Fillable Sample PN Passport Fall 2017 (Green River Community College)

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Sample PN Passport Fall 2017 (Green River Community College)

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BROWSE GREEN RIVER COMMUNITY COLLEGE FORMS

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Clinical Placements Northwest
Student/Faculty
Clinical Passport Requirements
Student / Faculty Name: Last, First, M.I. ___________________________________
College: ___________________________________________________________
Program: ___________________________________________________________
These requirements are in place for the health and safety of students, faculty and their
paents.
By contract with your academic instuon, all students and faculty parcipang in learning experiences at this healthcare site must meet the following health and
safety requirements. The academic instuon is responsible for ensuring that requirements have been met prior to parcipaon in paent care/clinical experience.
Records will be kept at the academic instuon and random review by the clinical aliates will occur on a regular basis. Documentaon must meet requirements at
all mes. Required immunizaons must include mm/dd/yyyy if available.
TUBERCULIN STATUS
Documentaon of an inial 2-step TST is required AND documentaon of
an inial 2-step was completed
If no records of previous posive TB tests or more than 12 months since
last TST then 2-step TST OR
Negave TB IGRA test within 12 months OR
If negave TST within 12 months → 1-step TST
If newly posive TST or TB IGRA → F/U healthcare provider (chest X-ray,
symptoms check and possible treatment documentaon of absence of
acve M. TB disease) and need to complete health quesonnaire
If history of posive TST → provide documentaon of TST reading, provide
proof of chest X-ray documenng absence of M. TB, medical treatment and
negave symptom check
If history of BCG vaccine → TST Skin Tesng as above or TB IGRA. If nega-
ve → OK; If posive → follow-up as above
HEPATITIS B
Documentaon of Series of 3 vaccines completed at appropriate me
intervals and post vaccinaon ter at 6-8 weeks aer series compleon. If
negave ter, then repeat series (consisng of doses #4—#6) and repeat
ter 6-8 weeks aer #6 dose. OR obtain challenge dose #4 and re-ter
aer 6-8 weeks OR
Provide documentaon of posive ter (an-HBs or HepB Sab) OR
Signed declinaon for students/faculty who decline vaccinaon
Specic healthcare instuons may require vaccinaon without excepon
(i.e., no declinaon)
MMR (Measles, Mumps, Rubella)
Proof of vaccinaon (2 doses at appropriate intervals) OR
Proof of Measles immunity by ter and
Proof of Mumps immunity by ter and
Proof of Rubella immunity by ter
VARICELLA
Proof of vaccinaon (2 doses administered at least 4 weeks apart) OR
Proof of immunity by ter
TETANUS, DIPTHERIA, PERTUSIS (Tdap)
Tdap required once
Td required every 10 years aer Tdap
CPR
American Heart Associaon (AHA) BLS Provider Card or Military Training
Network (MTN) Provider Card only
AUTHORIZATION FOR RELEASE OF RECORD
Kept on le by educaon instuon
REQUIRED EDUCATION
EACH HEALTHCARE INSTITUTION WILL COMMUNICATE TO FACULTY AND
STUDENTS ANY REQUIRED EDUCATIONAL CONTENT TO BE COMPLETED
PROIR TO PARTICIPATION IN PATIENT CARE.
TUBERCULIN STATUS
Annual TST OR
Annual TB IGRA test
If newly posive TST/IGRA results → F/U with healthcare provider (chest X
-ray, symptoms check and possible treatment documentaon of absence
of acve M. TB disease) and may need to complete health quesonnaire.
Previously documented posive TST results and prior negave chest X-ray
results. Complete Annual Symptom Check Form. If any “yes” responses
→ /F/U with healthcare provider.
INFLUENZA
Proof of seasonal vaccinaon(s) OR
Signed declinaon for student/faculty who decline vaccinaon
Specic healthcare instuons may require vaccinaon without excepon
(i.e., no declinaon) hp://ushot.healthmap.org/
BACKGROUND CHECKS
Naonal Criminal Background Check and Washington State Patrol Back-
ground Check (WATCH) upon admission/re-admission and re-entry/hire to
program to include all counes of residence & all Washington State coun-
es per RCW 43.43.830 and OIG and GSA screens. Exclude provider search
on:
OIG hp://exclusions.oig.hhs.gov/ (conducted monthly by
CPNW)
GSA hp://www.sam.gov (conducted monthly by CPNW)
Washington State Patrol Background Check (WATCH annually thereaer
Disclosure Statement (annual) and kept on le by educaon instuon
LICENSE (If individual is licensed as any healthcare provider [RN, LPN, NAC,
etc.] and in what specic State)
Current
Unencumbered
INSURANCE
Professional Liability $1,000,000/3,000,000 policy (This may be coverage
via the school or individual)
ADDITIONAL REQUIREMENTS (if applicable)
Some healthcare sengs may have addional requirements, such as the follow-
ing:
Vehicle Insurance (for access to VA & Military Facilies)
Personal Health Insurance
Drug Screen
Hepas A Vaccine
Current First Aid Card
Proof of U.S. Cizenship
Color Vision Test
Food Handlers License
Students and Faculty will be informed prior to clinical experience if oponal or
addional requirements need to be met.
SUBMITTED ONCE SUBMITTED EVERY YEAR
Clinical Placements Northwest ©2017
Green River College
Nursing Assistant
Clinical Placements Northwest
Student/Faculty
Clinical Passport Requirements
