VERIFICATION OF REQUIREMENTS for FACULTY and STUDENT CLINICAL AFFILIATES This form must be completed, signed by the appropriate school staff, and submitted to the Hospital one (1) week prior to the clinical experience. Please list students in alphabetical order by last name. HOSPITAL (Circle one): Adventist Bolingbrook Adventist Glen Oaks Adventist Hinsdale Adventist LaGrange Memorial SCHOOL: __________________________________________ DATES OF EXPERIENCE: __ __________to______________ UNIT/DEPT PROVIDING EXPERIENCE: __________________________________________________________________________ NAME: REQUIREMENTS (on file at the above named school): __________________________________ ( ) Hepatitis B vaccination & Titer (or signed declination) Instructor ( ) History of chicken pox or proof of immunity (titer or vaccination) ( ) Influenza Vaccine (after Sep 1 annually – complete separate form ) ( ) PPD (or chest X-­‐ray if positive PPD) ( ) Rubella Titer or 2 Proven MMR (Measles, Mumps, Rubella) ( ) TB Respirator Fit-­‐Tested (supply own respirator for experience) ( ) Criminal background check ( ) Current CPR Healthcare Provider Certification ( ) Liability Insurance ( ) Licensure, if applicable ( ) Negative Drug screen ( ) OSHA Bloodborne Pathogen Program 1. _______________________________ Student dmk 10-­‐12 ( ) Hepatitis B vaccination & Titer (or signed declination) ( ) History of chicken pox or proof of immunity (titer or vaccination) ( ) Influenza Vaccine (after Sep 1 annually – complete separate form ) ( ) PPD (or chest X-­‐ray if positive PPD) ( ) Rubella Titer or 2 Proven MMR (Measles, Mumps, Rubella) ( ) TB Respirator Fit-­‐Tested (supply own respirator for experience) ( ) Criminal background check ( ) Current CPR Healthcare Provider Certification ( ) Liability Insurance ( ) Licensure, if applicable ( ) Negative Drug screen ( ) OSHA Bloodborne Pathogen Program 2. _______________________________ ( ) Hepatitis B vaccination & Titer (or signed declination) Student ( ) History of chicken pox or proof of immunity (titer or vaccination) ( ) Influenza Vaccine (after Sep 1 annually – complete separate form ) ( ) PPD (or chest X-­‐ray if positive PPD) ( ) Rubella Titer or 2 Proven MMR (Measles, Mumps, Rubella) ( ) TB Respirator Fit-­‐Tested (supply own respirator for experience) ( ) Criminal background check ( ) Current CPR Healthcare Provider Certification ( ) Liability Insurance ( ) Licensure, if applicable ( ) Negative Drug screen ( ) OSHA Bloodborne Pathogen Program 3. _______________________________ ( ) Hepatitis B vaccination & Titer (or signed declination) Student ( ) History of chicken pox or proof of immunity (titer or vaccination) ( ) Influenza Vaccine (after Sep 1 annually – complete separate form ) ( ) PPD (or chest X-­‐ray if positive PPD) ( ) Rubella Titer or 2 Proven MMR (Measles, Mumps, Rubella) ( ) TB Respirator Fit-­‐Tested (supply own respirator for experience) ( ) Criminal background check ( ) Current CPR Healthcare Provider Certification ( ) Liability Insurance ( ) Licensure, if applicable ( ) Negative Drug screen ( ) OSHA Bloodborne Pathogen Program 4. _______________________________ ( ) Hepatitis B vaccination & Titer (or signed declination) Student ( ) History of chicken pox or proof of immunity (titer or vaccination) ( ) Influenza Vaccine (after Sep 1 annually – complete separate form ) ( ) PPD (or chest X-­‐ray if positive PPD) ( ) Rubella Titer or 2 Proven MMR (Measles, Mumps, Rubella) ( ) TB Respirator Fit-­‐Tested (supply own respirator for experience) ( ) Criminal background check ( ) Current CPR Healthcare Provider Certification ( ) Liability Insurance ( ) Licensure, if applicable ( ) Negative Drug screen ( ) OSHA Bloodborne Pathogen Program dmk 10-­‐12 5. _______________________________ Student 6. _______________________________ Student 7. _______________________________ Student ( ) Hepatitis B vaccination & Titer (or signed declination) ( ) History of chicken pox or proof of immunity (titer or vaccination) ( ) Influenza Vaccine (after Sep 1 annually – complete separate form ) ( ) PPD (or chest X-­‐ray