student health record - Central Piedmont Community College

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CPCC Nurse Aide/Phlebotomy
NURSE AIDE/PHLEBOTOMY STUDENT HEALTH RECORD
Welcome to Central Piedmont Community College! We are glad you have chosen CPCC to pursue your
education in a health program.
Submission of a Student Health Record is required by all students entering a Health Program.
PLEASE NOTE:
 Students must maintain a copy of all documentation submitted to the Medical Record Specialist.
Students may need to provide copies of their immunization records to clinical facilities.
 All records must be verified with a healthcare provider’s signature or stamp.
 Please do not fax medical information to CPCC.
 Students will be ineligible to participate in Clinicals until the Health Record is completed.
SUBMISSION OF HEALTH RECORD
Please DO NOT begin fulfilling the requirements in this packet until you have
registered and paid for registration.
SUBMISSION DEADLINE
Submit the completed Health Record to your instructor on the FIRST DAY OF CLASS.
If you have questions:
Contact Linda Porter, Medical Record Specialist
[email protected]
704-330-6163
Jennifer Boniface, Program Coordinator
[email protected]
704-330-2722 ext. 7274
DRUG SCREEN and MEDICAL PHYSICAL REQUIREMENTS
Drug Screening
A 13 panel Urine Drug Screening must be completed no more than 30
days prior to the first day of class to be accepted.
Physical Examination must be completed no more than 6 months
prior to the first day of class to be accepted.
Medical Physical
CRIMINAL BACKGROUND CHECK REQUIREMENTS
PLEASE NOTE THAT ALL STUDENTS MUST COMPLETE A CRIMINAL BACKGROUND CHECK.
INSTRUCTIONS
Specific instructions for completing the on-line criminal background check will be provided by
your instructor on the FIRST DAY OF CLASS..
If you have questions concerning this
requirement
Contact the Medical Record Specialist or Program Coordinator (see above).
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CPCC Nurse Aide/Phlebotomy
HEALTH INSURANCE REQUIREMENT
Health insurance requirement
All students must submit proof of health insurance coverage.
Coverage must be in effect by the first day of classes.
Coverage must be maintained throughout enrollment in the Program.
Students must update their health insurance information when the
coverage changes and/or expires and is renewed.
Coverage
There is no minimum coverage amount required.
Acceptable sources
There are many sources from which to obtain health insurance coverage.
A few examples include:
Medicaid, Affordable Care, Military insurance (Tri-Care), BCBS, Aetna, Cigna,
United Healthcare, etc.
Health insurance is also offered by the NC Community College System.
www.studentccsi.com
Not accepted as insurance
Sliding scale programs
PHYSICAL EXAMINATION
EXAMINATION
HEARING AND COLOR VISION
TESTS
SIGNATURES/FACILITY STAMP
Only a physician, physician assistant or nurse practitioner shall perform the
Physical Examination.
Hearing and vision tests must be included as part of the Physical Examination.
Vision test must include a color vision test.
The Physical Examination and Immunization Record forms must include the
healthcare provider’s signature and the address/phone number or facility
stamp.
SPECIAL NOTE
North Carolina State Law Section 15A NCAC 19A.0207 (Positive HIV and Hepatitis B Infected)
This law addresses HIV and Hepatitis B infected Health Care Workers (THIS INCLUDES STUDENTS IN
HEALTH PROGRAMS.)
Excerpt: “(b) All health care workers who perform surgical or obstetrical procedures or dental procedures
and who know themselves to be infected with HIV or Hepatitis B shall notify the State Health
Director...........The notification shall be made in writing to the Chief, Communicable Disease Control
Section, P. O. Box 27687, Raleigh, NC 27611-7687.”
If applicable: CPCC students are required to comply with this notification to the Chief,
Communicable Disease Control Section, P. O. Box 27687, Raleigh, NC 27611-7687.
IT IS IMPORTANT THAT STUDENTS MAINTAIN A COPY OF ALL REPORTS FOR THEIR
OWN FILES.
CPCC IS NOT RESPONSIBLE FOR PROVIDING STUDENTS WITH COPIES OF THEIR
HEALTH INFORMATION FOR CLINICAL FACILITIES OR FOLLOWING GRADUATION.
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CPCC Nurse Aide/Phlebotomy
VACCINATIONS AND DRUG SCREEN REQUIREMENTS
Students enrolled in the health programs may be at risk for exposure to serious, and sometimes deadly, diseases. If you work directly with patients
or handle material that could spread infection, you should get appropriate vaccinations to reduce the chance that you will get or spread vaccinepreventable diseases. Protect yourself, your patients, and your family members.
VACCINATION HISTORY
Immunization Records may be obtained from any of the following sources:
1.
(IMMUNIZATION/
VACCINATION RECORDS)
2.
3.
4.
5.
High School Records: Your immunization records do not transfer automatically. You
must request a copy.
Personal Shot Records-Must be verified by a doctor’s stamp or signature, by a clinic or
health department stamp.
Local Health Department
Military Records or WHO (World Health Organization) documents.
Previous College or University – Your Immunization Records do not transfer
automatically. You must request a copy.
Attach a copy of the Immunization Records to your Student Health Record.
INFORMATION ON REQUIRED VACCINATIONS AND/OR TITERS
Hepatitis B
HepB Surface Antibody titer (blood test) is required for CPCC students enrolled in health
programs.
A copy of the lab report must be submitted.
You are required to have documented evidence of a complete HepB vaccine series (3 vaccinations)
AND/OR a HepB Surface Antibody titer (blood test) that shows you are immune to Hepatitis B.
If you do not, then you need to:
 Get the 3-dose series (dose #1 now, #2 in 1 month, #3 Five months after #2).

Get HepB Surface Antibody titer 6-8 weeks after dose #3.
PLEASE NOTE:
 The HepB vaccination series takes 6 months to complete followed by the titer.
 A positive titer result indicates immunity to HepB.

MMR (Measles, Mumps, &
Rubella)
A negative titer result indicates you have no immunity to HepB and you will need to repeat the
3 HepB vaccination and titer.
If you were born in 1957 or later, you must provide:

Documentation of 2 doses of MMR vaccine OR

The positive MMR titer (blood test) that indicates immunity to Measles, Mumps and Rubella.
A copy of the MMR titer lab report must be submitted.
If you were before 1957, you must provide:


Documentation of 1 measles, 1 rubella and 2 mumps vaccinations OR
The MMR titer (blood test) that indicates you are immune to Measles, Mumps and Rubella.
A copy of the MMR titer lab report must be submitted.
PLEASE NOTE:

A positive titer result indicates immunity to Measles, Mumps and Rubella.

A negative titer result for Measles, Mumps or Rubella indicates you will need a MMR
vaccination.
Varicella (Chickenpox)
Varicella IgG titer is required for CPCC health students.
A copy of the titer lab report must be submitted.



A positive titer results indicates immunity to Varicella (chickenpox).
A negative titer result indicates no immunity to chickenpox and you will need 2 doses of the
varicella vaccine, 4 weeks apart.
A repeat varicella titer is required 6 weeks after the second vaccination.
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CPCC Nurse Aide/Phlebotomy
Tdap (Tetanus,
Diphtheria, Pertussis)
The Tdap vaccination includes Tetanus, Diphtheria and Pertussis (whooping cough).
The Tdap vaccination is a one-time, life-time vaccination.
You will need to provide:

Documentation of childhood DPT vaccinations AND documentation of a Tdap vaccination
OR

Documentation of a Tdap vaccination if childhood records are not available.
If you recently received a Tetanus (Td) and cannot provide documentation of childhood DPT
vaccinations,

A Pertussis titer is required to prove immunity to Pertussis.
A negative titer result indicates no immunity to Pertussis and you will need the Tdap
vaccination.
Tdap and Td are different. You should get a Td [tetanus] booster every 10 yrs.
Flu (Influenza)
Seasonal influenza vaccinations are available beginning in August each year.
Students are strongly encouraged to receive the flu vaccination.
Please note that the influenza vaccination is mandatory in most clinical facilities.
To learn more about these diseases and the benefits and potential risks associated with the vaccines, read the Center for Disease Control and
Prevention http://www.cdc.gov/vaccines/adults/rec-vac/hcw.html
PPD (Tuberculin Skin Test) Requirements
2 Step PPD
The initial PPD skin test is administered and then read 48-72 hours later.
A second PPD is required 2 to 4 weeks later.
These 2 PPDs complete the “2 Step PPD”.
If PPD test is positive
Students with a (+) PPD test results must have a chest x-ray as part of a TB Screening report. A copy of
the chest x-ray report must be submitted. A TB Screening report will be required annually thereafter.
Students who received a
Students who have received the BCG vaccination should consult with their physician regarding
receiving the PPD.
BCG vaccination
If the PPD is contraindicated by the MD, the student should submit a copy of a chest x-ray taken with
the past 5 years and a current copy of a current TB Screening report from a medical facility.
NOTE:
Reports specifying immunization information must include the name of the healthcare
facility providing the information.
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CPCC Nurse Aide/Phlebotomy
DRUG SCREEN REQUIREMENTS
Drug screen
Requirements
CPCC adheres to the policies and procedures of all clinical facilities with which the health programs
are affiliated for student clinical learning experiences. These policies and procedures address the
requirement for a drug screen and circumstances when policies are not followed.
13 panel Drug Screen
must include:
Amphetamines
Barbiturates
Benzodiazepine
Cannabinoid
Cocaine
Ecstasy (MDMA)
Positive drug screen due
to prescribed medications
Methadone
Methamphetamines
Methaqualone
Opiates
Oxycodone
Phencyclidine (PCP)
Propoxyphene
A positive drug screen due to prescribed medications must be substantiated by documentation from the
physician ordering the medications.
Positive drug screen due
to non-prescribed drugs
A positive drug screen due to non-prescribed drugs will result in the student being ineligible to participate in a
clinical experience. The student will be withdrawn from the program.
Sources for Drug screen
testing
There are many sources/facilities which offer drug screens. Be aware that many cannot complete the 13 panel
drug screen at a reasonable price.
Take the lists of drugs with you to insure they can complete the required 13 panel drug screen.
Novant Health Urgent Care and Total Screening Solutions are two possible resources from which to obtain the 13
panel drug screen. See attached information.
Results of drug
screen MUST BE
MAILED by the
ordering facility
directly to:
Linda Porter
Medical Record Specialist
CPCC
P. O. Box 35009
Charlotte, NC 28235-5009
NOTES:
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CPCC Nurse Aide/Phlebotomy
STUDENT HEALTH RECORD
COVER SHEET
NAME _________________________________________________
LAST
FIRST
Middle Initial
CPCC STUDENT ID #
PROGRAM
_________________________________
_______________________________________
MAILING ADDRESS
_____________________________________
_____________________________________
CPCC EMAIL ADDRESS
_____________________________________
_____________________________________
PHONE NUMBERS
HOME _______________________________
CELL ________________________________
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CPCC Nurse Aide/Phlebotomy
CENTRAL PIEDMONT COMMUNITY COLLEGE
PART I: AUTHORIZATIONS
SECTION A: AUTHORIZATION FOR DISCLOSURE: CPCC INTERNAL RELEASE
All medical records, physical examination results, reasonable accommodation request forms, or other medical
information must be collected on separate forms, maintained in separate medical files kept apart from a student's
general educational records, and treated as confidential in accordance with the Rehabilitation Act of 1973 and the
