Registration Checklist for Part-Time, Summers-Only Students
Required documentation to be submitted prior to registering for each clinical rotation, including externship Revised 3/23/16
Refer to CSD web page for forms: http://nau.edu/CHHS/CSD/Student-Resources/Forms/. Detailed instructions pertaining to these items are available
on pages 2 & 3 of this document. When submitting, please submit page 1 only. Save a copy of this completed form for future reference. Refer to
Page 2 and 3 on this form and to the CSD Graduate Student Handbook for information regarding Waiver eligible items.
Personal Information
________________________________________
Print Student Name
Phone: _______________________________________
Full-Time
Summers-Only
(Circle Program Track)
Pre-Pct P1 P2 P3 Externship
(Circle Clinical Rotation)
NAU email: __________________________________________________
Write “A” in the 1st blank if the document is “Attached” or “O” in the 2nd blank if the document is already “On File”.
Clinical Practicum Information form or Externship Information form
A or O
_______ _______
Copy of 25 Observation Hours
_______ _______
Student Responsibility Statement
_______ _______
Varicella (chicken pox -- Required for Externship Registration Only) DATE (month, day, year):
_______ _______
Bloodborne Pathogen Training
DATE (month, year you entered the program): _________
_______ __O____
MMR (Measles, Mumps, and Rubella)
DATES (month, day, year): #1 ______ #2 _______
_______ _______
Hepatitis B:
DATES (month, day, year): #1 ______ #2 _______ #3 _______
_______
The following items must remain current at ALL times throughout each clinical experience. If a document expires during a clinical experience, you
must submit a copy of the updated renewal to remain in the class. Expired documentation may result in being administratively dropped from
your clinical experience. Write in all expiration dates & indicate if the document is Attached or On File.
I have checked my CALIPSO file and confirm all items are current and correct.
Influenza Shot (expiration date is 12 months from the shot date)
_______
Expiration Date (month, day, year)
A or O
_____________ _______ _______
TB Test (Expiration date is 12 months from the test date)
_____________
_______ _______
Tdap (Tetanus/Diphtheria/Pertussis)
_____________
_______ _______
Fingerprint Clearance Card
_____________
_______ _______
HIPAA Test and included Confidentiality Statement (Expiration date is 12 months from the test date)
_____________
_______ _______
Copy of Current CPR Card
_____________
_______ _______
Copy of current, privately-purchased $1,000,000 minimum liability insurance policy
_____________
_______ _______
Background Check (Expiration date is 12 months from the report date; for externship only)
_____________
_______ _______
Physical Exam (Expiration date is 12 months from the exam date; for externship only)
_____________
_______ _______
14-Panel Drug Screening (Expiration date is 12 months from the test date; for externship only)
_____________
_______ _______
Submit THIS signed checklist and all appropriate documents as 1 complete packet (place this page on top & other documents, including
any proofs of renewal, in the order listed above). Allow 2 weeks then register for course.
I attest that I have had the required hours of CSD graduate coursework, per my Program of Study, prior to registering for my first clinical rotation.
I am aware that I must turn in the above information within the timeframes indicated and that it is my responsibility to ensure the most current
information is on file for all subsequent clinical experiences. Should any information be missing or outdated, I am aware that I may be
administratively dropped from this course and will not be awarded a grade for any current clinical rotation until all documents are on file.
__________________________________________________
Student Signature
OFFICE USE ONLY
_________________________________________________________
______________________
LOUIE ID #
_____________________________
Semester /Year of This Practicum
_____________________________________________________________
Professor Signature: Pre-Practicum (FT or FT Leveler only) approval Professor Signature: CSD 602/608 course instructor approval
Part-Time, Summers-Only Registration Checklist for Clinical Experience – Discussion of items
IF AN ITEM IS WAIVER ELIGIBLE, YOU MUST SUBMIT A LETTER OR EMAIL FROM YOUR SITE STATING THAT THE ITEM IS NOT NECESSARY AT YOUR
SITE. THIS CORRESPONDENCE MUST BE SUBMITTED WITH YOUR CSD PACKET (REGISTRATION CHECKLIST AND CLINICAL PRACTICUM
INFORMATION FORM OR EXTERNSHIP INFORMATION FORM) PRIOR TO BEING ALLOWED TO REGISTER FOR THE COURSE.
NO SITE IS ALLOWED TO “WAIVE” AN ITEM ON THIS REGISTRATION CHECKLIST THAT DOES NOT SAY “WAIVER ELIGIBLE”. OUR REQUIREMENTS
SUPERCE ANYTHING THAT A SITE WANTS TO WAIVE.
Clinical Practicum Information form or Externship Information form (on CSD website)

Submitted prior to each clinical rotation
Copy of 25 Observation Hours (usually from previous university/college; if needed to be acquired by part-time students, use form in third section of
CSD website forms page)
Student Responsibility Statement (on CSD Website)

Submitted only one time
Varicella (chicken pox vaccination -- Required with Externship Registration Only) (waiver eligible)

If pregnant, CDC recommends waiting until after giving birth; indicate this on the form
Bloodborne Pathogen Training (documentation already on file;
completed at your orientation)
MMR (Measles, Mumps, and Rubella) (waiver eligible)

Must submit copy of actual record

Series of two; must indicate both dates

Two vaccines are required if born after 1956 or provide titer test proving immunization

If pregnant, CDC recommends waiting until after giving birth; indicate this on the form
Hepatitis B (waiver eligible)

Series of three shots that takes at least seven months to complete; must provide documentation for all three dates

If pregnant, CDC states that the “risk is very low”; CSD recommends waiting until after giving birth; indicate this on the form
Influenza Shot (expiration date is 12 months from the shot date) (waiver eligible)
 If pregnant, CDC states that the shot may be taken while pregnant but may increase nausea
 If your rotation is between the months of October 1 – March 30, this item is not waiver eligible.
 It may or may not still be required at your Externship site.
 CSD recommends that you get the shot in September.
 There are some sites who will accept religious and medical exemption for the flu shot item, however, the site will probably require
you to the following:
 Use the site’s form for requesting an exemption.
 The form has to be signed by your religious leader or your medical doctor.
 If approved by the site, you will probably be required to wear a face mask in all patient care areas.
 Submit the site’s exemption form with your packet.
TB Test (waiver eligible)

Annual Renewal

Expiration date is 1 year from when the test was taken, not the vaccine serum expiration date on your form

Copy of negative results

If your TB test routinely shows a false positive, you will need a chest x-ray and verifying statement from your physician

If pregnant, CDC recommends that the shot may only be taken in the third trimester; CSD recommends waiting until after giving birth;
indicate this on the form
Tdap (Tetanus/Diphtheria/Pertussis) (waiver eligible)

Lasts 10 years

Given when adult

After 10 years, only need Tetanus booster shot

If pregnant, CDC recommends that the shot may only be taken in the third trimester; CSD recommends waiting until after giving birth;
indicate this on the form
Fingerprint Clearance Card (may have a slightly different title in your state but is not the same as the Background Check)

This is done in and for the county and state where you will be doing your clinical rotation

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It is usually done at a police department
Cards/Letters are usually valid for several years
It can take several months to obtain or renew the card/letter
Once you obtain the card/letter, provide a copy to the CSD department
Your county might not provide cards. Provide us with their equivalent documentation.
For graduate students that are having a clinical rotation in Arizona: Arizona legally requires that the AZ Fingerprint Clearance card be worn
around the neck at all times during a clinical rotation.
Letters from school districts and other places of employment are not acceptable.
If you are experiencing difficulty, contact your local FBI.
In Arizona, contact Department of Public Safety. 602-223-2279. Request the Level One IVP packet. Make sure you request this exact
packet because there are other packets for different purposes. Check first box: Department of Education Certification. Must have money
order payable to “DPS”.
Other possibilities:
 State of California Department of Justice, Bureau of Criminal Information and Analysis, PO Box 903417, Sacramento, CA 942034170
 Live Scan. Ask for Live Scan Records Review. Covers both fingerprinting and background check.
 www.Criminal BackgroundRecords.com
HIPAA Test and included Confidentiality Statement

Annual renewal

To get a copy of your HIPAA test and Confidentiality Statement report:
PC: Hold down ALT and Print Screen > open word > hold down Ctrl and V > view of screen should be pasted in word > file > print.
MAC: Command and Shift and 3 > image will save as file to desktop > file > print
Copy of Current CPR Card

Online courses are not allowed
Copy of current, privately-purchased, $1,000,000-minimum personal liability insurance policy

Must show beginning and ending dates of coverage (try marsh.com, HPSO.com, etc.)

You may purchase coverage early and set the Effective Date to just before your practicum begins
Background Check (This may have a slightly different title in your state but is not the same as the Fingerprint Clearance Card)(waiver eligible)

This is done in and for the county and state where you will be doing your externship

ALWAYS check with your intended externship site to see if they require a special agency or process for your background clearance

You provide a copy to the CSD department.

Annual Renewal-- Expiration date is 12 months from the report date

If you are experiencing difficulty, contact your local FBI.

Live Scan, in CA, covers both fingerprinting and background check.
Physical Exam (within last 12 months; provide statement from a physician; Exam through Campus Health Services is acceptable) (waiver eligible)
14-Panel Drug Screening (within last 12 months; provide report from the lab) (waiver eligible)

ALWAYS check with your intended externship site to see if they require a special agency or process for your drug screening

OCO sites require fentanyl and nicotine to be on the drug panel