if positive PPD) ( ) Rubella Titer or 2 Proven MMR (Measles, Mumps, Rubella) ( ) TB Respirator Fit-­‐Tested (supply own respirator for experience) ( ) Criminal background check ( ) Current CPR Healthcare Provider Certification ( ) Liability Insurance ( ) Licensure, if applicable ( ) Negative Drug screen ( ) OSHA Bloodborne Pathogen Program ( ) Hepatitis B vaccination & Titer (or signed declination) ( ) History of chicken pox or proof of immunity (titer or vaccination) ( ) Influenza Vaccine (after Sep 1 annually – complete separate form ) ( ) PPD (or chest X-­‐ray if positive PPD) ( ) Rubella Titer or 2 Proven MMR (Measles, Mumps, Rubella) ( ) TB Respirator Fit-­‐Tested (supply own respirator for experience) ( ) Criminal background check ( ) Current CPR Healthcare Provider Certification ( ) Liability Insurance ( ) Licensure, if applicable ( ) Negative Drug screen ( ) OSHA Bloodborne Pathogen Program ( ) Hepatitis B vaccination & Titer (or signed declination) ( ) History of chicken pox or proof of immunity (titer or vaccination) ( ) Influenza Vaccine (after Sep 1 annually – complete separate form ) ( ) PPD (or chest X-­‐ray if positive PPD) ( ) Rubella Titer or 2 Proven MMR (Measles, Mumps, Rubella) ( ) TB Respirator Fit-­‐Tested (supply own respirator for experience) ( ) Criminal background check ( ) Current CPR Healthcare Provider Certification ( ) Liability Insurance ( ) Licensure, if applicable ( ) Negative Drug screen ( ) OSHA Bloodborne Pathogen Program dmk 10-­‐12 8. _______________________________ Student ( ) Hepatitis B vaccination & Titer (or signed declination) ( ) History of chicken pox or proof of immunity (titer or vaccination) ( ) Influenza Vaccine (after Sep 1 annually – complete separate form ) ( ) PPD (or chest X-­‐ray if positive PPD) ( ) Rubella Titer or 2 Proven MMR (Measles, Mumps, Rubella) ( ) TB Respirator Fit-­‐Tested (supply own respirator for experience) ( ) Criminal background check ( ) Current CPR Healthcare Provider Certification ( ) Liability Insurance ( ) Licensure, if applicable ( ) Negative Drug screen ( ) OSHA Bloodborne Pathogen Program ________________________________ Printed Name ________________________________ Signature _________________________________ Title _________________________________ Date Forward this completed document in one of the following ways: Email to donna.kanak@ahss.org Fax to Mail to Donna M. Kanak, MS, RN Clinical Educator/QM Specialist 630-­‐856-­‐3046 Donna M. Kanak, MS, RN Clinical Educator/QM Specialist Nursing Education – Tupper Hall Adventist Hinsdale Hospital 120 N. Oak Street Hinsdale, IL 60521 dmk 10-­‐12 Permission must be obtained for bringing more than 8 students to any unit.
9. _______________________________ Student 10. _______________________________ Student ( ) Hepatitis B vaccination & Titer (or signed declination) ( ) History of chicken pox or proof of immunity (titer or vaccination) ( ) Influenza Vaccine (after Sep 1 annually – complete separate form ) ( ) PPD (or chest X-­‐ray if positive PPD) ( ) Rubella Titer or 2 Proven MMR (Measles, Mumps, Rubella) ( ) TB Respirator Fit-­‐Tested (supply own respirator for experience) ( ) Criminal background check ( ) Current CPR Healthcare Provider Certification ( ) Liability Insurance ( ) Licensure, if applicable ( ) Negative Drug screen ( ) OSHA Bloodborne Pathogen Program ( ) Hepatitis B vaccination & Titer (or signed declination) ( ) History of chicken pox or proof of immunity (titer or vaccination) ( ) Influenza Vaccine (after Sep 1 annually – complete separate form ) ( ) PPD (or chest X-­‐ray if positive PPD) ( ) Rubella Titer or 2 Proven MMR (Measles, Mumps, Rubella) ( ) TB Respirator Fit-­‐Tested (supply own respirator for experience) ( ) Criminal background check ( ) Current CPR Healthcare Provider Certification ( ) Liability Insurance ( ) Licensure, if applicable ( ) Negative Drug screen ( ) OSHA Bloodborne Pathogen Program ________________________________ Printed Name ________________________________ Signature _________________________________ Title _________________________________ Date dmk 10-­‐12