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