COVID-19 EDUCATION COMPLETION ACKNOWLEDGMENT FORM
Instructions:
Please watch the COVID-19 Compliance Hand Washing video, located at the Castle Branch link:
https://castlebranchknowledgebase.wistia.com/medias/mj4i08jomk
Complete all of the boxes below and submit the form to Castle Branch.
LAST, FIRST NAME: _____________________, _____________________
SCHOOL EMAIL ADDRESS: _____________________@asa.edu
(email address should be the same for the Castle Branch account)
STUDENT ID#: ___________________
QUESTIONS:
ANSWERS:
1. Based on the course content, I must wash my hands for 20 seconds for effective cleaning.
True
False
2. Based on the course content, hand washing is one of the most effective steps in preventing illness.
True
False
3. Based on the course content, I should wash my hands after touching doorknobs.
True
False
4. Based on the course content, when using hand sanitizer, I should rub my hands for at least 20 seconds.
True
False
5. Based on the course content, germs on thumbs and fingertips are easily missed if hands are not
washed carefully.
True
False
6. Based on the course content, you don’t need to worry about drying your hands well.
True
False
7. Based on the course content, you can wash your hands for less than 20 seconds if you use lots
of soap.
True
False
8. Based on course content, hand washing is not really important.
True
False
9. Based on the course content, hand hygiene is only important for health care workers.
True
False
10. Based on the course content, when washing your hands use the hottest water possible.
True
False
I, _______________________________, a student of ASA College, hereby affirm that the above educational
(Student Name)
course was completed on the date and time noted below.
Student Signature:
Form 1037
Date and time:
Page 1 of 1
Nursing Program Financial Responsibility Agreement
Clinical rotation is a mandatory component of education in all of our healthcare programs. Students must obtain the
following:
•
•
Castle Branch Compliance tracker: One-time fee
Complete a physical examination with PPD testing or QuantiFeron TB-Gold blood test that may or may not
include a chest x-ray: Annually
• Attain, or show proof of, the required vaccinations and titers.
• Attain, or show proof of, the required vaccinations and titer Hepatitis B or a signed Declination Waiver to the
satisfaction of the college or clinical site: One-time fee
• Hepatitis C screen to the satisfaction of the college or clinical site: One-time fee
• Flu vaccine: Annually
• Obtain a background check sanctioned by ASA and our clinical affiliates: One-time fee
• Satisfactorily pass a 10-panel drug screen: Annually
• Castle Branch HIPPA training: Annually
• Maintain BLS certification through American Heart Association for the duration of program.
• Nursing Malpractice Insurance: Annually
• Upon completion of the program, all students are expected to take the NCLEX exam within the first 90 days of
graduation
This list is not necessarily all-inclusive. Other items may be required.
Students must purchase navy blue scrubs which will be worn in both the classroom as well as clinical sites. There is also
an ASA College patch that can be purchased in the Nursing Department office. This must be sewn on the upper left sleeve
of the scrub top. The student is also required to bear all costs incurred in preparation for clinical rotation and NCLEX.
ASA College will attempt to assist all students in finding cost-saving ways to obtain the required tests, exams, and
certifications. However, ASA has no formal agreement with any organization at this time to provide cost-saving services
to our students. Students should be prepared to spend approximately $300 to $450 on obtaining their required clinical
requirements.
No student will begin clinical rotation until all requirements are met. Students will be given no less/no more than one
month to obtain all requirements and must submit all upload all documents to their Castle Branch account at least six
weeks prior to the start of clinical rotations. Failure to meet this requirement will result in the student being unable to
satisfy the clinical rotation requirement for graduation.
My signature below indicates that I understand the requirements above and agree to financial responsibility for all costs
related to and in preparation for the clinical rotation component of the Nursing program, and the certification board exam.
I agree that I will upload all required documents to my Castle Branch account at least six weeks prior to the start
of the clinical rotation.
Student Name: ________________________________________________
Student Signature______________________________ Date: ___________
Form 1009
Page 1 of 1
WEEKLY COVID-19 SYMPTOMS SCREENING ATTESTATION FORM
for Students in Clinical/Laboratory on Ground Placements
LAST, FIRST NAME: _____________________, _____________________
SCHOOL EMAIL ADDRESS: _____________________@asa.edu
STUDENT ID#: ___________________
CLINICAL/LAB FACULTY NAME: COURSE NUMBER AND NAME: NUR-___; ___________________________
____________________________
CLINICAL/LAB SECTION: ____________
CLINICAL/LAB DAY AND TIME: _________________________________________
Symptom Screening and Tracking: This self-screen must be performed by students before going to clinical/lab
and before starting the clinical/lab day. In conducting the self-screen, students must answer the following five (5)
questions on daily basis:
1. In the past 14 days, have you knowingly been in close contact with anyone who has tested positive
for COVID-19 or has symptoms of COVID-19?
YES
NO
2. In the past 14 days, have you tested positive for COVID-19?
YES
NO
3. Do you currently have a temperature of 100 degrees Fahrenheit or higher?
YES
NO
4. Do you have today, or have you had in the past 14 days any one, or more of the following
symptoms:
YES
NO
YES
NO
DATE
Sun.
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
Fever or Chills
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Cough, Difficulty Breathing
or Shortness of Breath
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Sore Throat, Congestion or
Runny Nose
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Nausea or Diarrhea
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Fatigue, Muscle Pain or
Body Ache
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
New Loss of Taste or Smell
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Headache
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
5. Have you traveled outside of the States of New York, New Jersey, Pennsylvania, or
Connecticut within the last 14 days? If YES, please see the information described in the “Travel
Advisory” section of the “COVID-19 Guidance for Students in Clinical Placement” and contact
your clinical faculty member.
Form 1038
Page 1 of 2
Instructions:
If you answered NO to all of the boxes above submit the form to your clinical/lab faculty on weekly basis.
If you answered YES to any of the questions above:
1. DO NOT COME TO THE CLINICAL/LAB. Stay home and contact your healthcare provider. You can return only
when cleared by your healthcare provider, with a note stating so, and 2 negative COVID-19 tests.
2. As soon as you have any of the above symptoms notify your Clinical/Lab Instructor via phone and email that you
will be absent from the clinical/lab.
3. In addition, on the same day, you must notify of absence, and schedule the future make-up hours:
a. To schedule laboratory make-up hours the Lab Coordinator, Prof. Dixon at mdixon@asa.edu
b. To schedule clinical make-up hours the Clinical Coordinator, Prof. Quismundo at mquismundo@asa.edu
4. Follow the CDC’s What to Do If You are Sick guidelines:
https://www.cdc.gov/coronavirus/2019ncov/if-you-are-sick/steps-when-sick.html
I, _______________________________, student of the ASA College, hereby affirm that the above answers
(Student Name)
are correct and true, to the best of my knowledge.
I understand that providing this information is for the health and safety of myself and my fellow students, ASA College
faculty and staff, coworkers/staff and/or the patients for whom I may care for.
I understand that if I must answer YES to any of the above, that said answer, by itself, will not be grounds for dismissal
from my school, but may be used to alter or adjust my education settings to protect the health of myself and others with
whom I may be required to come in contact with.
I agree and consent that my electronic signature is valid and has full legal effect.
Student Signature:
Date and time:
Form 1038
Page 2 of 2
ACKNOWLEDGEMENT OF RECEIPT OF
NURSING STUDENT HANDBOOK
This is to acknowledge that I
have
(Student First and Last Name)
received an electronic copy or read the ASA College’s Nursing Student Handbook.
I understand it contains important information on the Nursing Division’s policies,
procedures, rules, regulations, and benefits, that it is my responsibility to familiarize myself
with the material in the handbook, and that my conduct will be governed by its contents.
I further understand that ASA College reserves the right to modify, revoke, suspend,
terminate or change any and all such rules, regulations, plans, policies, procedures and/or
benefits, in whole or in part, at any time, with or without notice.
______________
Last Name, First Name
Student ID #
_____________
Signature
Form 1011 - Revised 08/2020
Date
Page 1 of 1
COVID-19 ATTESTATION FORM
For Students in Clinical and Nursing Lab Placements
I, _______________________________, student of ASA College, hereby swear to participate in clinical and nursing lab related
(Student Name)
activities approved by the College’s Division of Nursing governed by the guidelines noted herein. The Clinical/Lab Rotation
will take place:
NAME OF INSTITUTION:
________________________________
COURSE NUMBER: NUR-______
COURSE NAME: ______________________________________________
Through semester: ________, 20____
ASA College students are responsible for following all the COVID-19-related guidelines, rules, and procedures
established by the placement site to which they are assigned to complete their clinical training. The following are
current rules and regulations:
As of August 1,2021, NYC Clinical sites require all students to be vaccinated against COVID-19 virus or undergo
weekly COVID-19 testing at their own expense. This decision was made because of the increasing COVID-19 positivity
rate in NYC as the highly contagious Delta variant has now become the predominant circulating strain in the city.
Student with documentation of having completed vaccination against COVID-19 by August 1st 2021will be exempt
from weekly testing. Student must prove that he/she has received both doses of Pfizer or Moderna’s two-dose vaccine
series or the single dose of the Johnson & Johnson vaccine prior to August 1st, 2021. Proof of vaccination (vaccination
cards) must be uploaded in your Castle Branch account within 5 days of your clinical rotation date. ONLY upon
acceptance by Castle Branch will allow students to attend their clinical rotation.
As of August 1, 2021, students are allowed to opt-out of receiving a Covid-19 vaccination; but are aware they must be
tested for COVID-19 on weekly basis. Please note that students are responsible for testing and any cost that are
incurred. Student must email the negative COVID-19 test results to their assigned clinical faculty and the Nursing
Clinical Coordinator (Marilou Quismundo: mquismundo@asa.edu ) no later than 24 hours prior to the clinical start
date and time. If this does not occur, the student will not be allowed to attend the clinical rotation. This will be a
considered an unexcused absence, and as such it will be ground for dismissal from the clinical site. An unexcused
absence warrants an unsatisfactory grade for the clinical rotation, therefore the course. The student will forfeit the
right for any grievances related to this matter.
Regardless of being vaccinated or not all students are expected to perform actions that prevent the spread of infectious
diseases, including, but not limited to:
• Wear a face covering as per up-to-date New York State order
• Follow the clinical site requirements and safeguards
• Follow Program guidelines below for exposure notification
• Adhere to standard and transmission-based precautions as per the CDC guidelines
COVID-19 vaccines will continue to be offered at no cost to all NYC residence until further notice. ASA College’s Division of
Nursing highly encourages nursing students to take advantage of this opportunity. To locate the vaccination site near you
please go to: https://vaccinefinder.nyc.gov/
Form 1044
Revised 7/2021
ASSUMPTION OF RISKS: COVID-19, the virus responsible for the current global pandemic, is a highly contagious and
potentially lethal virus. An inherent risk of exposure to COVID-19 exists in any public place where people are present. The
College and Placement Site are following all CDC guidelines and recommended precautions in order to reduce the risk of
COVID-19 exposure and infection to all our students. Nevertheless, due to the nature of the novel coronavirus, it may not be
possible to completely shield students from all risk of infection. Therefore, while we will do everything within our power to
offer you the opportunity to complete your clinical training, by attending the clinical portion of the course, you will be assuming
some risk of infection.
For some individuals, COVID-19 presents unique risks of experiencing severe illness; especially those over the age of 65 and
those with certain underlying health conditions, including, but not limited to chronic kidney disease, COPD (chronic
obstructive pulmonary disease), serious heart conditions, sickle cell disease, type 2 diabetes mellitus, those who are
immunocompromised, and individuals who are severely obese (BMI of 30 or higher). In addition, individuals with the
following underlying conditions might also be at an increased risk for severe illness: moderate to severe asthma,
cerebrovascular (blood vessels) disease, cystic fibrosis, hypertension (high blood pressure), neurological conditions such as
dementia, liver disease, pregnancy, pulmonary fibrosis, smoking, thalassemia (a blood disorder), and type 1 diabetes. Please
consider carefully whether you are a member of a vulnerable population when deciding about participating in the clinical
portion of your Program.
Students who are unable or unwilling to assume the risks described above may withdraw from the Program before the
beginning of the semester. Students who withdraw from the Program will be able to return in the subsequent semester when
the clinical course, which is required for the completion of the Program, is offered and their graduation will be delayed.
Individuals who request to return to complete their Program at a later date must follow the readmission process as outlined in
the Nursing student handbook the request.at the time of request.
ACKNOWLEDGMENT OF UNDERSTANDING: I have read this attestation and assumption of risk, I fully understand its
terms, and understand that I do not have to participate in the on-site clinical rotation. I also understand that I can choose to
postpone the course. Should I choose to participate in an on-site clinical rotation, I agree to the following:
1. I understand that I am choosing to fulfill my clinical requirement through an in-person clinical experience and I accept
the associated risk.
2. I agree to comply with all safety regulations at my clinical facility, including guidance set forth by the NYS Department
of Health, which may include wearing Personal Protective Equipment (PPE/masks) at the clinical facility.
3. I understand that if I violate the safety policies and protocols at my clinical facility, I may be dismissed from the facility
and/or my Program and may also be subject to a Code of Conduct violation.
4. I understand that I may choose to complete the clinical portion of my Program curriculum at a later date, which will
delay my current expected graduation date.
5. I understand that if I choose not to complete the clinical rotation at this time, or I become uncomfortable at the clinical
site, I will notify Marilou Quismundo the Clinical Coordinator for the Nursing Program immediately via email at
mquismundo@asa.edu . I understand that I will receive an Incomplete grade for the course. I further understand that I may
not progress in the program until the clinical component of the course is completed and my incomplete grade is changed
to a letter grade.
Emergency Contact Person (optional):
Contact phone number:
I agree and consent that my electronic signature is valid and has full legal effect.
Student Signature:
Form 1044
Date and time:
Revised 7/2021