Student / Faculty Name: _____________________________ DOB _____________
College: ____________________________________________________________________
Program: ____________________________________________________________________
Form Veried by: ______________________________________________________________
Name ____________________________________________________ Date _______________
Name ____________________________________________________ Date_______________
Name ____________________________________________________ Date_______________
By contract with your academic instuon, all students and faculty parcipang in learning experiences at this healthcare site must meet the following health and
safety requirements. The academic instuon is responsible for ensuring that requirements have been met prior to parcipaon in paent care/clinical experience.
Records will be kept at the academic instuon and random review by the clinical aliates will occur on a regular basis. Documentaon must meet requirements at
all mes. Required immunizaons must include mm/dd/yyyy if available.
SUBMITTED ONCE SUBMITTED EVERY YEAR
TUBERCULIN STATUS
A. Two-step TST#1 Place Date _______ Read Date _______
Result: mm_______ Neg _______ Pos _______
Two-step TST#2 Place Date _______ Read Date _______
Result: mm_______ Neg _______ Pos _______
B. TB IGRA Date ____________ Result ___________
C. If New Posive/Exam/X-ray Date ____________ OR
D. Posive TST/Negave X-ray Date ____________
HEPATITIS B
(3 primary series shots [at 0, 1, 6 months] plus ter conrmaon (6-
8 weeks later)
A. Vaccinaon Dates
1._______________
2._______________ Immunity conrmed by ter
3._______________ Date ___________ OR
B. If negave ter aer inial series of 3 vaccines, then vaccine #4 and re-ter OR #5
and #6 vaccines and re-ter
1._______________
2._______________ Immunity conrmed by ter
3._______________ Date ___________ OR
C. Immunity conrmed by ter (an-HBs or HepB SAb) DATE ___________
D. Signed declinaon DATE __________
E. History of disease DATE __________ Known non-responder
MMR (Measles, Mumps, Rubella)
A. Vaccinaon Dates
1.____________ 2. ____________ OR
B. Immunity by ters: Measles Titer DATE __________
Mumps Titer DATE __________ Rubella Titer DATE __________
VARICELLA
(Chicken Pox)
A. Vaccinaon Dates
1.____________ 2. ____________ OR
B. Immunity by ter DATE __________
TETANUS/DIPTHERIA/PERTUSIS
A. Tdap DATE __________
B. Td DATE __________
AHA BLS Course
(Course must be American Heart Associaon (AHA) BLS Pro-
vider or Military Training Network (MTN) Course.)
Expiraon DATE ___________
Authorizaon for Release of Record
(School keeps this on le)
REQUIRED EDUCATION
EACH HEALTHCARE INSTITUTION WILL COMMUNICATE TO FACULTY AND
STUDENTS ANY REQUIRED EDUCATIONAL CONTENT TO BE COMPLETED
PROIR TO PARTICIPATION IN PATIENT CARE.
ALL STUDENTS AND FACULTY WITHIN CLINICAL PLACEMENTS NORTHWEST
MUST COMPLETE ALL STUDENT LEARNING MODULES ON THE CPNW WEB.
ANY QUESTIONS, PLEASE CONSULT YOUR PROGRAM
TUBERCULIN STATUS
A. Annual TST (given less than one year from previous TST)
DATE ________ Result: Neg _____ Pos _____ mm _____
DATE ________ Result: Neg _____ Pos _____ mm _____
DATE ________ Result: Neg _____ Pos _____ mm _____
B. Annual TB IGRA (drawn less than one year from previous IGRA)
DATE ________ Result: _____ DATE _____ Result: _____
DATE ________ Result: _____
C. If New Posive/Exam/Chest X-ray
EXAM DATE__________ X-ray DATE __________
D. For Known Posive/Possible Treatment → Complete Annual Symptom Check
Form. DATE__________
INFLUENZA (Eecve dates: 08/31/2017—06/30/2018)
A. Which healthcare provider administered vaccine? ______________________
B. Proof of seasonal vaccinaon DATE _________
DATE _________ DATE _________ DATE _________
C. Signed declinaon DATE ___________
BACKGROUND CHECK
A. Naonal Criminal Background Check Including the Exclusion Provider Search on
OIG and GSA upon Admission DATE __________
B. Provider Search: OIG/GSA—monthly
DATE __________; __________; __________; ________; __________
C. Washington State Patrol Check (WATCH) upon admission and then annually
DATE __________; __________; __________; ________; __________
D. Disclosure Statement annually (School keeps this on le)
DATE __________; __________; __________; ________; __________
LICENSE
(Any healthcare license, registraon)
A. State _______ License # __________________ Expiraon Date ___________ OR
B. Not Applicable
INSURANCE
A. Professional Liability Policy
Expiraon DATE __________; ___________
ADDITIONAL REQUIREMENTS (if applicable)
A. Vehicle Insurance DATE __________
B. Personal Health Insurance DATE __________
C. Drug Screening DATE __________
D. Hepas A Vaccine Two Doses DATES: 1) __________ 2) __________
E. Current First Aid Card DATE __________
F. Proof of U.S. Cizenship DATE __________
G. Condenality Statement DATE __________
H. Color Vision Test DATE __________
I. Food Handlers License DATE __________
This is not a comprehensive list; there may be more items.
Clinical Placements Northwest ©2017
Green RIver College
Practical Nursing
Lauren Cline
X
X
X
MD
2/2/17
X
X
X
X
X
X
X
X
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Sample PN Passport Fall 2017 (Green River Community College)

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Completed 26 July 2020

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