CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING
School of Nursing
PROGRAM AND HEALTH REQUIREMENTS
This packet contains information and forms which must be received at the School of Nursing within 60
days of admittance into the Graduate Nursing Program. No 600 level nursing course may be taken if all
program requirements are not met.
 Student Handbook:
 Go to the School of Nursing Home page at www.csuohio.edu/nursing
 Download the Graduate Student Handbook and read completely
 Print and sign the following sheet:
o Policy and Procedure Contract Form
 Program and Health Requirement Documentation:
 Medical Reports and Forms:
o
o
o
o
Student Information and Medical Requirements – page 2
Varicella (Chicken Pox) Immunization – page 3
Tuberculin Mantoux Skin Test or Chest X-Ray Verification – page 4
Hepatitis B Immunization – page 5
 Insurance & RN License Requirements and Forms:
o Student Liability Insurance Information – page 6
o Health Insurance Verification – page 6
o RN License and Registration Verification – page 6
 Additional Clinical Agency Requirements and Forms:
o Fingerprinting and Background Check Information – pages 7 - 8
o CPR Certification Information – page 9
o Agency Confidentiality and related forms – page 10 - 13
 Please keep a copy of all of these documents in your personal files. Faxed documents
will not be accepted.
Students may wish to check with the CSU Health & Wellness Services Department at (216) 687-3649,
since some medical services and immunizations can be obtained inexpensively through the Health & Wellness
Services Department which is located at 1836 Euclid Avenue, 2nd Floor.
Mailing Address: 2121 Euclid Avenue, JH 238 · Cleveland, Ohio 44115-2214
Campus Location: Julka Hall, Room 238 · 2485 Euclid Avenue · Cleveland, Ohio
(216) 687-3598
n:Forms/MSN PACKET – Program and Health Requirements-02062012-ls, rev-08/24/2012, rev-11/01/12
Page | 1
CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING
Program and Health Requirement Documentation:
STUDENT INFORMATION
This information is strictly confidential. Please print legibly:
Last
First
CSU I.D. Number
M. I.
Street
Address:
(City)
(
)
(State)
(
(Home Phone with Area Code)
)
(Zip)
_____/_____/_____
(Cell Phone with Area Code)
Female
(Birth Date)
Male
(Sex – Circle One)
Clinical Nurse Leader ♦ Forensic Nursing ♦ Nursing Education ♦ School Nurse Licensure Preparation ♦
Specialized Population ♦ MSN/MBA
(Graduate Nursing Program -- circle one)
American Indian
♦
Asian
♦ African American
Mixed ♦ Other
♦
Hispanic
♦
White
(Race – Circle One)
IMMUNIZATION STATUS – Students must provide documentation of satisfactory immunization status for the
following:
a. Varicella - Students are required to submit proof from a physician or health institution of having had
varicella (chicken pox) or the vaccination. If proof is not available, the student must have a blood titer
test showing immunity. Proof of immunity must be recorded on the Verification of Varicella (Chicken
Pox) Illness, Immunization or Blood Titer Test Form.
b. TB Mantoux Test - The TB Mantoux Test report is required for all students admitted to the Nursing
Program with the one-step TB Mantoux Test performed ANNUALLY throughout the program. The
results of the TB Mantox Test or Chest X-Ray should be indicated on the TB Mantox Skin Test of
Chest X-Ray Form.
The PPD and/or chest x-ray can be administered by your private physician or at the County
Tuberculosis Clinic located on the ground floor of the Bell Greve Building at Cleveland MetroHealth
Medical Center. The telephone number is (216) 778-3097. An appointment is required. The PPD is
also available at the CSU Health & Wellness Services Department.
c.
Hepatitis B – The School of Nursing strongly recommends that all nursing students receive the
Hepatitis B Vaccine. This is to be administered as a series of three injections. The date of each dose is
to be recorded on the Verification of Completed Hepatitis B Immunization form and submitted to
the School of Nursing. The vaccine is also available at the CSU Health & Wellness Services
Department.
WARNING: LATEX USE AND EXPOSURE
As a nursing student you will be exposed to latex gloves and other products containing natural
rubber latex which may cause allergic reactions such as skin rashes, hives, nasal, eye, or sinus
Page | 2
symptoms, asthma, and (rarely) shock. Do you have this allergy? Yes / No (circle one)
CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING
To be completed by a physician/nurse practitioner. Please return to:
School of Nursing
2121 Euclid Avenue, JH 238
Cleveland, OH 44115-2214
VARICELLA (CHICKEN POX) IMMUNIZATION
Student Name: __________________________________________________________
CSU ID Number: _______________________________________________________
Please provide one of the following:
Date of Illness:
_____________________
Date of Vaccination: _____________________
Date of Titer:
Results:
_____________________
 Positive
 Negative
__________________________________________________________________ _________________________________________________________________
Physician/Nurse Practitioner Name (Please Print)
Office Address
City, State
Zip Code
This information must be legible and include professional credentials.
______________________________________
______________________
Physician/Nurse Signature
Date
Place Office Stamp in the Box
on the Right for Validation:
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CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING
To be completed by a physician/nurse practitioner after the test has been read. Please
return to:
School of Nursing
2121 Euclid Avenue, JH 238
Cleveland, OH 44115-2214
TUBERCULIN MANTOUX SKIN TEST OR CHEST X-RAY
Student Name: __________________________________________________________
CSU ID Number: _______________________________________________________
Date administered:
____________________
Date read:
____________________
Results:
 Positive
 Negative
___________________________________________________________________ ________________________________________________________________
Physician’s//Nurse Practitioner’s Name (Please Print)
Office Address
City, State
Zip Code
This information must be legible and include professional credentials.
______________________________________
______________________
Physician/Nurse Signature
Date
If chest x-ray is needed, you must attach a copy of the results with this form. Documentation must include
date X-ray was read and the name and credentials of the individual who read the X-Ray.
Place Office Stamp in the Box
on the Right for Validation:
Page | 4
CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING
To be completed by physician or nurse. Please return to:
School of Nursing
2121 Euclid Avenue, JH 238
Cleveland, OH 44115-2214
HEPATITIS B IMMUNIZATION
Student Name: _______________________________________________
CSU ID Number: ____________________________________________
Physician/Nurse Practitioner Name & Credentials (Please Print):
Date of First Dose
Physician/Nurse Practitioner Signature
Date
Physician/Nurse Practitioner Name & Credentials (Please Print):
Date of Second Dose
Physician/Nurse Signature
Date
Physician/Nurse Practitioner Name & Credentials (Please Print):
Date of Third Dose
Physician/Nurse Signature
Date
Physician/Nurse Practitioner Name & Credentials (Please Print):
Date of Titer
Results
Physician/Nurse Signature
Date
* * * EVIDENCE OF EACH DOSE MUST BE SUBMITTED TO THE SCHOOL OF NURSING * * *
Place Office Stamp in the Box
on the Right for Validation:
Page | 5
CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING
Insurance & RN License Requirements and Forms:
Student Liability Insurance

