RN NURSING STUDENT COMPLIANCE PACKET
PRESBYTERIAN SCHOOL OF NURSING BLAIR COLLEGE OF HEALTH QUEENS UNIVERSITY OF CHARLOTTE
Dear Newly Admitted Student, Congratulations on your admission into the Presbyterian School of Nursing! My name is Rachel Tsiamis and I am the Compliance Coordinator for the Blair College of Health. In this packet you will find the forms that you are required to submit. All future CPR and PPD renewals and other compliance documents will need to be submitted to me as well. If you have any questions about your health forms and/or the health information that you need to submit, please do not hesitate to contact me. Students are also required to meet our technical standards. Technical standards are required functions that are non-academic in nature and include the areas of cognitive, communication, psychomotor, physical, behavioral, professional and social skills and abilities. These skills are required to ensure the health and safety of patients, students, faculty and other health care providers. Students must maintain satisfactory demonstration of academic and technical standards for admission, progression and graduation from the Presbyterian School of Nursing, with or without reasonable accommodations. Inability to meet these requirements will result in dismissal from the program. For the complete policy and for examples of technical standards please see Policy number 11 in the PSON Nursing Student Handbook. Please keep in mind that you may not be able to attend clinical experiences until you are in compliance with all of your required documentation. The FBI Background check takes a minimum of six (6) weeks for us to receive the results back. Please make sure that you submit your FBI background check in a timely * manner to ensure that we have your results back before classes begin. If you would like to mail your completed health forms and/or documents, please send them to: ATTN: Compliance Coordinator Blair College of Health Queens University of Charlotte 1900 Selwyn Avenue Charlotte, NC 28274 You may also fax them to my attention at 704-688-7530. If you would like to submit your documents in th nd person, I am located on the 5 Street Campus on the 2 Floor in office 223. Thank you so much and again please do not hesitate to contact me if you have any questions about your health forms and/or health information that you are required to submit. Sincerely,
Rachel Tsiamis Compliance Coordinator Blair College of Health Queens University of Charlotte T: 704.688.2781 F: 704.688.7530 *Students that are admitted into the program right before classes start, for example students admitted into the BSN or ABSN program from the waitlist a few days before classes start, will be given additional time to submit their Health compliance documents and two Background checks.
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RN NURSING STUDENT COMPLIANCE CHECKLIST Please ensure that you have completed and submitted the following documents:
Medical History Forms Physical Examination Form (dated within the past year) 3 doses of DTP or Td (2 from childhood) and one dose of Td/Tdap booster being within the last 10 years (required) (if records not available, must repeat series as adult) MMR (one of the following required) 2 doses of MMR 2 doses of Measles, 1 dose of Mumps, and 1 dose of Rubella A positive blood titer for Measles, Mumps, and Rubella (*include copy of report)
Two – Step Tuberculin Skin Test 2‐step PPD process: PPD #1 is placed and read. If PPD #1 is negative, PPD #2 is placed and read 1 – 3 weeks later. If either PPD is positive, or if the student has ever had a positive PPD, a negative chest X‐ray is required ‐ *include copy of report
Varicella/Chicken Pox (one of the following is required) A positive blood titer for Varicella ‐*include copy of report 2 doses of the Varicella vaccine Hepatitis B (one of the following is required) 3 doses of Hepatitis B vaccine A positive blood titer for Hepatitis B ‐*include copy of report Hepatitis B Vaccine Declination Form Influenza Vaccine or Influenza Declination Form 12 – Panel Drug Screening Copy of your American Heart Association Healthcare Provider CPR card BIB Background check This is a two‐step process. First you fill out the attached form and fax (highly suggested) or mail the form along with the payment in. Then BIB will email you a username and password along with a URL link. Please copy and paste the URL link, username, and password because they are very sensitive. The username and password are only good for about a month. Please check both your Spam and Junk folder to see if the email when there. FBI Background check Malpractice Insurance (MSN students only)
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Guidelines for completing student medical forms
Records must be documented in ink and any corrections must be signed. All immunization records must include month, day and year of administration. History of disease is NOT acceptable. Only positive blood titers or proof of immunization will be accepted. MD, PA, or NP must complete and sign Physical Examination or it will not be accepted. Clinician must sign official Immunization Record and include facility stamp or it will not be accepted.