Americans with Disabilities Act.
As indicated by my signature below, I consent to disclosure of the medical, criminal background check and, if
applicable, FBI information to administrators, Division Directors, Program Chairs, and other college officials involved
in a request for reasonable accommodation or evaluation of qualifications for or performance in a course, program,
service, activity or for purposes of implementing and enforcing necessary restrictions and accommodations; and for
First Aid and safety personnel if a known disability may require emergency treatment.
By signing below, I authorize Central Piedmont Community College and the Division to release and disclose any
and/or all pertinent medical information as indicated in the above provision.
I also authorize the release and disclosure of pertinent medical information by Central Piedmont Community
College to the Division officials and/or Faculty who need to be aware of medical conditions that may require
special needs. I understand that if I refuse to release my medical information to CPCC officials/faculty, I may lose my
eligibility to continue as a student in CPCC's Health Programs.
______________________________
STUDENT SIGNATURE
_______________________
DATE
_____________________________
STUDENT'S NAME PRINTED
____________________
STUDENT ID NO.
__________________
PROGRAM
_____________________________________________________________________________________________
_
SECTION B: MEDICAL RECORDS RELEASE OF INFORMATION
TO OFF-CAMPUS CLINICAL FACILITIES
Off-campus clinical facilities may require medical information on students in programs with clinical assignments.
Central Piedmont Community College is responsible for providing the clinical facility with medical data abstracted from
the student’s medical record. This data may include vaccinations received, medical test results and drug screen
results.
The facility may also require that the student provide a copy of their medical packet.
By signing below, I authorize Central Piedmont Community College and the Division to release and disclose any
and/or all pertinent medical information as indicated in the above provision, to an affiliating clinical facility which may
require this information as a condition of my assignment to the facility. I understand that if I refuse to release my
medical information to CPCC officials/clinical facilities, I may lose my eligibility to continue as a student in CPCC's
Health Programs. I further understand that failure to release the records may result in the facility denying my clinical
assignment. I also understand that I may not be able to fulfill the Program's graduation requirements.
______________________________________
STUDENT SIGNATURE
____________
DATE
______________________________________
STUDENT'S NAME PRINTED
_____________________
STUDENT ID NO.
_________________
PROGRAM
Revised 11/13lkp
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CPCC Nurse Aide/Phlebotomy
SECTION C. HEPATITIS B VACCINATION ACCEPTANCE
AGREE TO RECEIVE THE HEPATITIS B VACCINATION SERIES AND TITER
understand that due to my status as a student in a health
program there is a high risk of occupational exposure to blood and/or other potentially infectious materials.
I further understand that I am also at a greater risk of acquiring Hepatitis B virus (HBV) infection as the
result of my exposure to blood and/or other potentially infectious materials. I have been informed about
Hepatitis B and the Hepatitis B vaccine that is available.
1. I, ___________________________________________
agree to receive the Hepatitis B Vaccination series.
I understand that this vaccination is a series of (3) doses administered in the following sequence:
initial dose; second dose one month later; and the third dose administered six months from the first dose
(or five months from the second dose). I understand that official documentation must be submitted
immediately following the administration of each Hep. B vaccination. . I also understand that if I
decide, at any time, to discontinue the vaccination series I must sign a declination form immediately.
Furthermore, I understand that if the Hepatitis B vaccination becomes medically contraindicated (e.g.