Cleveland State University covers students through a blanket student liability insurance plan when they are
enrolled in the nursing program while participating in clinical experiences under the direction, supervision,
and control of the Cleveland State University School of Nursing. The limits of liability are $1,000,000 each
claim, $3,000,000 aggregate.
o All students enrolled in a CSU Master of Science in Nursing Program will be covered with this
insurance when the Semester registration is paid.
Health Insurance Verification

Each student must carry some form of health insurance for his/her own protection.

The student may obtain insurance from a private agency or participate in CSU’s Student Health Insurance
Plan. Insurance plan brochures are available in the Health & Wellness Services Department, 1836 Euclid
Avenue, 2nd Floor or on their website: www.gmsouthwest.com/schools/csu

Please document below information related to your Health Insurance coverage.
Student’s Name
(Last, First, M.I.)
CSU I.D. Number
Policy Holder’s Name (if different from Student): __________________________________
Company Name: ____________________________________________________________
Dates of Coverage: ______________________________________________
Policy Number: _________________________________________________
Group Number: _________________________________________________
RN License and Registration Verification:


All students enrolled in a CSU Master of Science in Nursing Program are required to maintain a valid active
RN License from their state of residence. A valid active RN License Number must be on file in the School of
Nursing at all times; the current date must be within the ‘Issue’ and ‘Expiration’ date range to be considered
active.
Please document below information related to your license and update accordingly.
RN License #
State Issued
Date Issued
Expiration Date
Page | 6
CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING
Additional Clinical Agency Requirements:
In addition to the other requirements addressed in this packet, agencies also require every nursing student to
submit proof of a clean background check and current CPR Certification—Basic Life Support for Health Care
Provider.
Fingerprinting and Background Check

If you have been fingerprinted within the past 12 months, please provide an official copy of the results.

