School of Health Sciences Immunization and Physical Exam ...



School of Health SciencesImmunization, CPR, and Physical Exam RequirementsThe immunization requirements on this form are required of all individuals applying to the School of Health Sciences program. You MUST submit your health documentation in PDF format for each immunization requirement listed on this form at one time or single correspondence. Below is a listing of the types of accepted records and the facilities from which we can accept immunization documentation records. Official school immunization records. (We cannot accept elementary, high school, or college immunizations printed on transcripts and/or report card)Childhood immunizations on official health immunization forms and/or “booklet” have been signed and dated by a physicianState Health Departments (example: Clinics)HospitalsPhysician’s Office (Notes from a Doctor or anyone in his/her office verifying history of disease or that immunizations were given or are not accepted. If immunizations are from a physician’s office, immunizations must be on a printout indicating dates given along with office address/contact information)College/University Health Centers (Immunizations printed on a transcript are not accepted)Drug/Grocery Stores (example: Walgreens, CVS, Albertsons, or Walmart)Urgent Care Centers (example: CareNow)Titers Military records clearly indicating when immunizations and/or titers were given and/or completedPayment receipts are not accepted as proof of immunizations.A valid physical exam is required at entry into all Health Sciences programs and must be submitted on the attached Physical Exam form.CPR: Annual Basic Life Support for Health Care Providers CPR certification. CPR certification from the American Heart Association is the only approved CPR course and must be face to face or hybrid training. Completely online courses are not accepted. School of Health SciencesImmunization, CPR, and Physical Exam RequirementsImmunization RequirementsMMR: Positive Immunoglobulin G (IgG) antibody titers to Measles (Rubeola), Mumps and Rubella andDocumentation of two (2) FULL MMR injections, i.e. 2 Measles (Rubeola), 2 Mumps, and 2 Rubella orPositive Immunoglobulin G (IgG) antibody titers to Measles (Rubeola), Mumps and Rubella.If titer is negative or equivocal, the applicant must get one MMR injection. Note: Documentation of “history of disease” is not accepted.Varicella: Positive Immunoglobulin G (IgG) antibody titer for Varicella (chicken pox) andDocumentation of Two (2) Varicella (chicken pox) injections administered at least one-month apart orPositive Immunoglobulin G (IgG) antibody titers to Varicella.If titer is negative or equivocal, the applicant must get one Varicella injectionNote: Documentation of “history of disease” is not accepted.Tetanus, Diphtheria, Pertussis (Tdap): 1 dose required to apply to all health sciences programsOne (1) injection administered within the last ten (10) years.Hepatitis A: required to apply for Dental Hygiene, Paramedic, Emergency Medical Services, Occupational Therapy Assistant, and all Nursing programsOne (1) Hepatitis A injection required for application: second injection must be received six months after the first (see individual information packets for due date)orPositive Hepatitis A Total Antibody titer.If titer is negative or equivocal, the applicant must repeat the series and receive one Hepatitis A injection. Twinrix series is accepted.Hepatitis B: Completed Hepatitis B series required to apply to all health sciences programsHepatitis B series andPositive Hepatitis B Surface Antibody titer.If titer is negative or equivocal, the applicant must receive a challenge dose which is a test for a response. The challenge dose must be followed by another titer. If the titer is again negative or equivocal, the entire series must be repeated and followed by an additional Hepatitis B Surface Antibody titer.Twinrix series is accepted. orTwo (2) Heplisav B andPositive Hepatitis B Surface Antibody titer.TB (PPD) screening: required to apply to all health sciences programs.TB skin test, QuantiFeron Gold (blood test) or T-Spot is accepted.If screen results are positive (+), those results and documentation of a chest x-ray is required and must be negative for active disease.TB screening must be within 12 months of program application and must be updated each year when accepted to a health sciences program.Influenza (flu) Vaccine: required upon acceptance to all health sciences programs.The Health Sciences Division will notify students when the current Influenza (flu) vaccine is available (usually late August each year).Influenza documentation must include date administered, vaccine administered, injection site, specific dose, route, vaccine manufacturer, Lot Number, and expiration date. Incomplete information will result in rejection of the documentation. Flu Vaccine FormYou must use this form for documentation of your flu vaccine.Applicant Full Name Date of Birth Email Address Student ID # Date administeredName of vaccine administeredInjection siteDoseRouteManufacturerLot NumberExpiration dateSignature of health professional administering the vaccine is required for the form to be accepted. SignatureDatePrinted name Phone Number (_ )Address Physical Exam FormYou must use this physical exam form. The form must be completed by a physician or nurse practitioner.Applicant Full Name Date of Birth Email Address Student ID # Height Weight Temp Blood Pressure Sex Vision ________________ Glasses ______________ Contact Lenses R __________ L __________History: Include any significant information regarding previous medical and surgical conditions and use of alcohol and/or drugs.General Appearance: NormalCheck each item in appropriate columnAbnormalDescribe every abnormality in detail (attach additional sheet if necessary).Eyes-ears-nose-throatMouth-teeth-neckThyroidHeart and VascularLungsAbdomen and VisceraHerniaScarsBack, vertebraeExtremitiesSkinNeurologicalPhysician RecommendationBased upon your physical examination, is the applicant free of any restrictions in his/her ability to turn and/or Yes ____ No ____move heavy objects? If “no,” please describe:Is applicant able to see and hear adequately to practice as a health care professional? If no, please explain:Yes No Is applicant free of any pathological conditions either physical or mental that would interfere with the practiceYes No of a health care profession? If “no,” please describe:Physician or nurse practitioner signature is required for this form to be accepted:Signature of Physician or Nurse PractitionerDatePrinted Name of Physician or Nurse Practitioner Physician Address ___________________________________________ Phone Number _____________________ ................
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