Public Health – Health Requirements Checklist Instructions: Complete all of the items listed below by the deadline. All forms can be downloaded from the CHS Clinical Requirements webpage or Castle Branch. Student Account Set-up  Set up student account with Castle Branch (https://portal.castlebranch.com/HF84) Health Requirements  MMR Vaccinations (2 MMR’s are required)  Tdap (Tetanus/Diphtheria/acellular Pertussis)  Physical Examination form  American Heart Association BLS for Healthcare Provider certification (we will NOT accept any other certification)

 TB/PPD Clearance – ONE of the following is required o Copy of a current 2-step TB o Copy of two annual TB tests; one of which needs to be current o If you’ve had a positive TB test, please provide the following: date of positive TB with reading in mm, a current negative chest x-ray (1 year or less), and TB Monitoring Questionnaire.  Seasonal Influenza on CHS form  HIPAA & Bloodborne Pathogens Certification  Health Insurance Once you have complete the requirements listed above, you must scan and upload a copy of the documentation into your Castle Branch health tracker prior to the deadline given.

Questions: If you have technical questions about Castle Branch, please contact: (888) 7234263. If you have questions about the health requirements, please contact: Risa Tanaka at (808) 236-5816 or [email protected].

Updated on 2/28/14

Physical Examination Form (3 pages) to be completed within 1 year of entry or upon request of the Dean Name: ___________________________________ HPU ID Number: __________________ Immunization Record and Health Report to be signed or stamped by health care provider. Information written on this report is NOT proof of immunization or labs. Immunizations/Screens 1. Mumps:  Immunization is required. 2.

Rubeola (Measles):  Immunization is required.

3.

Rubella:  Immunization is required.

4.

Tdap (Tetanus/Diphtheria/acellular Pertussis) – NOTE: effective Fall 2014 Tdap is required for ALL students:  Immunization within the last 10 years is required  For adults: Those who did not get the Tdap should get one dose as a booster. Most pregnant women not previously vaccinated with Tdap should get a dose before leaving the hospital. (Source: U.S. Centers for Disease Control and Prevention) Tuberculosis (TB/Mantoux/PPD): Last two annual TB tests OR two-step TB test required  2 annual TB tests: Tests must be less than 1 year apart and must be less than a year old.  Two-step TB tests: Two TB tests within a two-week time period, the second one administered a week after the first one is read.  Positive TB test: Positive TB test and results AND x-ray report/card with clear or negative findings. X-ray must be less than 1 year old.

5.

Student Signature: __________________________________ Date: ___________________ Student’s Signature is acknowledgement that they understand the requirements of immunizations.

Health Care Provider Signature: ___________________________ Date: ______________

Health Questionnaire: To be completed by Student prior to Physical Examination

_____ Yes _____ No

Do you have any physical limitations that would affect your ability to lift, turn, or transfer patients?

_____ Yes _____ No

Do you have any limitations in use of your senses, such as in sight, hearing, which would limit your ability to practice a health profession?

_____ Yes _____ No

Do you have any other condition that might interfere with your ability to practice in the health care profession?

If you answered “yes” to any of the above, please explain your limitations in detail, including any medications you take on a regular basis in the past year (attach a separate sheet of paper if necessary): _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

History: Include any significant information regarding previous medical/surgical or psychiatric conditions and use of alcohol or drugs: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

Student Signature: ___________________________________________ Date: ____________________________

Health Care Provider’s Certification of Fitness: PHYSICAL EXAMINATION FORM 

Students will be examined for evidence of being able to meet the physical requirements necessary for a nursing student: o Ability to stand, sit, kneel, bend, push, pull, carry, walk, reach, and twist o Manual dexterity to perform fine motor tasks needed for essential nursing tasks and use of equipment. o Ability to see, hear, and feel. o Ability to lift at least 50 pounds (essential to assist clients with ambulation, transfers, positon changes, transport).