Required Immunizations – Must Submit Proof ___
___ ___ ___ ___
3 doses of Tdap (Tetanus, Diphtheria, Pertussis) or Td (Tetanus, Diphtheria) doses with one of those doses being within the past 10 years. If enrolling in college for the first time the booster must be Tdap. 2 doses of Measles (Rubeloa), 1 Mumps, 1 Rubella (MMR is preferred) or positive blood titers (include lab report). If 50 years or older, Rubella dose not required. 3 doses of Polio (oral) doses – only if 17 years old or younger. 2 doses of Varicella (chicken pox) or a positive blood titer (include lab report). 2‐Step Tuberculin Skin Test (PPD) within 12 months of starting classes. 2‐Step PPD – If initial PPD is negative, second PPD is given 1 – 3 weeks later. Must submit results of both tests. If history of positive PPD, please submit a recent negative chest x‐ray (within past 5 years) and complete the TB Screening Form.
Please note: “History of Disease” is not acceptable. You must submit proof of vaccine(s) administration or positive blood titer(s). Highly Recommended – But Not Required ___
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Hepatitis B Series (3 doses), you must either submit proof of vaccines, or sign and submit the Hepatitis B declination form.
Report of Medical History When completing document please print clearly using black ink only. ___________________________________________ ________________________ Last Name First Name MI Social Security Number ___________________________________________ ________________________ Permanent Address City State Zip Code Phone Number _________________ ____________ ________________________ Date of Birth Gender Marital Status Entering Class: FR SO JR SR Yr: ____ Semester: _________ Fall/Spring/Summer Family Insurance Coverage: YES or NO Queens Student Coverage: YES or NO ________________________ __ ___________ ____________________ Name of Emergency Contact Phone Number Relationship
The following health history is confidential, does not affect your admission status, and, except in an emergency situation or by court order, will not be released without your written consent. Please attach additional sheets for item requiring an explanation. Family and Personal Health History (please type or print in black ink.) Has any person, related by blood, had any of the following? High Blood Pressure
Y
N
Relative
Stroke
Cancer type_____
Heart attack before age 55
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Cholesterol or blood fat disorder Diabetes
Y
N
Relative
Alcohol or Drug problems
Y
N
Relative
Psychiatric illness
Glaucoma
Suicide
Blood or clotting disorder
Have Have you ever had (or do you have now) any of the following:
Y
N
Year
Y
N
Year
Y
N
Year
High blood pressure Rheumatic fever Pain or pressure in chest Heart trouble Shortness of breath
Mononucleosis
Pneumonia
Hay fever
Arthritis
Chronic cough Tuberculosis
Concussion
Headaches
Asthma
Smoke 1+ pack cigarettes per week Shoulder dislocated Recurrent back pain
Alcohol/drug addiction Rehab
Tumor or cancer Allergy injection therapy Thyroid condition Serious skin disease
Hearing loss
Knee problems Neck injury
Severe menstrual cramps Hernia
Diabetes
Anorexia / Bulimia
Eye problem other than glasses Broken bones
Irregular Periods Blood transfusion Bladder / Kidney infection Kidney stones
Dizziness or fainting Paralysis
Severe head injury Epilepsy / Seizures Depression / Anxiety Anemia / Sickle Cell Anemia Sexually transmitted disease Back injury
Please list any medications, vitamins and/or minerals (prescription and non‐ prescription) you use, and indicate how often you use them. Name:___________________ Dosage: ___________ Name: ___________________ Dosage: __________ Name: ___________________ Dosage: __________ Name: ____________________ Dosage: __________ Name: ___________________ Dosage: __________ Name: ____________________ Dosage: __________
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Allergies Check each item Y or N. Every Y must be fully explained use an additional sheet if necessary. Have you ever experienced adverse reactions (hypersensitivities, allergies, upset stomach, rash, hives, etc.) to any of the following? If Yes please indicate the type of reaction, your age at the time of reaction and if the reaction has occurred more than once.
Substance
Y
N
Explanation
Penicillin Sulfa Other antibiotic Aspirin Other pain reliever Latex Insect bites Food Other
Has your academic career been interrupted due to physical or emotional problems? ______________________________________________________________________________________ Is there any loss or serious impairment of any organ? ______________________________________________________________________________________ Other than for a routine check‐up, have you seen a healthcare professional in the past six months? _______________________________________________________________________________ If yes, please explain ______________________________________________________________________________________ Have you been a patient in a hospital in the last 12 months? _____________________________________ If yes, please explain_____________________________________________________________________ Have you had a serious illness or injury, other than already noted? ______________________________________________________________________________________
Statement by Student: I have personally supplied the foregoing information and attest that it is true and complete to the best of my knowledge. I hereby give permission to any Doctor, Hospital, or Medical Agency to release confidentially to Queens University of Charlotte any information they may have concerning my medical condition and their professional contact with me. I hereby authorize any necessary medical treatment for myself. Student Signature: _______________________________________ Date: __________________ Parents/Legal Guardians of Students Under 18 I hereby authorize any medical treatment for my son/daughter that may be advised or recommended by the Physicians or health care professionals of the Queens University of Charlotte Health & Wellness Center. Parent/Legal Guardian Signature: ___________________________________ Date:___________ University Policy for All Students It is the student’s responsibility to keep parents/legal guardians informed about personal health matters. All reasonable effort will be made to secure the student’s permission should the University deem it necessary to communicate with the parents/legal guardians regarding 10/12 RT medical concerns.
PHYSICAL EXAMINATION BY MD, NP, OR PA
(required – must by competed and signed)
_____________________________________________________________________ Last Name First Name MI Date of Birth __________________________________________________________________________ Permanent Address City, State, Zip code Phone Number Height: _____ Weight: _____ TPR___/___/___ BP: ___/___ Vision: Corrected Right: 20/__ Left: 20/__ Hearing (gross) Right: ____ Left: ____ Uncorrected Right: 20/__ Left: 20/__ 15ft. Right: ____ Left: ____ Color Vision: ________ Urinalysis: Sugar: ______ Albumin: ______ Micro: ______ Hgb or Hct (if indicated): ____________ Head, Ears, Nose, Throat Eyes Respiratory Cardiovascular Gastrointestinal Hernia Genitourinary Musculoskeletal Metabolic / Endocrine Neuropsychiatric Skin Mammary
Normal
Abnormal
Describe
Is the student under treatment for any medical or emotional condition: Yes No If yes, please explain: Is there any loss of, or seriously impaired function of any organ? Yes No If yes, please explain: Recommendation for physical activity (lifting, standing, walking, etc.) Unlimited Limited Please explain if limited: Based on my assessment of this student’s physical and emotional health on this day, he/she appears able to participate in the activities of a health professional in a clinical setting. Yes No Please explain if no: Signature of Healthcare Professional
Print Name & Title
Street Address of Facility
City, State, and Zip
Phone Number
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Date
IMMUNIZATION RECORD (Required – must be completed and signed by clinician) Last Name
First Name
MI
Mo/Day/Yr #2:
Mo/Day/Yr #3:
Date of Birth
DTP or TD (please indicate)
Mo/Day/Yr #1:
Mo/Day/Yr #4:
Td Booster (within last 10 years)
#1:
Oral Polio (if 17 yrs. and younger)
#1:
#2:
MMR
#1:
#2:
Measles
#1:
Mumps
#1:
Rubella
#1:
Attach results of positive blood titer Attach results of positive blood titer Attach results of positive blood titer
2 – Step Tuberculin Skin Test (PPD)
#1 date/result:
#2 date/result:
Chest x‐ ray (if applicable)
Date/result
Varicella Vaccine or Positive blood Titer Results
#1:
#2:
Hepatitis B Series (recommended, not required)
#1:
2#:
#3:
#3:
Attach results of positive blood titer Attach results of positive blood titer
Clinician Signature (required): ______________________________________ Date: __________
Clinic Stamp (required):
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CPR REQUIREMENT While in the nursing program you must maintain continuous CPR certification. This certification must by the American Heart Association, BLS for Healthcare Providers and include the following components: Adult CPR and relief of airway obstruction Child CPR and relief of airway obstruction Infant CPR and relief of airway obstruction Automated External Defibrillation (AED) Your card must indicate that you were instructed in all the above modules. It must also indicate your name, the date of your class, and the date your card expires. Please attach a photocopy of your card below: (front of card) (back of card)
You are responsible for submitting a photocopy of your new card before the old card expires while enrolled in the Presbyterian School of Nursing at Queens University of Charlotte.
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DRUG SCREENING FORM Consistent with our clinical partners practice regarding a drug free environment, all applicants selected for admission to any program or course in the School of Nursing must provide documentation of a negative (urine), twelve panel drug screen that has been collected and processed using a NIDA‐approved laboratory. Chain of custody in handling of the specimen must be maintained. You will not be permitted to enroll in courses unless the drug screen is negative. If the results come back positive you will need to submit a copy of your current prescription(s) from your Healthcare to this form. You may have this drug screen completed at the Queens University Health and Wellness Center. There is a fee for this service. Please call 704‐337‐2220 to schedule an appointment. You may also use your healthcare provider, clinic, or independent laboratory. Please investigate the cost at each provider before having the test performed. You only need a twelve panel drug screen. Test results should be attached to this sheet.
_____________________________________________________ Last Name First Name MI ________________ ________________ Date of Birth Student ID Number ___________________________________ Results of Twelve Panel Urine Drug Screen (attach the lab report) _____________ Date of Testing
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HEPATITIS B VACCINE DECLINATION FORM This form should only be completed if any of the following applies to a student: Has not received all three (3) doses of the Hepatitis B Vaccine by the start date of classes Has a negative blood titer to Hepatitis B Does not wish to receive the Hepatitis B Vaccine Read the following and sign below. A witness signature/date and printed name is required at the time the student/faculty member signs (the dates must match). A witness can be a family member, friend, colleague, etc. Do not turn in the form without the witness section fully completed.
I understand that due to my occupational exposure (as a nursing student) to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B Virus (HBV) Infection. I have been advised of the importance of obtaining the Hepatitis B Vaccine however I decline to be vaccinated at this time or will not complete my vaccine series by the deadline. I understand that by declining this vaccine or by having an incomplete vaccine series, I continue to be at risk of acquiring Hepatitis B Virus Infection, a serious disease. I agree to hold Queens University of Charlotte and its affiliated clinical agencies harmless in the event that I do develop the disease. _____________________________________________ _______________________ Student/Faculty Signature Date _____________________________________________ Printed Name _____________________________________________ _______________________ Witness Signature Date _____________________________________________ Printed Name
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ANNUAL TUBERCULOSIS (PPD) SCREENING FORM Student Name:______________________________________ ID Number: _______________ List of all Known Allergies: _______________________________________________________ ______________________________________________________________________________ List of all changes in your health since your last screening: ______________________________ ______________________________________________________________________________ Do you have: (Check appropriate column) History of positive PPD test History of positive Chest X‐Ray History of INH treatment History of other TB treatment Productive cough Unexplained fever Weight loss Loss of appetite Night sweats Lethargy Weakness Shortness of breath Chest pain Please check the appropriate column for the following questions. Have you had a recent exposure to TB? Are you being treated for TB? Have you received any immunizations within last 30 days
Yes
No
Yes
No
Your signature on this form indicated that you have answered the above questions accurately to the best of your knowledge. When submitting the form electronically, you agree that typing your name on the signature line serves as your signature. Student Signature: _______________________________________ Date: __________________ This screening tool must be completed every 12 months while enrolled in the program and is required of those students who require a chest x‐ray in lieu of a PPD. Please see the Compliance Coordinator with any questions
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Background Investigation Bureau Background Screening Request Form Queens University- ___________ Below are the steps necessary to complete the request for the required background check for Queens University: 1. Submit payment of $11.50 per name by credit card or money order to Background Investigation Bureau. 2. Upon receipt of your payment, BIB will send you an email with a link and user credentials to log into BIB’s site. Please allow 1-3 business days. You will log in and submit the required information needed to conduct the background check, as well as an electronic authorization and release of information allowing Queens to conduct the background check. Please submit your information within 3 days of receiving the email. 3. Once you submit your information online, your background check results will be reported to Queens. NAME: _______________________________________ AKA: ________________________________________ EMAIL ADDRESS: ____________________________________________________________________________ Please check form of payment _________ Credit Card ________ Money Order - CREDIT CARD AUTHORIZATION - Amount to be charged: $ 11.50 per name By my signature below, I authorize Background Investigation Bureau to process and charge my credit card for my criminal record searches. PLEASE PRINT CLEARLY AND COMPLETE ALL SECTIONS
Credit Card Type: ______________________ (Visa / MasterCard / Discover / AmEx) Credit Card Number: ____________________________________________ Expiration Date: _______________ Credit and Security PIN __________________ (3 to 4 digit number in signature block on back of card) Cardholder Name: ___________________________________________________________ (as written on card) Billing Address: ______________________________________________________________________________ City: _______________________________________
State: ___________
Zip: ____________
Cardholder Telephone Number: (____) ______________________ Alt Phone: (____) _____________________ Cardholder Signature: X ______________________________________________ Date: ____________________
Please send this form and money order to: Background Investigation Bureau Attn: Client Services 9710 Northcross Center Court Huntersville, NC 28078 -or-
For Credit Card orders ONLY - Fax this form to: 704-439-3901 Background Investigation Bureau Ph: 877-439-3900 Fax: 877-439-3901 |
[email protected] CONFIDENTIAL
OBTAINING YOUR FINGERPRINTS Below you will find directions on how to obtain fingerprints for your FBI Background check. All reports/results must be sent directly to Queens University of Charlotte from the FBI. Reports sent to students from the FBI will not be accepted.
