SWCC Nursing Program Student Statement of Health Form Page 2 of 2
Have you traveled to an Ebola virus affected area (Guinea, Liberia, Sierra Leone, Mali) in the 30 days prior to
beginning a clinical rotation.
I agree to notify the SWCC faculty and the clinical agency if I have been in contact with an individual who is
sick and has traveled to an Ebola virus affected area in the 30 days prior to a clinical activity.
EMERGENCY CONTACT INFORMATION:
In case of emergency, I give the Southwest Virginia Community College Nursing Program
permission to obtain medical assistance and to notify my emergency contact person(s).
Signature of Student: Date
BY MY SIGNATURE BELOW, I VERIFY THAT THE INFORMATION PROVIDED
ON THIS FORM IS A TRUE AND ACCURATE REPORT OF MY HEALTH STATUS
AND I AUTHORIZE THE SOUTHWEST VIRGINIA COMMUNITY COLLEGE
NURSING PROGRAM TO RELEASE THIS INFORMATION TO THE AGENCIES
WHERE I HAVE CLINICAL LABORATORIES.
Student Signature: Print Name: Date: