INSTRUCTIONS
Every Allied Health Program has Clinical Requirements with different cover pages.
Please find your program below and see what is required so you can print the correct forms.
Once you find your program below, please print off the required forms.
PLEASE MAKE SURE YOU MAKE COPIES OF ALL FORMS OR DOCUMENTS BEFORE SUBMITTING TO THE CLINICAL ADMISSIONS COORDINATOR
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GHO (General Hospital Orientation)
CPR/BLS
PHYSICAL
PPD
CHEST X-RAY
SYMPTOM ASSESSMENT
TDAP
FLU
HEP B
MMR
VARICELLA
PREGNANCY
INSURANCE
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South Carolina Passport Project
You will use careLearning to complete your required training before reporting to a hospital to begin clinical
rotation. You can create a new account or re-use your existing account at: http://passport.carelearning.com.
Here is some supplementary information:
1. When you begin this process, it will be easiest if you have access you to your email account (Wavenet
Email), as the program will require you to verify your account during the process.
2. You will purchase courses for $10.00 and have access to them for 365 days.
3. Your classroom will automatically be populated with the courses that are common to all students. However, in
most cases you will be required to also complete education specific to the hospital that you are reporting to for
clinical rotation. You will be able to add those to your classroom as you need them.
Below are the 15 modules that need to be completed for Horry Georgetown Technical College:
Abuse & Neglect
AIDET
Bloodborne Pathogens
Culturally Competent Care
Disaster Preparedness
Electrical Safety
Fire Safety
Hand Hygiene
Hazard Communications
HIPPA
Isolation ad Standard Precautions
Lewis Blackman Patient Safety Act
Moving, Lifting and Repetitive Motion



You will need to manually add these two modules:
Tidelands, Conway, Grand Strand, Waccamaw (GHO)
Tidelands Health – Ebola Prepareness
4. To be considered compliant in your state you must complete the courses each year no more than 365 days
apart.
5. The school or hospital you report to may request that you re-purchase earlier than when your classroom
expires so that you are compliant in your training for the full semester.
(Example: If you completed the courses in October of last year, you may be required to take them again
upon your return to school in August so that you will not expire mid-semester.)
6. Should you experience difficulty, please contact us at 866-617-3904 or email
support@carelearning.com Monday-Friday 8am-6pm.
7. You must remit copies of your transcripts along with the five confidentiality forms that
will be accessible at the conclusion of the Tidelands (GHO) module.
Tidelands Health
Confidentiality Agreement
Employee Name (Please Print)
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In consideration of my access to records maintained at Tidelands Health (GHS), whether in paper or electronic form, I agree to be bound by the following
terms and conditions during my employment at Tidelands Health.
1.
I understand that my computer password is unique to me. I will not disclose it, or permit others to use it. If my password becomes known to any other
person or group by reason of disclosure, I shall inform Information Systems immediately. Use of the software or documentation provided by Tidelands
Health is limited to the person authorized by this agreement. I will not remove any materials from the premises for use on any other computer.
2.
GHS communication systems are considered Tidelands Health property and meant for business use only. Employees shall have no expectation of privacy
while using company property, even if using a password. I understand that all communication systems and files are subject to monitoring. I understand that
GHS is authorized to monitor oral, electronic and written communications for “business use only” purposes. GHS is permitted to monitor systems such as
phone use, voice mail, computer network, and Internet use, and will also include other communication systems, as necessary. Non-business use of Internet
or e-mail is prohibited.
3.
Tidelands Health prohibits transmission, downloading, or access to offensive or improper (as determined by the Administrative Compliance
Committee) material.
4.
My authorization to use the electronic information systems at Tidelands Health is limited to specific information required in the performance of my duties. I
understand that accessing phi in electronic or printed form for reasons other than treatment, payment, or operations is prohibited by federal HIPAA
regulations.
5.
I understand that any information I may access is to be kept strictly confidential and is the proprietary property of Tidelands Health.
6.
Failure to comply with the terms hereof may result in disciplinary action up to and including termination of my employment with Tidelands Health.
7.
I agree to abide by the confidentiality laws of the State of South Carolina and of the United States.
8.
NEITHER THIS AGREEMENT NOR ANY PROVISION OF THIS AGREEMENT CONSTITUTES AN EMPLOYMENT CONTRACT OR ANY
OTHER TYPE OF CONTRACT. YOUR EMPLOYMENT RELATIONSHIP WITH TIDELANDS HEALTH IS FOR AN INDEFINITE PERIOD AND
EITHER YOU OR TIDELANDS HEALTH MAY TERMINATE THE RELATIONSHIP AT ANYTIME, FOR ANY
REASON NOT PROHIBITED BY LAW.
Student Signature
Print Name:
____
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HR\WCH\GMH FORMS
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Date _____
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EXHIBIT A
(GSRMC)
STATEMENT OF RESPONSIBILITY
For and in consideration of the benefit provided the undersigned in the form of experience in a clinical setting at Grand Strand Regional Medical Center,
LLC d/b/a Grand Strand Regional Medical Center (“Hospital”), the undersigned and his/her heirs, successors and/or assigns do hereby covenant and agree
to assume all risks and be solely responsible for any injury or loss sustained by the undersigned while participating in the Program operated by Horry
Georgetown Technical College (“School”) at Hospital unless such injury or loss arises solely out of Hospital’s gross negligence or willful misconduct.
Signature of Program Participant/Print Name
Date
Parent or Legal Guardian if Program Participant is under 18/Print Name
Date
EXHIBIT B (GSRMC)
PROTECTED HEALTH INFORMATION, CONFIDENTIALITY, AND SECURITY AGREEMENT
•
Protected Health Information (PHI) includes patient information based on examination, test results, diagnoses, response to treatment, observation, or conversation
with the patient. This information is protected and the patient has a right to the confidentiality of his or her patient care information whether this information is in
written, electronic, or verbal format. PHI is individually-identifiable information that includes, but is not limited to, patient’s name, account number, birth-date,
admission and discharge dates, photographs, and health plan beneficiary number.
•
Medical records, case histories, medical reports, images, raw test results, and medical dictations from health care facilities are used for student learning activities.
•
Students enrolled in school programs or courses and responsible faculty are given access to patient information. Students are exposed to PHI during their clinical
Although patient information is removed, all healthcare information must be protected and treated as confidential.
rotations in healthcare facilities.
•
Students and responsible faculty may be issued computer identification (IDs) and passwords to access PHI.
Initial each to accept the Policy
Initial
Policy
1.
It is the policy of the school/institution to keep PHI confidential and secure.
2.
Any or all PHI, regardless of medium (paper, verbal, electronic, image or any other), is not to be disclosed or discussed with
anyone outside those supervising, sponsoring or directly related to the learning activity.
3.
Whether at the school or at a clinical site, students are not to discuss PHI, in general or in detail, in public areas under any
circumstances, including hallways, cafeterias, elevators, or any other area where unauthorized people or those who do not have
a need-to-know may overhear.
4.
Unauthorized removal of any part of original medical records is prohibited. Students and faculty may not release or display
copies of PHI. Case presentation material will be used in accordance with healthcare facility policies.
5.
Students and faculty shall not access data on patients for whom they have no responsibilities or a “need-to-know” the content
of PHI concerning those patients.
6.
A computer ID and password are assigned to individual students and faculty. Students and faculty are responsible and
accountable for all work done under the associated access.
7.
Computer IDs or passwords may not be disclosed to anyone. Students and faculty are prohibited from attempting to learn or
use another person’s computer ID or password.
8.
Students and faculty agree to follow Hospital’s privacy policies.
9.
Breach of patient confidentiality by disregarding the policies governing PHI is grounds for dismissal from Hospital.
•
I agree to abide by the above policies and other policies at the clinical site. I further agree to keep PHI confidential.
•
I understand that failure to comply with these policies will result in disciplinary actions.
•
I understand that Federal and State laws govern the confidentiality and security of PHI and that unauthorized disclosure of PHI is a violation of law and may result in
civil and criminal penalties.
Signature of Program Participant/Print Name
Date
Parent or Legal Guardian if Program Participant is under 18/Print Name
Date
Conway Medical Center
CONFIDENTIALITY AND SECURITY AGREEMENT
I understand that Conway Medical Center and its affiliate organizations, (hereinafter “CMC”) in which or
for whom I work, volunteer or provide services, or with whom the entity (e.g., physician practice) for which I
work has a relationship (contractual or otherwise) involving the exchange of health information, CMC,
has a legal and ethical responsibility to safeguard the privacy of all patients and to protect the confidentiality
of its patients’ health information. Additionally, CMC must assure the confidentiality of its human
resources, payroll, fiscal, research, internal reporting, strategic planning, communications, computer
systems and management information (collectively, with patient identifiable health information
“Confidential Information”).
In the course of my employment/assignment or association with CMC, I understand that I may
come into the possession of this type of Confidential Information. I will access and use this information
only when it is necessary to perform my job related duties in accordance with CMC’s Privacy and
Security Policies, which are available from CMC. I further understand that I must sign and comply
with this Agreement in order to obtain authorization for access to Confidential Information.
1. I will not disclose or discuss any Confidential Information with others, including friends or family, who do
not have a need to know it.
2. I will not in any way divulge copy, release, sell, loan, alter, or destroy any Confidential Information except as
properly authorized.
3. I will not discuss Confidential Information where others can overhear the conversation.
4. I will not make any unauthorized transmissions, inquiries, modifications, or purging of Confidential Information.
5. I agree that my obligations under this Agreement will continue after termination of my employment, expiration of
my contract, or my relationship ceases with CMC.
6. Upon termination of any relationship with CMC, I will immediately return any documents or media containing
Confidential Information to CMC.
7. I understand that I have no right to any ownership interest in any information accessed or created by me during
my relationship with CMC.
8. I will act in the best interest of the CMC and in accordance with its Code of Conduct at all times during my
relationship with CMC.
9. I understand that violation of this Agreement may result in the disciplinary action, corrective action, up to
and including termination of employment, suspension, and loss of privileges, and/or termination of authorization
to work within CMC, in accordance with CMC’s policies.
10. I will only access or use systems or devices I am officially authorized to access, and will not demonstrate the
operation or function of systems or devices to unauthorized individuals.
1
11. I understand that I should have no expectation of privacy when using the CMC information systems. CMC may
access, review, and otherwise utilize information stored on or passing through its systems, including e-mail, in order
to manage systems and enforce security.
12. I will practice good workstation security measures such as locking up diskettes when not in use, using hospital
approved screen savers with activated passwords appropriately, and position screens away from the public view.
13. I will practice secure electronic communications by transmitting Confidential Information only to authorized entities,
in accordance with approved standards.
14. I will:
a. Use only my officially assigned User-ID and password.
b. Use only approved licensed software.
c. Use a device with virus protection software.
d. Contact the Information Technology department if my password is accidentally revealed to request a new password.
15. I will never:
a. Share/disclose user- IDs or passwords.
b. Use tools or techniques to break/exploit security measures.
c. Connect to unauthorized networks through the systems or devices.
d. Install unauthorized software on hospital computer systems.
16. I will notify my manager or appropriate Information Technology person if my password has been seen, disclosed,
or otherwise compromised, and will report activity that violates this agreement, privacy, and security policies,
or any other incident that could have any adverse impact on Confidential Information.
The following statements are additional requirements for physicians using CMC systems containing patient
identifiable health information (e.g., Meditech):
17. I will only access software systems to review patient records when I have that patient’s consent to do so. By
accessing a patient’s record, I am affirmatively representing to CMC at the time of each access that I have the
requisite patient consent to do so, and CMC may rely on that representation in granting such access to me.
18. I will only access patient information to the extent it is reasonable and necessary for me to treat a patient. The
information that I review will be kept confidential, and I will only review so much of a patient’s medical record as is
necessary for me to render appropriate treatment. If I am given access to a patient’s medical record due to a consult,
emergency situation, or an on-call situation at which time I am not the patient’s primary attending physician, I will only
access that patient’s information to the extent it is needed for me to render appropriate medical treatment. Under no
circumstances will I access a patient’s information without a patient’s verbal or written consent or for whom I am not
rendering medical treatment.
19. I will ensure that only appropriate personnel in my office will access the CMC’s software systems and Confidential
Information and that I will annually train such personnel on issues related to patient confidentiality and access.
20. I will accept full responsibility for the actions of my employees who may access the CMC’s software systems and
Confidential Information
By signing this document, I acknowledge that I have read this Agreement and I agree to comply with all the terms and conditions stated above.
Employee/Consultant/Vendor/Office Staff/Physician Signature
Facility Name
Date
Employee/Consultant/Vendor/Office Staff/Physician Printed Name
Business Entity Name
2
Please enter name, H# and program before printing this form.
Student Name: ____________________________
Student H#________________________________
Program: __________________________________
Health Science Division – Student Health Record
CPR FORM
CPR REQUIREMENT:

Basic Life Support Certification for the Healthcare Provider by American Heart Association (AHA) or
American Red Cross (ARC) only

Requires successful completion of cognitive and skills demonstration for healthcare provider (Adult,
Child, Infant, and Choking Skills)

Must renew CPR certification every 2 years
CPR Completion Date:
Certifying Agency:
 AHA
Instructor’s Initials
Expiration Date:
 ARC
Certification:
Signature below indicates verification of above initials in student completion of stated CPR requirement
___________________________________________________________________________________
Printed Name
Signature
Title (RN, NP, MD)
CPR Instructor Affiliation ______________________________________________________________
NOTE: This form serves as temporary documentation for CPR. As soon as the actual card arrives, the
student is responsible to provide copy of the card, which will replace this form.
Form 2; revised 10/31/2011
CPR Information
Class Must Be CPR/BLS (Basic Life Support)
Horry Georgetown Technical College - Continuing Education
Betty Turner, Program Manager
743 Hemlock Avenue, Bldg. 200 Suite 108
Myrtle Beach, SC 29577
843-477-2020 or 843-477-2079
Betty.Turner@hgtc.edu
Dates of CPR classes for 2016 can be found at www.hgtc.edu/jobtraining
Students must bring own book and mask.
Cost: $69.00
_______________________________________________________________________________________________________________________________
Advance Medical Transport, LLC
Andrew Brown, NRP - Training/Compliance Manager
875 Nicholas Street, Suite A
Murrells Inlet, SC 29576
843-340-0109 or 843-957-0124
Brown.a@4uamt.com
Teaches full classes as well as individual skills checks
Dates of CPR classes in 2015:
January 6 and 23
Feb. 10 and 20
March 9 and 31
June 2 and 16
July 7 and 23
August 6 and 13
Nov. 16 and 23
Dec. 8, 16 and possibly 29
April 6 and 23
Sept. 8 and 15
May 5 and 12
Oct 5 and 14
Dates of CPR classes in 2016: TBD (Please call Andrew Brown to inquire)
Students must register at least 1-week prior to the scheduled class.
Students must bring own book.
Cost: $45.00
______________________________________________________________________________________________________________________________
Tina Bussa
Cost - $40.00
Contact: bussatina@gmail.com
_______________________________________________________________________________________________________________________________
Joanne Clarey
843-545-3400 Ext. 3407
jclarey@georgetowncountysc.org
BLS for Healthcare
Providers Skills Sessions
Grand Strand Regional Medical Center
Training Center ID: SC05817
2000 Coastal Grand Cir Suite 520
Myrtle Beach, SC 29577
USA
843-839-9933
Horry County Fire & Rescue
Training Center ID: SC20285
2560 Main St Suite 1
Conway, SC 29526-3756
USA
843-915-7289
https://www.horrycountyfirerescue.com
Midway Fire Department
Training Center ID: SC05971
112 Beaumont Dr
Pawleys Island, SC 29585-7589
USA
843-545-3620 cgilmore@gtcounty.org
http://www.midwayfirerescue.org
McLeod Regional Medical Center
Training Center ID: SC15248
555 E Cheves St
Florence, SC 29506
USA
843-667-2000
Pee Dee Regional CTC Training Center
ID: SC05608
1209 W Evans St
Florence, SC 29501-3406
USA
8436654671 carolinacenter@bellsouth.net
http://PDCTC.COM
Pee Dee Regional EMS Training Center
ID: SC15505
1314 W Darlington St
Florence, SC 29501-2122
USA
8436625771 www.pdrems.com
http://www.pdrems.com
Robeson Community College
Training Center ID: NC05367
US301 N & I-95
Lumberton, NC 28359
USA
910-272-3408
fgwillia@robeson.cc.nc.us
Southeastern Regional Medical Center
Training Center ID: NC06011
PO Box 1408
Lumberton, NC 28359
USA
910-671-5805
pitman01@srmc.org
Student Name: ________________________________
Student H#___________________________________
Program: ____________________________________
Health Science Division – Student Health Record
DIRECTIONS:
Please print in ink or type Section I before going to your physician for examination. Be sure to answer all questions fully
and include your name at the top of each page. Health information, including immunization records will be released to
authorized clinical agencies with your consent (as designated by your signature on page 2). Students will not receive
clearance for clinical without a complete record. Students must submit the completed “Student Health Record” prior to
program matriculation. If you have questions concerning a disability, or if requesting reasonable accommodations
contact Student Counseling Services at 349-5302. If requesting accommodations, you must provide appropriate medical,
psychological and/or psychiatric documentation to support this request. A copy of immunizations/titer lab results must
accompany this form.
SECTION I (to be completed by student)
Name:
(Last)
(First)
(Middle)
Other Name(s) Student Known As:
Birthdate:
Home Address:
(Street)
(City)
(State)
(Zip)
Telephone:
(Home)
(Cell)
Past Medical History:
Have you had?
Rubeola
Rubella
Mumps
Chicken pox (MD documented)
Infectious Mono
Positive TB Skin Test
Recurrent Herpes Viruses
Sexually Transmitted Disease
Heart disease
Heart murmurs
Mitral Valve Prolapsed
High Blood Pressure
Rheumatic fever
Diabetes
Kidney/Bladder Abnormality
Form 3a; Revised 11/09/2015
(Work)
ALLERGIES:
Yes
No
Have you had?
Stomach/Intestinal Abnormality
Arthritis
Asthma
Hay fever
Color blindness
Recurrent headaches
Back problems
Organ transplant
Insomnia
Frequent Anxiety
Frequent Depression
Worry or Nervousness
Hepatitis (specify: A,B,C,D,E)
Epilepsy/Convulsions
Other (explain below):
Yes
No
1
Student Name: ________________________________
Student H#___________________________________
Program: ____________________________________
Health Science Division – Student Health Record
If you answered “yes” to any question, please give dates and treatments:
Please list any other medical conditions not addressed above:
Please list all medications that you are currently taking:
Student Signature
Date
SECTION II: Physical Examination (To be completed by the physician, physician assistant, or nurse practitioner)
Directions: Please review Section I completed by the student and then complete all of the following items in Section II.
Height:
Corrected Vision:
Weight:
Blood pressure:
Pulse:
RIGHT: 20/
LEFT: 20/
Respirations:
Temp:
Hearing: (Please circle)
RIGHT: Normal Impaired
LEFT: Normal Impaired
A. Does the student have any abnormalities in the following systems? (Give dates, description of abnormality and
treatment of ALL findings - see below)
System
Eyes
Ears
Nose, throat
Neurological
Respiratory
Cardiovascular (including murmurs)
Gastrointestinal
Yes
No
System
Musculoskeletal
Metabolic/Endocrine
Genitourinary
Skin
Immunological
Psychiatric
Other (please explain)
Yes
No
B. If you have answered “yes” to any item in A above, please complete the following: (Additional information may be
provided on a separate page identified with student’s name).
Date
Diagnosis
Form 3a; Revised 11/09/2015
Treatment
Restrictions/Limitations
(Bending, lifting, pulling, etc.)
2
Student Name: ________________________________
Student H#___________________________________
Program: ____________________________________
Health Science Division – Student Health Record
ESSENTIAL FUNCTIONS REQUIRED OF STUDENTS FOR ADMISSION AND PROGRESSION IN THE
(PROGRAM NAME)
The following standards are considered essential criteria for participation in the Allied Health Programs. Students
selected for Allied Health programs must be able to independently engage in educational activities and clinical training
activities in a manner that will not endanger clients/patients, other students, staff members, themselves, or the public.
These criteria are necessary for the successful implementation of the clinical objectives of the Allied Health Programs. In
order to be admitted, or to be retained in the Allied Health Programs after admission, all applicants with or without
accommodations must (by initialing the items you agree the student will be able to perform the function):

Possess sufficient visual acuity to independently read and interpret the writing of all size.

Independently be able to provide verbal communication to and receive communication from
clients/patients, members of the health care team, and be able to assess care needs through the use of
monitoring devices, stethoscopes, infusion pumps, fire alarms, and audible exposure indicators, etc.

Possess sufficient gross and fine motor skills to independently position and assist in lifting client/patients,
manipulate equipment, and perform other skills required in meeting the needs of nursing care.

The student (Observer) is free of communicable illnesses
Does the student have any restrictions/limitations?
If yes, how many weeks are restrictions/limitations in effect:
If yes, what date will the restrictions/limitations be lifted:
If yes, will the student be required to follow-up with your office:
If yes, date of scheduled appointment for follow-up:
Yes
________
No
________
Yes
________
No
________
I hereby certify to the best of my knowledge that the preceding information is complete and accurate.
Print Name of Physician, Physician Assistant, or Nurse Practitioner
Date
Signature of Physician, Physician Assistant, or Nurse Practitioner
Date
Form 3a; Revised 11/09/2015
3
Student Name: ________________________________
Student H#___________________________________
Program: ____________________________________
Health Science Division – Student Health Record
NOTE: Some allied health programs may have additional requirements. Individual students assume responsibility for
ensuring all requirements have been met according to the designated curriculum for the program of which he/she is
seeking entry.
MANDATORY HEPATITS B VACCINE/DECLINATION
Instructions:
Check the appropriate box(es) to indicate your compliance with the Hepatitis B requirement (if you have not
completed the entire series, please check the first two boxes).
DECLINATION

I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at
risk of acquiring Hepatitis B virus (HBV) infection. I have been informed of the opportunity to be vaccinated with
Hepatitis B Vaccine. However, I decline Hepatitis B vaccination at this time. I understand that by declining this
vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future, I continue to have
occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with
Hepatitis B vaccine, I will make arrangements at that time.
SERIES IN PROGRESS

* I am in the process of receiving the Hepatitis B Vaccine and will provide documentation of all three vaccinations
as they are completed.
SERIES COMPLETED

I have completed the series of three vaccinations (submit via immunization record or form 7)
Student Signature
Form 3a; Revised 11/09/2015
H#
Date
4
Please enter name, H# and program before printing this form.
Student Name: ___________________________
Student H#_______________________________
Health Science Division – Student Health Record
Program: ________________________________
WAIVER OF REPEAT PHYSICAL EXAMINATION
I, _________________________________________________, as a student enrolled in a Health Science
Division Program at Horry-Georgetown Technical College, do hereby declare that I have sustained no
changes in my physical health condition from my initial student health examination required for
program admission.

It is my understanding that in the event a physical health change occurs, it is my responsibility to
immediately notify the following individuals of such change(s):
1. Primary Course instructor and Clinical Instructor
2. Health Record Coordinator

Following notification of health physical change(s), it is my responsibility to:
1. Make an appointment with a healthcare provider for physical examination and
completion of a new Health Science Division – Student Health Record (form 3a)
2. Provide completed form 3a to the Health Record Coordinator for verification of
current eligibility for clinical without restrictions (specifically page 3 of health record).

If restrictions are indicated on form, the Health Record Coordinator will notify the student’s
designated Program Coordinator for guidance regarding further clinical continuation.

In the event I fail to notify the appropriate individuals of such health changes, HGTC Allied Health
Division is released from all liability relevant to my physical health status, and such failed actions on
my behalf may result in dismissal from the program of study and/or constitute legal action thereof.
Printed Name
Form 3b; Revised 10/31/2011
Signature
Date
1
Student Name: _____________________________
Student H#_________________________________
Health Science Division – Student Health Record
Program: __________________________________
Purified Protein Derivative (PPD) / Tuberculin Skin Test (TST) Form
All information must be completed or it will not be accepted. PPDs must be read within 48-72 hours of administration.
Date/Time
Given
PPD
Step 1
Step 2
Semester
Injection
Site
Lot # &
Manufacturer
Expiration
Result
Induration
 Negative
Positive
______mm
 Negative
Positive
______mm
 Negative
Positive
______mm
Date/Time
Read
Initials

An initial 2-Step PPD and Semester PPDs are required for all Allied Health programs.

Step 2 should administered 7 days after the completion of Step 1 being read.

Semester PPD must be administered and read within 30-days prior to the start of each semester.

If PPD result is POSITIVE (>10 mm induration), student must provide proof of negative CXR.

If Positive PPD – documentation from physician stating any further care is required.
------------------------------------------------------------------------------------------------------------------------------------------------Certification: Signature below indicates verification of above initials in administration of PPD/TST.
Signature: _____________________________________________________________________________
Signature: _____________________________________________________________________________
Signature: _____________________________________________________________________________

Documentation may be provided on other forms or records but must meet the stated guidelines for
clinical clearance.
Form 4a; Revised 03/10/2016
Please enter name, H# and program before printing this form.
Student Name: _____________________________
Student H#_________________________________
Health Science Division – Student Health Record Program: __________________________________
CHEST X-RAY FORM
(Required with 1st time positive PPD)
CXR Date: ________________ Result: _____________________________ Initials: __________
NOTE: Copy of actual result must be attached.
If CXR is NEGATIVE, student must complete an ANNUAL SYMPTOM ASSESSMENT (form 4c).
If CXR is POSITIVE, student will be referred to DHEC for treatment (if applicable) according to DHEC
guidelines. Clearance from primary care provider is required for return to clinical setting if student
was referred for positive CXR.
Certification:
Signature below indicates verification of above initials in administration of/and reporting result of
CXR
______________________________________________________________________________
Signature
Title (RN, NP, MD)
______________________________________________________________________________
Signature
Title (RN, NP,MD)
______________________________________________________________________________
Signature
•
Title (RN, NP, MD)
Documentation may be provided on other forms or records but must meet the stated
guidelines for clinical clearance
Form 4b: revised 10/31/2011
Please enter information into the form before printing. Remember to sign and date the form after printing.
Student Name: ________________________________
Student H#___________________________________
Health Science Division – Student Health Record
Program: ____________________________________
ANNUAL SYMPTOM ASSESSMENT
Instructions:
Complete this form ONLY if you had a Positive (+) Tuberculin Skin Test with a Negative (-) CXR.
Date: _______________ Date of Positive PPD: ______________ Date of Negative CXR: _______________
Have you been treated with tuberculosis medication?
Yes
No
Have you ever received a BCG (tuberculosis vaccine)?
Yes
No
Have you been exposed to an isolated case of TB this year?
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Do you have any of the following?
• Productive cough (> 3 weeks)
•
Persistent weight loss without dieting
•
Persistent low-grade fever
•
Night sweats
•
Loss of appetite
•
Swollen glands in the neck
•
Recurrent kidney or bladder infections
•
Coughing up blood
•
Shortness of breath
•
Chest pain
If you answered “YES” to any of the above questions, please explain:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
(Note: Clearance from a primary care provider, which may include repeat CXR, is required prior to clinical
attendance if you answered “YES” to any of the above questions).
Student’s Signature: _________________________________________
Form 4c; revised 10/31/2011
Date: __________________
Please enter name, H# and program before printing this form.
Student Name: ___________________________
Student H#_______________________________
Health Science Division – Student Health Record
Program: _________________________________
Tetanus, Diptheria, Pertussis (TDAP) Form
Injection
Lot #
Manufacturer:
Expiration:
Injection Site:
Date
Initials
1.
Booster
Certification:
Signature below indicates verification of above initials in administration of TdaP immunization.
________________________________________________________________________________________
Signature
Title (MD, NP, RN)
________________________________________________________________________________________
Signature
Title (MD, NP, RN)
________________________________________________________________________________________
Signature
•
Title (MD, NP, RN)
Documentation may be provided on other forms or records but must meet the stated guidelines for
clinical clearance.
Form 6; Revised 10/31/2011
Please enter name, H# and program before printing this form.
Student Name: ___________________________
Student H#_______________________________
Health Science Division – Student Health Record
Program: _________________________________
INFLUENZA FORM
(Influenza A/B; H1N1 Combination Vaccine)
Injection 1 (Lot Number): __________________ Date: ______________ Initials:_____________
Expiration Date: ______________ Manufacturer: ______________ Injection Site: _____________
Certification:
Signature below indicates verification of above initials in administration of, or reporting of,
documented result for Influenza Immunization(s).
_____________________________________________________________________________
Signature
Title (MD, NP, RN)
_____________________________________________________________________________
Signature
Title (MD, NP, RN)
_____________________________________________________________________________
Signature
•
Title (MD, NP, RN)
Documentation may be provided on other forms or records but must meet the
stated guidelines for clinical clearance
Form 5; Revised 10/31/2011
Please enter name, H# and program before printing this form.
Student Name: ___________________________
Student H#_______________________________
Health Science Division – Student Health Record
Program: _________________________________
HEPATITIS B FORM
Injection
Lot #
Manufacturer:
Expiration:
Injection Site:
Date
Initials
1.
2.
3.
Or
Hepatitis B Titer Result: _______________________ Date: _____________________ Initials: ____________
Or
Declination/Waiver (Must sign page 4 of HGTC Health Science Division - Student Health Record)
Certification:
Signature below indicates verification of above initials in administration of Hepatitis B immunization and/or
titer result.
________________________________________________________________________________________
Signature
Title (MD, NP, RN)
________________________________________________________________________________________
Signature
Title (MD, NP, RN)
________________________________________________________________________________________
Signature
Title (MD, NP, RN)
•
Documentation may be provided on other forms or records but must meet the stated guidelines for
clinical clearance.
•
Titer result may be reported on this sheet but must be accompanied by lab result with reference range
clearly designated.
Form 7, Revised 10/31/2011
Please enter name, H# and program before printing this form.
Student Name: ___________________________
Student H#______________________________
Health Science Division – Student Health Record
Program: _______________________________
MEASLES, MUMPS, RUBELLA (MMR) FORM
Positive Titer Results Are Required
MEASLES Titer Result:
Date:
Initials:
MUMPS Titer Result:
Date:
Initials:
RUBELLA Titer Result:
Date:
Initials:

If NEGATIVE or EQUIVOCAL titer result, requires immunizations as follows:

Plus, new titers must be drawn upon completion of the immunizations:
1. If all 3 MMR or Measles or Mumps are Negative or Equivocal: Two (2) doses of MMR are required
2. If Rubella is Negative or Equivocal: One (1) dose of MMR is required
Injection
Lot #
Manufacturer:
Expiration:
Injection Site:
Date
Initials
1.
2.
Certification:
Signature below indicates verification of above initials in administration of MMR immunization and/or titer result.
________________________________________________________________________________________
Signature
Title (MD, NP, RN)
________________________________________________________________________________________
Signature
Title (MD, NP, RN)
________________________________________________________________________________________
Signature
Title (MD, NP, RN)

Documentation may be provided on other forms or records but must meet the stated guidelines for clinical
clearance.

Titer result must be accompanied by actual lab result with score and reference ranges clearly designated.
Form 8; revised 02.15.2016
Please enter name, H# and program before printing this form.
Student Name: ___________________________
Student H#_______________________________
Health Science Division – Student Health Record
Program: _________________________________
VARICELLA (CHICKENPOX) FORM
Positive Titer Results Are Required
VARICELLA Titer Result:
Date:
Initials:

If NEGATIVE or EQUIVOCAL titer result, requires series of two varicella immunizations.

Plus, new titers must be drawn upon completion of the immunizations.
Injection
Lot #
Manufacturer:
Expiration:
Injection Site:
Date
Initials
1.
2.

Physician documented history of Varicella not accepted as proof of immunity.

Requirement met with Positive Varicella Titers only.
Certification:
Signature below indicates verification of above initials in administration of Varicella immunization and/or titer
result.
________________________________________________________________________________________
Signature
Title (MD, NP, RN)
________________________________________________________________________________________
Signature
Title (MD, NP, RN)
________________________________________________________________________________________
Signature
Title (MD, NP, RN)

Documentation may be provided on other forms or records but must meet the stated guidelines for clinical
clearance.

Titer result must be accompanied by actual lab result with score and reference ranges clearly designated.
Form 9, Revised 02.15.2016
Student Name: ___________________________
Student H#_______________________________
Program: _________________________________
Health Science Division – Student Health Record
PREGNANCY POLICY & PREGNANCY CLEARANCE FORM
We, in the Allied Health Science Division ________ program, recognize the need to protect all of our students from any
potential harm to themselves or their unborn children, if pregnant. This policy is implemented to achieve this goal.
Because of the changes in health needs and potential restrictions on activities during pregnancy, the following will apply
to pregnant students:
The student will:
1. Inform the clinical instructor and course coordinator as soon as possible regarding the pregnancy and the
estimated date of delivery.
2. Obtain the Pregnancy Policy and complete Pregnancy Policy Form and submit as noted below.
3. Submit to the course coordinator the appropriate documentation of pregnancy clearance from the healthcare
provider (medical doctor or nurse midwife) at the designated times throughout the pregnancy to verify the
student is in satisfactory physical condition to attend class, skills labs, and clinical.
4. If at any time the health care provider states the student is unable to perform expected tasks, functions, and
studies for the current program course(s), the student may be given an incomplete (I) or withdrawal (W)
according to the elapsed time in the course and length of absence. Individual student situations will be brought
before the faculty and/or Department Chair for discussion and recommendations.
 When the pregnancy is confirmed
 At the end of the first trimester
 At the end of the second trimester and each subsequent month
 After delivery, prior to returning to class, skills lab, and clinical.
 If the nursing faculty becomes concerned about the health and well-being of the pregnant student and
the unborn child.
5. Students are encouraged to wait (6) weeks after delivery before returning to school.
6. Each nursing student will be expected to sign the statement below indicating she has read this policy and that
she understands that failure to abide by this policy will be grounds for withdrawal (W) from the course by the
course coordinator.
7. If any clinical agency has restrictions, the student will follow the guidelines of the agency in addition to those
established by the department.
STUDENT AGREEMENT:
I have read and agree to abide by the pregnancy policy as stated above. I understand that failure to abide by the policy
will be grounds for withdrawal from the program course(s) by the course coordinator.
Student Signature
Form 10, Revised 03/10/2016
Date
Student Name: ___________________________
Student H#_______________________________
Program: _________________________________
Health Science Division – Student Health Record
PREGNANCY CLEARANCE FORM (Part I)
This form is to verify the medical status of the above named student related to the following school related activities:
class attendance, skills practice lab, and clinical at an agency or hospital setting. Health Care Provider
clearance is required at designated intervals throughout the pregnancy as noted in the table below.
Visit
#
1
Date:
Reason For Visit
Status: Student is medically cleared for
participation in school related activities as noted
above.
 Yes  No
Confirmation of Pregnancy
Any restrictions?
 Yes
 No
List: __________________________________
Estimated Date of Delivery:
Estimated Length of Confinement:
2
6 to 8 week Visit
Any restrictions?
 Yes
 No
List: __________________________________
3
Monthly Visit
Any restrictions?
 Yes
 No
List: __________________________________
4
Monthly Visit
Any restrictions?
 Yes
 No
List: __________________________________
5
Monthly Visit
Any restrictions?
 Yes
 No
List: __________________________________
6
Monthly Visit
Any restrictions?
 Yes
 No
List: __________________________________
7
Monthly Visit
Any restrictions?
 Yes
 No
List: __________________________________
8
Monthly Visit
Any restrictions?
 Yes
 No
List: __________________________________
Form 10, Revised 03/10/2016
Provider
Initials
Instructors
Initials
Student Name: ___________________________
Student H#_______________________________
Program: _________________________________
Health Science Division – Student Health Record
PREGNANCY CLEARANCE FORM (Part II)
Visit #
Date:
9
Provider
Initials
Reason For Visit
9th Month: Weekly Visit
Any restrictions?
 Yes
 No
List: __________________________________
10
9th Month: Weekly Visit
Any restrictions?
 Yes
 No
List: __________________________________
11
9th Month: Weekly Visit
Any restrictions?
 Yes
 No
List: __________________________________
12
9th Month: Weekly Visit
Any restrictions?
 Yes
 No
List: __________________________________
13
Postpartum Clearance
Student is no longer pregnant and has been
released from my care for return to school on
______________________________________.
Any restrictions?
 Yes  No
List: __________________________________
Notes:
Certification:
Provider signature below must match initials above and verifies student pregnancy status/clearance.
Practice Name/Phone Number
Signature
Title (MD, CNM)
Practice Name/Phone Number
Signature
Title (MD, CNM)
Practice Name/Phone Number
Signature
Title (MD, CNM)
Form 10, Revised 03/10/2016
Instructors
Initials
Please enter name, H# and program before printing this form.
Student Name: ___________________________
Student H#_______________________________
Health Science Division – Student Health Record
Program: _________________________________
VACCINE ALLERGY/WAIVER FORM
Vaccine
Contraindication to student receiving vaccine:
 TST/PPD
 Documented Allergy to Vaccine or Component of Vaccine
 Influenza
 Pregnancy
 TDaP
 Hepatitis B

Initials
EDC: __________________
Must be for live virus vaccine
 Currently
Immunosuppressed/Immunocompromised
 MMR

Disease/Condition: ______________________
 Varicella

Date Vaccine can be safely administered __________________

Certain health conditions/diseases are considered valid contraindications to vaccine administration.

Pregnancy is not a contraindication to receiving inactivated vaccines such as: Hepatitis B vaccine, Tdap
vaccine, or flu vaccine (CDC Recommended Adult Immunization Schedule – United States 2010)

Breast-feedings is not a contraindication for any vaccine, except smallpox (CDC, New ACIP Guidelines, May
2008)
Certification:
Signature below indicates verification of above initials in reporting of valid contraindication for student not
receiving designated vaccine.
Signature
Title (MD, NP, PA)
Signature
Title (MD, NP, PA)
Signature
Title (MD, NP, PA)
Revised: 4/15/2011
1
Student Name: _________________________________ H#____________________
Program: ________________
CLINICAL CLEARANCE REQUIREMENTS
(ADN, PN, PHL, SURG TECH, PARAMEDICS, DMS, PATIENT CARE & RAD)
(PLEASE REMIT 1-SIDED COPIES OF ALL RECORDS – YOU KEEP ALL ORIGINALS)
FORM
REQUIREMENT
CRITERIA
EXPIRES:
1.
GENERAL HOSPITAL
ORIENTATION
1 Year
2.
CPR
3.
HEALTH SCIENCE
DIVISION STUDENT
HEALTH RECORD
TUBERCULIN
SKIN TEST /
PURIFIED PROTEIN
DERIVATIVE
CXR
ONLINE COMPETENCY CERTIFICATE

Check with Clinical Admission Coordinator for instructions or program website

Please print the confidentiality forms and turn in to the Clinical Admission Coordinator
HEALTHCARE PROVIDER CPR CERTIFICATION FOR BASIC LIFE SUPPORT (BLS)

Accept only American Heart Association (AHA) or American Red Cross (ARC)

Must provide card or CPR form as proof of certification
Form (Pages 1-4)

Page 2 of form must be signed by student

Page 3 of form must be signed by healthcare provider
Initial 2-Step PPD/TST (required even if student had BCG without documentation of 2 step)
Step 1. Initial
(Read at 48-72 hours)
Step 2. 1-3 weeks after 1st
(Read at 48-72 hours)
1-Step 90-Day PPD Each Semester
Chest x-ray (with documentation from physician stating any further treatment required)
*Only to be done if you have a positive PPD/TST result; If CXR is negative you do not repeat
unless symptomatic
Annual Symptom Assessment
*Complete form annually if you have a history of a positive PPD/TST with a negative CXR
TIV OR LIAV Vaccine x 1

Based on prevalent strains each new season
TDAP Vaccine x 1

Td booster every 10 years after single adult TdaP dose
Series of 3 Immunizations (recommended schedule below)
Dose 1 - Now
Dose 2 - 1 month after dose 1 Dose 3 - 5 months after dose 2
4a.
4b.
4c.
6.
SYMPTOM
ASSESSMENT
FLU VACCINE (only Fall
and Spring Semesters)
TDAP (ADULT)
7.
HEPATITIS B
5.
8.
MEASLES
MUMPS
RUBELLA
(MMR)
Or POSITIVE Hep B titer
Or Declination/Waiver Form (page 4 of Health Record)
POSITIVE Titers to Each Component
Date of Titers: _________________
Measles (Rubeola)
If NEG or EQUIVOCAL = MMR X 2
Mumps
If NEG or EQUIVOCAL = MMR X 2
Rubella (German Measles)
If NEG or EQUIVOCAL = MMR X 1
2 Years
1 Year
Each
Semester
End of Flu
Season
10 Years
N/A
N/A
Combination MMR Vaccine x 2
*Can be given 28 days apart:
MMR # 1: ____________
MMR # 2: ____________
9.
VARICELLA
POSITIVE Varicella Titer
Date of Titers: __________
If NEG or EQUIVOCAL = VAR x 2
N/A
VARICELLA Vaccine x 2
*Can be given 28 days apart:
Varicella # 1: __________
Varicella # 2: __________
10.




PREGNANCY FORM

To be submitted if currently pregnant (primary instructor must receive a copy)
N/A
Titers must be provided on actual laboratory report with values & reference ranges clearly defined
Healthcare Provider (HCP) documentation of “immune” or “positive” not accepted
WAIVER /DECLINATION accepted only for HCP documented allergy to immunization/component of immunization; certain exclusions may apply to pregnant
individuals.
If renewal/expiration falls within a semester, the renewal must be completed prior to beginning that semester
Revised: 02/15/2016
Student Name: _________________________________ H#____________________
Program: ________________
EMT CLINICAL CLEARANCE REQUIREMENTS
(PLEASE REMIT 1-SIDED COPIES OF ALL RECORDS – YOU KEEP ALL ORIGINALS)
FORM
1.
2a.
2b.
3a.
3b.
REQUIREMENT
CPR
HEALTH SCIENCE
DIVISION STUDENT
HEALTH RECORD
WAIVER OF REPEAT
PHYSICAL EXAM
TUBERCULIN
SKIN TEST /
PURIFIED PROTEIN
DERIVATIVE
CXR
3c.
SYMPTOM
ASSESSMENT
4.
FLU VACCINE (only
Fall and Spring
Semesters)
HEPATITIS B
5.
6.



PREGNANCY FORM
CRITERIA
HEALTHCARE PROVIDER CPR CERTIFICATION
 Accept only American Heart Association (AHA) or American Red Cross (ARC)
 Must provide card or CPR form as proof of certification
Form (Pages 1-4)
 Page 2 of form must be signed by student
 Page 3 of form must be signed by healthcare provider
 To be completed annually after the initial health physical and if there has been no
change in health status
EXPIRES:
2 Years
Initial 2-Step PPD/TST (required even if student had BCG without documentation of 2 step)
Step 1. Initial
(Read at 48-72 hours)
Step 2. 1-3 weeks after 1st
(Read at 48-72 hours)
1-Step 90-Day PPD Each Semester
Each
Semester
Chest x-ray (with documentation from physician stating any further treatment)
*Only to be done if you have a positive PPD/TST result; If CXR is negative you do not
repeat unless symptomatic
Annual Symptom Assessment
*Complete form annually if you have a history of a positive PPD/TST with a negative
CXR
TIV OR LIAV Vaccine x 1
 Based on prevalent strains each new season
Series of 3 Immunizations (recommended schedule below)
Dose 1 - Now
Dose 2 - 1 month after dose 1 Dose 3 - 5 months after dose 2
Or POSITIVE Hep B titer
Or Declination/Waiver Form (page 4 of Health Record)
 To be submitted if currently pregnant (primary instructor must receive a copy)
1 Year
1 Year
End of Flu
Season
N/A
N/A
Titers must be provided on actual laboratory report with values & reference ranges clearly defined
Healthcare Provider (HCP) documentation of “immune” or “positive” not accepted
WAIVER /DECLINATION accepted only for HCP documented allergy to immunization/component of immunization; certain
exclusions may apply to pregnant individuals.
Revised 02/15/2016
Student Name: _________________________________ H#____________________
Program: ________________
MASSAGE THERAPY CLINICAL CLEARANCE REQUIREMENTS
(PLEASE REMIT 1-SIDED COPIES OF ALL RECORDS – YOU KEEP ALL ORIGINALS)
FORM
1.
2a.
2b.
2c.
REQUIREMENT
HEALTH SCIENCE
DIVISION STUDENT
HEALTH RECORD
TUBERCULIN
SKIN TEST /
PURIFIED PROTEIN
DERIVATIVE
CXR
3.
SYMPTOM
ASSESSMENT
TDAP (ADULT)
4.
HEPATITIS B
CRITERIA
Form (Pages 1-4)
 Page 2 of form must be signed by student
 Page 3 of form must be signed by healthcare provider
EXPIRES:
1 Year
Initial 2-Step PPD/TST (required even if student had BCG without documentation of 2 step)
Step 1. Initial
(Read at 48-72 hours)
Step 2. 1-3 weeks after 1st
(Read at 48-72 hours)
1-Step 90-Day PPD Each Semester
Each
Semester
Chest x-ray (with documentation from physician stating any further treatment required)
*Only to be done if you have a positive PPD/TST result; If CXR is negative you do not repeat
unless symptomatic
Annual Symptom Assessment
*Complete form annually if you have a history of a positive PPD/TST with a negative CXR
TDAP Vaccine x 1
 Td booster every 10 years after single adult TdaP dose
Series of 3 Immunizations (recommended schedule below)
Dose 1 - Now
Dose 2 - 1 month after dose 1 Dose 3 - 5 months after dose 2
10 years
N/A
Or POSITIVE Hep B titer
Or Declination/Waiver Form (page 4 of Health Record)
5.
MEASLES
MUMPS
RUBELLA
(MMR)
POSITIVE Titers to Each Component
Date of Titers: _________________
Measles (Rubeola)
If NEG or EQUIVOCAL = MMR X 2
Mumps
If NEG or EQUIVOCAL = MMR X 2
Rubella (German Measles)
If NEG or EQUIVOCAL = MMR X 1
N/A
Combination MMR Vaccine x 2
*Can be given 28 days apart:
MMR # 1: ____________
MMR # 2: ____________
6.



PREGNANCY FORM

To be submitted if currently pregnant (primary instructor must receive a copy)
N/A
Titers must be provided on actual laboratory report with values & reference ranges clearly defined
Healthcare Provider (HCP) documentation of “immune” or “positive” not accepted
WAIVER /DECLINATION accepted only for HCP documented allergy to immunization/component of immunization; certain
exclusions may apply to pregnant individuals.
Revised 02/15/2016
Student Name: _________________________________ H#____________________
Program: ________________
PHARMACY TECH CLINICAL CLEARANCE REQUIREMENTS
(PLEASE REMIT 1-SIDED COPIES OF ALL RECORDS – YOU KEEP ALL ORIGINALS)
FORM
REQUIREMENT
CRITERIA
EXPIRES:
1.
GENERAL HOSPITAL
ORIENTATION
1 Year
2.
CPR
3a.
HEALTH SCIENCE
DIVISION STUDENT
HEALTH RECORD
WAIVER OF REPEAT
PHYSICAL EXAM
TUBERCULIN
SKIN TEST /
PURIFIED PROTEIN
DERIVATIVE
CXR
ONLINE COMPETENCY CERTIFICATE

All allied health programs to access through

Please print the confidentiality forms and turn in to the Clinical Admission Coordinator
HEALTHCARE PROVIDER CPR CERTIFICATION

Accept only American Heart Association (AHA) or American Red Cross (ARC)

Must provide card or CPR form as proof of certification
Form (Pages 1-4)

Page 2 of form must be signed by student

Page 3 of form must be signed by healthcare provider

To be completed annually after the initial health physical and if there has been no change in
health status
Initial 2-Step PPD/TST (required even if student had BCG without documentation of 2 step)
Step 1. Initial
(Read at 48-72 hours)
Step 2. 1-3 weeks after 1st
(Read at 48-72 hours)
1-Step 90-Day PPD Each Semester
Chest x-ray (with documentation from physician stating any further treatment required)
*Only to be done if you have a positive PPD/TST result; If CXR is negative you do not repeat
unless symptomatic
Annual Symptom Assessment
*Complete form annually if you have a history of a positive PPD/TST with a negative CXR
TIV OR LIAV Vaccine x 1

Based on prevalent strains each new season
TDAP Vaccine x 1

Td booster every 10 years after single adult TdaP dose
Series of 3 Immunizations (recommended schedule below)
Dose 1 - Now
Dose 2 - 1 month after dose 1 Dose 3 - 5 months after dose 2
3b.
4a.
4b.
4c.
6.
SYMPTOM
ASSESSMENT
FLU VACCINE (only Fall
and Spring Semesters)
TDAP (ADULT)
7.
HEPATITIS B
5.
8.
9.
10.
11.
12.




MEASLES
MUMPS
RUBELLA
(MMR)
VARICELLA
BOARD OF PHARMACY
INSURANCE
PREGNANCY FORM
Or POSITIVE Hep B titer
Or Declination/Waiver Form (page 4 of Health Record)
POSITIVE Titers to Each Component
Date of Titers: _________________
Measles (Rubeola)
If NEG or EQUIVOCAL = MMR X 2
Mumps
If NEG or EQUIVOCAL = MMR X 2
Rubella (German Measles)
If NEG or EQUIVOCAL = MMR X 1
Combination MMR Vaccine x 2
*Can be given 28 days apart:
MMR # 1: ____________
MMR # 2: ____________
POSITIVE Varicella Titer
Date of Titers: __________
If NEG or EQUIVOCAL = VAR x 2
VARICELLA Vaccine x 2
*Can be given 28 days apart:
Varicella # 1: __________
Varicella # 2: __________
CURRENT SOUTH CAROLINA BOARD OF PHARMACY
Policy Coverage - up to $1,000,000 each claim professional liability coverage
Up to $3,000,000 aggregate professional liability coverage

To be submitted if currently pregnant (primary instructor must receive a copy)
2 Years
1 Year
1 Year
Each
Semester
End of Flu
Season
10 Years
N/A
N/A
N/A
N/A
Titers must be provided on actual laboratory report with values & reference ranges clearly defined
Healthcare Provider (HCP) documentation of “immune” or “positive” not accepted
WAIVER /DECLINATION accepted only for HCP documented allergy to immunization/component of immunization; certain exclusions may apply to pregnant
individuals.
If renewal/expiration falls within a semester, the renewal must be completed prior to beginning that semester
Revised: 02/15/2016
Student Name: _________________________________ H#____________________
Program: ________________
PTA CLINICAL CLEARANCE REQUIREMENTS
(PLEASE REMIT 1-SIDED COPIES OF ALL RECORDS – YOU KEEP ALL ORIGINALS)
FORM
REQUIREMENT
CRITERIA
EXPIRES:
1.
GENERAL HOSPITAL
ORIENTATION
1 Year
2.
CPR
3a.
HEALTH SCIENCE
DIVISION STUDENT
HEALTH RECORD
WAIVER OF REPEAT
PHYSICAL EXAM
TUBERCULIN
SKIN TEST /
PURIFIED PROTEIN
DERIVATIVE
CXR
ONLINE COMPETENCY CERTIFICATE

All allied health programs to access through

Please print the confidentiality forms and turn in to the Clinical Admission Coordinator
HEALTHCARE PROVIDER CPR CERTIFICATION

Accept only American Heart Association (AHA) or American Red Cross (ARC)

Must provide card or CPR form as proof of certification
Form (Pages 1-4)

Page 2 of form must be signed by student

Page 3 of form must be signed by healthcare provider

To be completed annually after the initial health physical and if there has been no change in
health status
Initial 2-Step PPD/TST (required even if student had BCG without documentation of 2 step)
Step 1. Initial
(Read at 48-72 hours)
Step 2. 1-3 weeks after 1st
(Read at 48-72 hours)
1-Step 90-Day PPD Each Semester
Chest x-ray (with documentation from physician stating any further treatment required)
*Only to be done if you have a positive PPD/TST result; If CXR is negative you do not repeat
unless symptomatic
Annual Symptom Assessment
*Complete form annually if you have a history of a positive PPD/TST with a negative CXR
TIV OR LIAV Vaccine x 1

Based on prevalent strains each new season
TDAP Vaccine x 1

Td booster every 10 years after single adult TdaP dose
Series of 3 Immunizations (recommended schedule below)
Dose 1 - Now
Dose 2 - 1 month after dose 1 Dose 3 - 5 months after dose 2
3b.
4a.
4b.
4c.
6.
SYMPTOM
ASSESSMENT
FLU VACCINE (only Fall
and Spring Semesters)
TDAP (ADULT)
7.
HEPATITIS B
5.
8.
MEASLES
MUMPS
RUBELLA
(MMR)
Or POSITIVE Hep B titer
Or Declination/Waiver Form (page 4 of Health Record)
POSITIVE Titers to Each Component
Date of Titers: _________________
Measles (Rubeola)
If NEG or EQUIVOCAL = MMR X 2
Mumps
If NEG or EQUIVOCAL = MMR X 2
Rubella (German Measles)
If NEG or EQUIVOCAL = MMR X 1
2 Years
1 Year
1 Year
Each
Semester
End of Flu
Season
10 Years
N/A
N/A
Combination MMR Vaccine x 2
*Can be given 28 days apart:
MMR # 1: ____________
MMR # 2: ____________
9.
10.
11.




VARICELLA
INSURANCE
PREGNANCY FORM
POSITIVE Varicella Titer
Date of Titers: __________
If NEG or EQUIVOCAL = VAR x 2
VARICELLA Vaccine x 2
*Can be given 28 days apart:
Varicella # 1: __________
Varicella # 2: __________
Policy Coverage - up to $1,000,000 each claim professional liability coverage
Up to $3,000,000 aggregate professional liability coverage

To be submitted if currently pregnant (primary instructor must receive a copy)
N/A
N/A
Titers must be provided on actual laboratory report with values & reference ranges clearly defined
Healthcare Provider (HCP) documentation of “immune” or “positive” not accepted
WAIVER /DECLINATION accepted only for HCP documented allergy to immunization/component of immunization; certain exclusions may apply to pregnant
individuals.
If renewal/expiration falls within a semester, the renewal must be completed prior to beginning that semester
Revised: 02/15/2016
PTA Liability Insurance
The link is www.hpso.com
They will get a quote and apply as a student. Click on the professional liability tab.
They must do 1 million and 3 million aggregate.
Once you receive your policy, please submit Certificate of Insurance showing the coverages.
Please Print Your Information
legibility
NON-EMPLOYEES ID CARD AUTHORIZATION
SSN: _______________________________________
DOB: _____________________________
Legal First Name: ____________________ MI: _____
Last Name: ________________________
Preferred First Name: __________________________
Name Suffix:  II  III   IV  V  Jr  Sr
Gender: M  F
Address:__________________________________________________________________________
_________________________________________________________________________________
City: ____________________________
State:_______________
Zip Code: _____________
County: _________________________
Telephone Number :_____________________________
Cell Number: _____________________
School: _______________________________________
Email Address:_____________________________________________________________________
Start Date:________________________
Stop Date: ____________________________________
McLeod Department (for clinical rotation): ______________________________________________
Present or Past Employee of McLeod Health
_____ yes
_____ no
Location of Rotation: ________________________________________________________________
(Florence, Darlington, Dillon, Loris, Seacoast)
TO BE COMPLETED BY MCLEOD HUMAN RESOURCES:
Department Director: _______________Job Code #: ____________Cost Center #: ____________
Immunizations
Below are some of the places that offer the immunizations required for the Allied Health programs.
Immunization
Beach Urgent
Care
843-626-2273
Carolina
Health
Pharmacy
843-215-8200
CVS Minute
Clinic
866-389-2727
Doctor’s Care
843-238-1461
Little River
Medical
Center
843-663-8000
Med Plus
843-357-2443
Passport
Health
480-646-9038
Southern
Urgent Care
843-357-4357
Sliding Scale
MMR Titer
Varicella Titer
Hep B Titer
$90.00
$40.00
Tuberculin Skin
Testing (PPD) x 1
Chest X-Ray with
Positive PPD
$25.00
$50.00
$50.00
$30.00
$18.00
$64.00
$28.00
$60.00
$40.00
$42.00
$40.00
$35.00
$100.00
MMR Vaccine x 1
$84.00
$130.00
$125.00
$85.00
Hep B Vaccine x 1
$79.00
$140.00
$96.00
$65.00
Varicella Vaccine x1
$128.00
$186.00
$185.00
TDAP (Adacel)
Vaccine
$58.00
$65.00
$70.00
$92.00
$50.00
$20.00
$32.00
$29.00
$35.00
$20.00
$25.00
$79.00
$50.00
$100.00
Flu
$28.00
Physical Exam
$75.00
Current students may also contact the Employee Health Nurse at your assigned clinical site to inquire.
Disclaimer: HGTC cannot be held responsible for the prices above. It’s the student’s responsibility to call and confirm availability and prices.
HGTC is not affiliated with any of these providers regarding provision of health care services and is unable to recommend any specific provider.
Revised: February 19, 2016
$45.00