Student Health Services Rutgers Health Sciences Campus at Newark Rutgers, The State University of New Jersey 90 Bergen Street, Suite 1750 Newark, NJ 07103
Dear Continuing Education Student, The attached health documentation is required for your participation in the continuing education curriculum per University Policy. These requirements are for your protection as well as the protection of patients and staff. All RBHS policies are based on CDC recommendations and NJ state law for healthcare workers, including students. NOW: Read through all forms in this packet Schedule an appointment with your healthcare provider for completion of the History and Physical and Immunization Record If you have additional immunization records from a licensed healthcare facility, you may provide those for consideration to fulfill your requirements Give the Healthcare Provider Checklist to your healthcare provider NEXT: Submit the completed o History and Physical and Immunization Record (no other forms will be accepted) o Lab reports (titers, chest-x-ray if necessary) o Proof of a “two step” PPD or an FDA approved blood assay for TB (such as Quantiferon Gold) as indicated on the Immunization Record. This consists of two PPD tests placed approximately 1-3 weeks apart. Each test must be read 48-72 hours after placement. Please make sure to have your health care provider complete, sign and date all forms. Give the Healthcare Provider Checklist to your healthcare provider so that the appropriate tests are performed. Your provider may not be familiar with some of these requirements, but they are, in fact, REQUIRED. The checklist may help to avoid the wrong tests being ordered at an increased cost to you, as any cost incurred related to the above requirements is your responsibility. The healthcare provider checklist is NOT to be returned to Student Health Services. Students are expected to be current with seasonal flu vaccination. Please 0$,/ the completed forms to: 5XWJHUV6FKRRORI'HQWDO0HGLFLQH &RQWLQXLQJ'HQWDO(GXFDWLRQ $WWQ-DQLFH*LEEV %HUJHQ6WUHHW% 1HZDUN1-
Student Health Services Rutgers Health Sciences Campus at Newark 90 Bergen Street, Suite 1750 Newark, NJ 07103
Immunization Record PART I: To be completed by the student. Please print or type. Last name
First name
DOB (month day year)
Street Address
Telephone (cell)
MI
School/Grad year/program (if SHRP or SN) RSDM-Cont. Dental Education City
State
Zip
Email
PART II: To be completed and signed by health care provider (all items must be completed) Date (mo day year) Health History and Physical Form
__ /__ /___
Tuberculosis - Two PPDs or an FDA approved blood test are required regardless of prior BCG (unless #1 is positive) PPD #1 (date placed __ /__ /___ )
Date read
Results (if applicable)
__ /__ /___ PPD#1
___ mm induration
PPD #2 (date placed __ /__ /___ )
__ /__ /___ PPD#2
___ mm induration
FDA approved blood test for TB (eg. Quantiferon Gold) (attach report)
__ /__ /___
Positive Negative Indeterminate
__ /__ /___
___ mm induration
__ /__ /___
Positive Negative Indeterminate Normal Findings:
OR
If PPD positive (≥10 mm), is the patient free of TB symptoms? Yes No List date of positive PPD and induration Was the patient treated? Yes No For how long?______________________ FDA approved blood test for TB (Quantiferon Gold) (attach report) Chest x-ray required within the past 12 months if TB blood test is positive or not drawn (attach report) Adult Tdap (Tetanus, Diphtheria & Acellular Pertusis) (Adacel or Boostrix) MMR (Measles, Mumps, Rubella) MMR Dose #1 MMR Dose #2 OR Measles (Rubeola) serologic immunity (attach lab report & list date of lab test) Mumps serologic immunity (attach lab report & list date of lab test) Rubella serologic immunity (attach lab report & list date of lab test)
__ /__ /___
Hepatitis B (at least one of three doses is required prior to enrollment) Hepatitis B dose #1, #2, #3 AND serologic testing REQUIRED: Hepatitis B Surface Antigen (attach lab report) QUANTITATIVE Hepatitis B Surface Antibody Titer* (qualitative will not be accepted per CDC guidelines) (attach lab report)
__ /__ /___ Dose 1 __ /__ /___ Dose 2 __ /__ /___ Dose 3 __ /__ /___ __ /__ /___
__ /__ /___ __ /__ /___ Dose 1 __ /__ /___ Dose 2 __ /__ /___ Dose 3 __ /__ /___ __ /__ /___ __ /__ /___
Immune Non-immune Immune Non-immune Immune Non-immune
Positive Negative Immune (≥10 mIU/mL) Non-immune
*Please defer the Hep B Surface Ab titer until 1-2 months after the 3 dose series is complete.