Any comments r/t history provided: ______________________________________________________________ _____________________________________________________________________________________________ Gender: __________ Age: __________ Height: __________ Weight: _________ Blood pressure: _________________________ Pulse: ____________ Build: Slender _________ Medium _________ Heavy _________ Obese _________ Color vision: _______ Vision: OD 20/______ OS 20/________ Corr-to 20/________ Normal

Abnormal Details of Abnormality Head, neck, face, & scalp Eyes, ears, nose Mouth, teeth, gingiva, & throat Thyroid Lungs Heart & vascular Abdomen & viscera Hernia Neck, back, & spine Upper extremities Lower extremities Other musculoskeletal Skin and lymphatics Neurologic Psychiatric (specify deviations noted) Lab Data (if indicated): Hgb: __________ WBC: __________ Urinalysis (dipstick): __________ I have examined ___________________________________ and have found her/him to be free from any impairments or restrictions that may impede functioning in a health care role. Comments: ___________________________________________________________________________________ _____________________________________________________________________________________________

___________________________________________

______________________________________________

Signature of Health Care Provider and License Number

Printed name of Stamp of Health Care Provider

Address: ______________________________________________

STUDENT/FACULTY INFLUENZA VACCINE 2016-2017 Flu season runs from August – March. If you are filling out this form outside of the flu season, please check the “will be receiving box”

PRINT Name:

Date:

Hawai’i Pacific University has mandated that I receive the influenza vaccination due to new facility requirements.

Provider Information: ________________________ □ Received 2016-2017 inactivated influenza vaccine

Date: _________________

Provider Information: ________________________ □ Received 2016-2017 activated influenza vaccine

Date: _________________

□ Will be receiving when the flu vaccine is available

Medical Contraindication: _____________________ □ Medical contraindications (systemic allergic reaction to ingredients, Guillain-Barre syndrome, etc.)

Provider Signature: __________________________ ** Please inform your clinical instructor that you are NOT able to take the flu shot, as you will need to adhere to hospital and unit policies (i.e. wearing a mask throughout flu season while at clinical)

__________________________________________

_______________

Student Signature

Date

Tuberculosis Monitoring Questionnaire HPU’s affiliation agreements with the various health care agencies require that we monitor TB status of nursing students on an annual basis. Individuals with a previous history of a positive PPD, followed by a negative chest x-ray, are requested to provide ongoing TB monitoring by filling out this questionnaire to monitor for symptoms of tuberculosis. Please check “yes” or “no” in the appropriate box. This form will be reviewed by the Health Records Assistant and you will be contacted if further follow up is required.

Have you experienced any of the following symptoms in the last year?

Cough longer than three weeks Cough of blood Shortness of breath Chest pain Persistent weight loss without dieting Night sweats Chills/fever Fatigue (more than usual)

Yes

No

       

       

If yes, please explain ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________

Print Name: ____________________________________ Student ID: ___________________

Signature: _____________________________________ Date: ________________________

For Office Use Only Reviewed By: ______________________________

Health Insurance Requirement for Clinical Level Nursing Courses Students who will be purchasing their health insurance through HPU need to sign and submit the “Health Insurance Intent to Purchase Agreement” to Castle Branch under the Insurance section by Sunday, July 10th, 2016. This agreement is binding. Once you purchase your health insurance, you must submit a copy of the receipt of purchase or a copy of the insurance card to Castle Branch by: Monday, August 29th, 2016. __________________________________________________________________________

Health Insurance Intent to Purchase Agreement I, (print name) _________________________________________, a level ______ (indicate the level you will be entering for Fall 2016, 1 – 5) intend to purchase health insurance through HPU for the coming semester. I have read the information provided to me and understand the current insurance rates are not yet published. Because health insurance is mandatory to work in the clinical facilities, I understand that I must turn in a copy of my receipt of purchase or a copy of my insurance card. This proof is due no later than Monday, August 29th, 2016. I understand that if I do not show proof by this date I will lose my clinical seat.

_________________________________________ Signature

____________________________ Date

HIPAA and Bloodborne Pathogen Training Instructions

HIPAA Training: 1. Go to http://www.hawaiistatecenternrc.org/Student-Center 2. Click on the training module located on the right hand side of the webpage 3. Read the information and follow the link 4. Complete the Post-Test (link located under the training module on the webpage listed in #1) and print the last page before closing 5. Sign and upload the page to your Castle Branch tracker Bloodborne Pathogen Training: 1. Log into a computer in the Library or Computer Lab. Or if you wish to access the training from your own personal computer, please set up HPU Cloud to your computer: a. Set up Cloud – Go to http://www.hpu.edu/vdi and download the VMware Horizon View Client to your personal computer or tablet. Be sure to enter the default connection server: cloud.hpu.edu. If you have questions, please call the ETC at 236-5807. 2. Click on the Windows icon 3. Click on Computer 4. Double Click on Video folder 5. Double Click on Bloodborne Pathogens – 2011 to watch video 6. After watching the video, return to the Video folder and double click the CNHS Bloodborne Pathogens Training Post Test Survey link 7. Complete Post-Test and print the last page 8. Upload the page to your Castle Branch tracker