If you reside in Mecklenburg County, go to the Mecklenburg County Sherriff’s Department, and the Permits Bureau Office: 715 East 4th Street Suite 200 Charlotte, NC Please go to their website for hours and instructions: http://charmeck.org/mecklenburg/county/MCSO/CommunityServices/Page s/Fingerprinting.aspx If you reside outside of Mecklenburg County, please contact your local Sheriff’s Department in your county of residence for instructions on how to obtain your fingerprints.
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OBTAINING YOUR FBI BACKGROUND CHECK
Below you will find directions on how to obtain your FBI background check. All reports/results must be sent directly from the FBI to the Presbyterian School or Nursing. Reports sent to the student will not be accepted. All reports will be reviewed by the appropriate program. If you have any items in your history that will be reported on the FBI record, please make an appointment with your department chair. 1.) The website that you go to, to request your FBI ground check is: http://www.fbi.gov/about‐us/cjis/background‐checks The above links should take you to a page that says “Identification Record Request/Criminal Background Check”. 2.) Scroll down until you see “How to Request a Copy of Your Record” Click Option 1: Submit your request directly to the FB” 3.) Make sure you complete the following by clicking on the forms under the appropriate steps: Step 1: Application Information Form A.) Select the reason that you are requesting an FBI Background Check B.) Then click on the form where it says “You can now continue to the form.” C.) Fill out your personal information D.) Under “Mail Results to Address” use the following address: C/O: Presbyterian School of Nursing ATTN: (State your nursing program here – ASN/BSN/ABSN/RN to BSN/MSN) Address 1: Queens University of Charlotte Address 2: 1900 Selwyn Avenue Address 3: (leave blank) City: Charlotte State: NC Postal (Zip) Code: 28274 E.) Select your payment method (if using a credit card, make sure you submit the credit card payment form along with you application form). The Credit card payment form is located under Step 3: Submit a payment on the main “Identification Record Request/Criminal Background Check” page. 4.) Review the FBI Identification Record Request Checklist to ensure that you have included everything needed to process your request (found under Step 4). 5.) Mail the required items – signed applicant information form, fingerprint card, and payment in U.S. dollars, for each person or copy requested – to the following address: FBI CJIS Division – Record Request 1000 Custer Hollow Road Clarksburg, WV 26306 Note: Although the FBI employs the most efficient methods for processing these requests, processing times may take approximately six to eight weeks depending on the volume of requests received.
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It is a PSON policy that all Graduate Students must carry liability insurance. The four below companies offer Liability Insurance to students. Please submit a copy of the insurance certificate showing proof of coverage to the Compliance Coordinator who is located on the 5th Street Campus. The PSON requires MSN students to have Professional Liability Insurance with minimum coverage $1,000,000 per incident and $3,000,000 aggregate. Although we do not endorse any of the companies listed below, students have purchased liability insurance through the following providers:
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Professional Nursing Organizations Nurses Service Organization – www.nso.com or call 1-800-247-1500 Health Providers Service Organization – www.hpso.com or call 1-800982-9491 Marsh – www.proliability.com or call 1-800-621-3008
