PLEASE FILL IN REVERSE SIDE - City Tech - New York City ...

NEW YORK CITY COLLEGE OF TECHNOLOGY

DEPARTMENT OF NURSING

Name:

Emplid ID

Has met the following health requirement of the Nursing Department.

Semester of NUR course:

PLEASE NOTE ALL ITEMS MUST BE ANSWERED: PHYSICAL EXAM:

DATE___________

Flu Shot Form A

Tdap: Tetanus-Diphtheria-Acellular Pertussis Booster: DATE__________

Measles (Rubeola) Titer Date Drawn ____ Titer Value ____ Immune __ Non-Immune __ Revaccination Date __

Mumps

Titer Date Drawn ____ Titer Value ____ Immune __ Non-Immune __ Revaccination Date __

Rubella

Titer Date Drawn ____ Titer Value ____ Immune __ Non-Immune __ Revaccination Date __

MMR Vaccination:

Date #1______ Date #2 ______

MMR Revaccination (If Titer is negative or equivocal- See above)

Varicella

Titer Date Drawn ____ Immune __

Non-Immune __

Revaccination (If Titer is negative or equivocal)

Date #1 _____ Date #2 __

Hepatitis B Hepatitis B

Dates of Vaccinations #1 ______ #2 _________ #3 __________

And

Titer Date Drawn _____ Immune __

Non-Immune __

Hepatitis C

Titer ________________

TB Testing:

Annual PPD is required for nursing students who are providing documentation that QuantiFERON TB Gold is negative or a 2-Step PPD was negative (Results measured in mm). The documentation must be written in or attached. If the nursing student does not have proof of the QuantiFERON TB Gold is negative or a 2-Step PPD was negative, then administer one of those TB Tests.

Annual PPD____________________________Results_____________ mm

QuantiFERON?TB Gold Date______________Results______________OR Two-Step PPD See Below

1st PPD/ MANTOUX TEST: ------RESULTS:

DATE: ------

* If PPD/Mantoux is newly positive, follow-up chest x-ray is required and chest x-ray report must be attached. ** If PPD/Mantoux is negative, a second PPD/Mantoux must be repeated within 2-3 weeks. Second PPD required if more than 1year since last PPD and results not available for proof of negative status.

2nd PPD/ MANTOUX TEST: ------RESULTS:

DATE: ------

URINALYSIS_________________ RESULTS________________________________________ DATE___________________ CBC:_____________________RESULTS_________________________________ DATE________________

PLEASE SPECIFY ANY HEALTH PROBLEMS:

This certifies that the above named student is physically capable of functioning in a hospital setting for twelve hours perweek. Practitioner Signature

Practitioner Official Stamp

Date

PLEASE FILL IN REVERSE SIDE

ADDENDUM TO HEALTH REQUIREMENTS

Pursuant to Section 405.3(b) for the New York State Hospital Codes, the following Statements of Physical Examination is req uired:

Is there and emotional, mental or physical condition for which this student is under medical observation and/or taking medication:

{ } YES

{ } NO

If"yes",please specify

Based on my physical examination and the patient's medical history, I believe that the above referenced is free from a health impairment which is of potential risk to patients or which might interfere with the performance of his/her duties, including the habituation or addiction to depressants, stimulants, narcotics, alcohol or other drugs or substances which may alter the individual's behavior.

PRACTITIONER SIGNATURE

LICENSE NUMBER

rev 7/20AN

(Please check one) My Private Doctor

Form A Flu Shot Documentation

I received my flu vaccine for 2021/2022 from:

My Pharmacy

Name:

_________________________________

Title/Department:

_________________________________

Date of Birth:

_________________________________

Home Address:

_________________________________

Phone Number:

__________________________________

Facility: ____ HHC

____PAGNY

____Contractor

____Vendor

____Volunteer

Date Vaccine Received:

_________________________________

Influenza Vaccine 0.5 ml IM given in (site) ___________________________

Manufacturer: ________________ Lot #: _________________ Expiration Date: ________________

Reaction to the Vaccine: No ________ Yes _________ (Describe Reaction) ___________________

Name of Provider (Please print)/ Pharmacy Stamp: _________________________________

Signature of Provider/ Pharmacist:

_________________________________

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