Varicella (Chicken Pox) Varicella Dose #1 Varicella Dose #2 OR
__ /__ /___ Dose 1 __ /__ /___ Dose 2
Varicella serologic immunity (list date and attach lab report) Seasonal flu vaccination (if attending between October 15 and March 15)
__ /__ /___ __ /__ /___
Page 1
Immune Non-immune
Provider: please sign this form on page 2
Student Health Services Rutgers Health Sciences Campus at Newark 90 Bergen Street, Suite 1750 Newark, NJ 07103
Healthcare provider
Address/Stamp
Print name Signature
Phone
Date
Fax
Page 2 Cat 1 CE+ r3.10.15
Health Care Provider Check List History and Physical
□ A completed health history and physical exam, dated, signed and stamped by the healthcare provider, on our forms.
□ 2-step PPD * regardless of history of having received BCG
PPD
Please include date placed and date read with millimeters of induration For a PPD ≥10 mm now or in the past, you must submit a chest x-ray report within the last 12 months
OR
□ an FDA approved blood test for TB (such as Quantiferon Gold) LabCorp test # 182873
Tdap
Quest Diagnostic test # 19453
□ Adult Tdap (tetanus/diphtheria/acellular pertussis) (Adacel/Boostrix) (one-time administration) □ 2 doses of Measles, Mumps, and Rubella vaccine
MMR
OR
□ MMR IgG titers showing immunity – attach lab report LabCorp test #058495
Quest Diagnostic test #85803A
□ 3 doses of Hepatitis B vaccine are required AND
□ Hepatitis B Surface Antigen - attach lab report LabCorp test # 006510
Hep B
Quest Diagnostic test # 265F
□ Hepatitis B Surface Antibody QUANTITATIVE titer (the result must be a number) attach lab report. If 3 doses of the Hep B vaccine have not been administered, please defer the Hep B Surface Ab titer until one month after the 3 dose series is complete. LabCorp test # 006530 Quest Diagnostic test # 51938W These are CDC recommendations for all healthcare workers. Your patient will not be permitted to matriculate without these tests.
□ 2 doses of Varicella vaccine, at least 1 month apart Varicella
OR
□ Varicella IgG titer showing immunity- attach lab report LabCorp test # 096206
Seasonal Flu Vaccine
Quest Diagnostic test # 54031E
□ Seasonal vaccination required
* Students working in healthcare with documented annual PPDs may submit that documentation to fulfil this requirement.
Cat 1 CE+ r3.10.15
Student Health Services Rutgers Health Sciences Campus at Newark Rutgers, The State University of New Jersey 90 Bergen Street, Suite 1750 Newark, NJ 07103
Health History and Physical Form PART I: To be completed by the student. Please print or type. Last name
First name
DOB (month day year)
Male Female
Telephone (cell)
MI
School/Grad year/program (if SHRP or SN) RSDM-Cont. Dental Education
Street Address
City
State
Zip
Email HEALTH HISTORY (attach pages as needed) Past surgeries Allergies Medications taken regularly
Ongoing health problems
PART II: To be completed by the healthcare provider. PHYSICAL EXAM (Must be completed by a non‐relative physician, nurse practitioner, or physician’s assistant)
Physical exam date (within the past 6 months): Visual acuity (with correction, if any):
OD
OS
Correction Yes No
Height (inches)
BMI
BP
Pulse
Weight (pounds)
Normal
Abnormal Not done If abnormal, please explain:
General appearance
______________________________________________
Skin (scars, tatoos)
______________________________________________
Head
______________________________________________
Eyes
______________________________________________
Ears, Nose, Throat
______________________________________________
Neck
______________________________________________
Lymph Nodes
______________________________________________
Heart
______________________________________________
Lungs
______________________________________________
Abdomen
______________________________________________
Spine
______________________________________________
Extremities
______________________________________________
Neurological Exam
______________________________________________
Healthcare provider
Address/Stamp
Print name Signature
Phone
Date
Fax
Cat 123 r 1.6.15