialing Requirements
Core Orientation
Date Completed:
Agency-Specific Requirements
Date Completed:
Health Insurance (if applicable)
Provider Name:
“
By my signature below, I certify the information I provide on and in connection with this form is true, accurate, and complete to the best
of my knowledge. I am aware of the academic consequences of false or omitted information as grounds for disqualification or dismissal
from the educational experience.”
Student Signature: __________________________________ Date: ________________
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participation in a clinical setting of the participating agencies. This list represents the highest standards as evaluated by the CCEP
Committee. Note that clinical agency contracts may specify additional requirements based on the areas in which students are placed, or
Universal Credentialing Requirements (for the PASSPORT)
1. AHA BLS- Provider- CPR Training (if applicable)
Approved course is American Heart Association Basic Life Support
Provider course.
2. Professional Liability Insurance
Per agency contractual agreement requirement
Minimum of $1 million per incident and $3 million aggregate
3. Background Check
• Social Security Number Trace
• NC Statewide Criminal Record Search
(7 years)
• County Court Criminal Conviction Search (7 years) (if resided
outside of NC)
• National Sex offender Database Search
• Office of Inspector General (OIG)
• Office of Foreign Assets Control (OFAC)
• General Services Administration (GSA)
Note: The assigned agency does not arrange nor cover the cost of this
screening.
Once per program admission and progression
Repeat for:
Per agency contractual agreement requirement
Readmission
Transfer from another school or from one program to
another with same school
Students must notify school if there has been a change in
status including charges or convictions within 5 days per
academic policy
4. Drug Screen (urine)
Once per program admission and progression and/ or with cause. Must
repeat for readmission or program transfer.
Note: UNC Hospitals require an * expanded drug screen (see clinical
agreements/contract for requirements).
Amphetamine, Methamphetamine, Barbiturates, Benzodiazepines,
THC, Cocaine, Opiates, Methadone, Oxycodone, Propoxyphene, PCP,
MDMA (Ecstasy)
* Fentanyl, Methaqualone, Extended Opiates, Phencyclidine,
Marijuana Metabolite
5. Required Immunizations:
Current CDC recommendations
Type:
Requirement:
Measles
2 doses or positive titer
Mumps
2 doses or positive titer
Rubella
2 doses or positive titer
Varicella
2 doses or positive titer
Tetanus/Diphtheria/ (Tdap)
1 dose Tdap, then Td booster every 10 yr.
Hepatitis B (HBV) Series
Energix-B or Recombivax B 3 doses or positive titer If
incomplete series, then
Heplisav-B 2 doses 4 weeks apart
For declination or waiver, a copy must be on file at the
school and/or be approved by the facility or agency.
Influenza
Annual- Fall See Academic/Agency guidelines
“Optimally, vaccination should occur before onset of influenza
activity in the community. Health care providers should offer
vaccination by the end of October” on the Influenza Vaccination
Information for Health Care Workers’ page
https://www.cdc.gov/flu/professionals/healthcareworkers.htm
Tuberculosis Screening Preplacement
(https://www.cdc.gov/tb/topic/testing/healthcareworkers.htm)
• Baseline Individual TB Risk Assessment including TB symptom
evaluation, and either a 2-step TB skin test (given 1-3 weeks apart) or
a TB blood test within 12 months of program admission or
readmission. If a student has had a positive TB skin test in the past,
such as due to TB exposure/infection or receiving the BCG vaccine,
documentation of a chest x-ray for the + test will be required along
with the Baseline Individual TB Risk Assessment and TB symptom
evaluation.
• Students are no longer required to get annual TB skin tests unless
there is a known exposure or ongoing transmission at a healthcare
facility.
• Students will receive annual TB education via the Core Orientation
Baseline Individual TB Risk Assessment
Baseline TB Symptom Assessment
2-step TB skin test (given 1-3 weeks apart) OR
TB Blood Test within 12 months of program admission or
readmission
Documentation of a chest x-ray is required for a past +
PPD or blood test. If current +PPD or blood test, additional
evaluation for TB disease will be required as deemed
necessary from a healthcare provider.
Annual TB education and risk assessment
Must complete Core Orientation and Agency Specific Requirements in addition to the requirements listed here.
Official documentation of all requirements must be kept by the school program or by the vendor contracted for electronic
documentation.
Updated January 27, 2021
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North Carolina Consortium for Clinical Education and Practice

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Completed 10 April 2021

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