It is in your best interest to complete your background check as early as possible, as it usually takes between
three to six weeks for us to receive your results.

If you are a U.S. Citizen who has lived in your current state of residence for five (5) or more years you
are only required to provide the Civilian (BCI) Check.

If you are a U.S. Citizen who has lived in your current state of residence for fewer than five (5) years or
you are NOT A U.S. Citizen:
o You are required to provide BOTH a Civilian (BCI) Check & Federal (FBI) Check
Fingerprinting Locations
Off Campus (Outside Ohio)

Contact your state’s authorized background check program for Civilian (BCI) Check
Off Campus (Ohio) – National WebCheck



www.OhioAttorneyGeneral.gov/WebCheck
1-800-282-0515
You will be given a list of Deputy Registrar locations across Ohio
On CSU Campus – Julka Hall (JH), room 170-A



(216) 687-4625
Monday – Thursday 9:00am – 12:00 pm and 1:00 pm – 4:00 pm
Follow these steps:
 Bring invoice below to the Office of Treasury Services in Main Classroom (MC), room 115
 Pay the fee
 Take your receipt, driver’s license/state ID, and a completed Request for a Background
Check via Electronic Fingerprinting form to Julka Hall (JH), room 170-A to be
fingerprinted.
Cleveland
State
University
 Results are sent directly
to the
School
of
College of Education and Human Services
Electronic Fingerprinting Invoice
BCI: $35.00
FBI: $40.00
BCI & FBI: $75.00
ACCOUNT#: 0060-0010-0512-40-Lab_Fees
Page | 7
CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING
On CSU Campus (continued):
Page | 8
CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING
Cardiopulmonary Resuscitation
All students are required to maintain CPR certification – Basic Life Support (BLS) for the Healthcare Provider.
You may complete the course through any providers authorized by the American Heart Association.
o You must submit documentation of current CPR certification.
o If you have already completed the correct course within the past twelve months, please provide
documentation.
o Your CPR certification for Healthcare Provider MUST BE renewed every twenty four (24) months.
A copy of your two-year re-certification card must be submitted upon completion of the course
biennially.
CPR Locations
Off Campus (Outside Ohio)

Contact any local provider authorized by the American Heart Association.
Off Campus (Ohio) – CPR Ohio



www.cprohio.com
(216) 251-0747
15480 Triskett Avenue, Cleveland, OH 44111
On CSU Campus – Sigma Theta Tau, International
Nu Delta Chapter


http://www.csuohio.edu/nursing/progandhealth.html
(216) 875-9874
Page | 9
STUDENT OR ON-SITE FACULTY WAIVER
Clinical training in a health care setting assumes certain risks, including the possibility of exposure to an infectious disease, injury from equipment or
medical materials, and illness or injury to oneself, employees, patients or visitors. I understand that The Cleveland Clinic, d/b/a/ Cleveland Clinic Health
System and its member hospitals and their affiliates (the “Clinical Site(s)”) do not provide any accident, malpractice, health, medical, or workers’
compensation insurance coverage for any illness or injury I may acquire or cause at a Clinical Site. I acknowledge and as consideration for the
opportunity to participate in clinical training at Clinical Sites, I hearby waive, for myself or any heirs and/or assigns, any and all claims which I might
have against the Clinical Site, or its agents or representatives, in any way resulting from personal injuries, illness, or property damage sustained by me
and arising out of my participation in the Training Program at the Clinical Site, except for claims arising out of the gross negligence or reckless or willful
misconduct of the Clinical Sites or their employees.
In the event I am exposed to blood or other bodily fluids from a patient who is a carrier of a contagious or infectious disease or a patient who is, in the
judgment of the Clinical Site, at risk of carrying a contagious or infectious disease, Clinical Site shall, with my consent, either administer immediate
precautionary treatment consistent with current medical practice or refer me to an Emergency Room. I shall pay for the initial screening tests or
prophylactic medical treatments. Clinical Site shall have no responsibility for any further diagnosis, medication or treatment and I acknowledge and
assume the risk or working with patients at risk of carrying a contagious or infectious disease, except for the risk of gross negligence or willful or
reckless misconduct on the part of the Clinical Site, its trustees, officers, agents, and employees.
CONFIDENTIALITY AND NON-DISCLOSURE STATEMENT
It is understood that during the course of my participation in the Training Program at Clinical Site, I may obtain confidential information about or from
Clinical Site (“Confidential Information”). Confidential Information includes, but is not limited to, financial or proprietary data about Clinical Site,
information about Clinical Sites’ business and employees, patient information, methods of operating, development plans, programs, documentation,
techniques, trade secrets, systems, know-how, policy statements, access to proprietary software applications and databases, and other confidential data.
The information may be in the form of verbal, visual, written, or computerized data. I agree to maintain in strict confidence all Confidential Information
and will not disclose Confidential Information (including, but not limited to, PHI) to anyone, including my family and friends, under any circumstances,
unless I am required by law, or I have Clinical Site’s prior written consent. I will not make copies of Confidential Information. Prior to discussion of or
writing about any Clinical Site patient in an academic context relative to my program of study, all individually identifiable infor4mation will be removed
or the PHI will be de-identified in compliance with the requirements of the Federal Health Insurance Portability and Accountability Act of 1996
(HIPPA).
I agree to maintain patient confidentiality in both written and verbal communication with other students, instructors, any other individuals, in clinical
rounds or class discussion, as well as in any published materials. I understand that patient confidentiality is of such great importance that PHI is NEVER
to be shared with anyone even if it is years after I participate in the Training Program.
Under the Federal Health Insurance Portability and Accountability Act of 1996 (HIPPA), Protected Health Information (“PHI”) is defined as individually
identifiable health information, which is health information created, received or used by Clinical Site relating to (a) the past, present, or future physical or
mental health or condition of a patient, or (b) payment for the provision of healthcare to a patient, PHI contains identifiers that identify a patient or for
which there is a reasonable basis to believe the information can be used to identify a patient. Examples of individual identifiers include, but are not
limited to, patient name, complete addresses, social security number, date of birth, medical record number and dates of treatment. PHI may include any
or all of these individual identifiers coupled with a patient’s health information, examples of which are a social security number and diagnosis, date of
birth and past medical history, or dates of treatment and symptoms present at the time of treatment. PHI may be accessed only by those individuals who,
with in the scope of their employment or training responsibilities have a legitimate need for such information for purposes of patient care, research,
education or administrative uses. I agree that any breach of the Agreement may cause Clinical Site substantial and irreparable damages and, therefore, in
the event of any such breach, CCF shall have the right to seek specific performance and other injunctive and equitable relief without the need to post
bond.
The acquisition release, discussion or other use of Confidential Information for purposes other than to conduct normal authorized business activities
during my training at Clinical Site is strictly prohibited. Violation of confidentiality is a very sensitive matter and will be considered grounds for removal
from the Training Program, any related employment offer and/or consideration for future employment opportunities.
I understand and agree to my obligations as stated in this signed waiver and statement and that this document shall remain in effect for the duration of my
student clinical rotations (or faculty duties) at the Clinical Sites, and that the waiver and obligations of confidentiality and non-disclosure shall remain in
effect indefinitely.
Signed:____________________________________________
Date:________________________________
__________________________________________________
[Printed Name of Student or On-Site Faculty]
School: ______________________________
Page | 10
Return to:
6/15/2012
Joyce Leonette
216-636-2190 Fax
leonetj@ccf.org
HSB-111
Cleveland Clinic Template – Student/Faculty On-Boarding
STUDENT
I.D. BADGE DATA SHEET
FIRST NAME ___________________________________________________________________
LAST NAME ____________________________________________________________________
SCHOOL _______________________________________________________________________
Job Title: STUDENT
Dept: ____________________
Clinical Rotation Period
Expiration Date: _____________
FROM: _______ / _______ / _______
TO: _______ / _______ / _______
Clinical Instructor: ___________________________ E-mail: ___________________________
VEHICLE REGISTRATION
Year: ___________ Make: _______________________ Model: ______________________
License #: _________________________
Vehicle Color: ______________________
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
The following to be completed by Protective Services
<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<
BADGE # ____________________
BADGE DESIGN:
STUDENT
VEHICLE REG.# _____________
ACCESS
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Revised 1.26.2010
DATABASE GROUP: STUDENT
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