Statement of Good Health
It is a State regulation that all employees of nursing homes in Kansas have a current work physical on file
with their employers. All nurse aide and medication aide students must comply with this regulation.
The physical exam must be completed and a copy must be on file in the Allied Health Office at Butler
Community College by THE FIRST DAY OF CLASS.
Name of Student _______________________________________________________________________
Date ________________________ Butler Student ID# ______________________________________
Address ____________________________________________________________________________
City ___________________________________________ State _________ Zip Code ______________
Enrolled in (check one): CNA____ CMA ___ Course Site _________________________
PHYSICIAN’S STATEMENT
I have this date examined the above person. I find no evidence of mental or physical illness nor evidence
of communicable disease, back problems or other orthopedic problems. This person has no lifting
restrictions.
Signature: ___________________________________________ Date: ___________________________
Printed name, address of physician: _______________________________________________________
______________________________________________________
Phone: ___________________
TB skin test (PPD) and/or chest x-ray to rule out Tuberculosis is required. The two step TB test is
recommended when doing initial testing. The student may participate in clinical after the first test if it is
negative with follow-through on second testing. The test/s must be documented by a physician, their
office personnel, or a health department representative. Students are not authorized to complete this form.
Significant
Non-significant
PPD
Non-significant
Rev 01/15EJP