pregnant or have reaction to the vaccine) a Hepatitis B vaccination declination form must be signed. The
declination form will be kept in the student’s health records.
2. I, __________________________________________
3. I, __________________________________________ further understand that following the
completion of the Hepatitis B vaccination series I must have a Hepatitis B surface antibody titer
blood test performed two months from the completion date to verify immunity through vaccination.
I also understand that a copy of the Hepatitis B titer test lab report must be submitted and will be placed
in my medical records. Should the titer test be negative I understand I will be required to consuIt with my
physician to begin the HepB series again or receive a booster. I will then be required to repeat the HepB
titer.
I further understand that clinical facilities which require the Hep.B vaccination can refuse a student’s clinical
assignment to their facility. Should this occur, I ____________________________________ further
understand my standing in the Program could be jeopardized and Clinical/Graduation requirements may
not be met.
________________________________
_______________
_________________________
Student Signature
Date
Program Name
HEPATITIS B VACCINATION SERIES WAS COMPLETED PREVIOUSLY
_____ I completed the HepB vaccination series on ______________(date), and will provide
documentation
to validate this.
_____ I completed the HepB Surface Antibody titer test on ______________. (Lab report
attached)
HEPATITIS B SURFACE ANTIBODY TITER
_____ I completed the HepB series and will now complete the HepB Surface Antibody titer test
and
submit a copy of the lab report.
____________________________________
Student Signature
_________________
Date
__________________________
Program Name
Revised 3/12 lkp
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CPCC Nurse Aide/Phlebotomy
PART II: REPORT OF FAMILY AND PERSONAL MEDICAL HISTORY
(Please type or print in black INK.) To be completed by student
LAST NAME (print)
FIRST NAME
MIDDLE NAME
*STUDENT ID NO.
____
ADDRESS
CITY
STATE
Cell phone number ______________________________
DATE OF BIRTH (mo/day/yr)
CLASS YOU ARE ENTERING (circle):
ZIP
AREA CODE/PHONE
Email address _________________________________________________
Last 4 digits of SS# ___________
PREVIOUSLY ENROLLED HERE
YES
NO
IF YES, DATES _____________________________
GENDER
□
M
□
F
SEMESTER ENTERING (circle): FALL
FR. SO.
SPRING
SUMMER 1 SUMMER 2
ATTACH Copy of Insurance card
_____________________
TELEPHONE (Number Of Insurance Company)
HOSPITAL/HEALTH INSURANCE (* NAME AND ADDRESS OF COMPANY)
NAME OF POLICY HOLDER
*SOCIAL SECURITY NO.
EMPLOYER
______________________ _____
IS THIS AN HMO/PPO/MANAGED CARE PLAN?
GROUP NUMBER
POLICY OR CERTIFICATE NUMBER
NAME OF PERSON TO CONTACT IN CASE OF AN EMERGENCY
YES
NO
RELATIONSHIP
ADDRESS
AREA CODE/PHONE
The following health history is confidential, does not affect your admission status and, except in an emergency situation or by court order, will not be
released without your written permission. Please attach additional sheets for any items that require fuller explanation.
FAMILY & PERSONAL HEALTH HISTORY
(Please type or print in black ink) To be completed by student
Has any person, related by blood, had any of the following:
Yes
No
Relationship
High blood pressure
Yes
No
Relationship
Yes
Cholesterol or blood fat
disorder
Diabetes
Glaucoma
Stroke
Heart attack before age 55
Blood or clotting disorder
No
Relationship
Cancer (type:)
Alcohol/drug problems
Psychiatric illness
Suicide
* HEIGHT
* WEIGHT
Have you ever had or have you now: (please check at right of each item and if yes, indicate year of first occurrence)
Yes
No
Year
Yes
No
Year
Yes
No
Year
Yes
High blood pressure
Hay fever
Jaundice or hepatitis
Kidney stone
Rheumatic fever
Allergy injection
therapy
Arthritis
Rectal disease
Protein or blood
in urine
Hearing loss
Heart trouble
Pain or pressure in
chest
Shortness of breath
Severe or recurrent
abdominal pain
Hernia
Concussion
Pneumonia
Frequent or severe
headache
Dizziness or fainting
spells
Severe head injury
Chronic cough
Paralysis
Head or neck radiation
treatments
Tumor or cancer
(specify)
Malaria
Disabling depression
Asthma
No
Year
Sinusitis
Easy fatigability
Severe menstrual
cramps
Irregular periods
Anemia or Sickle
Cell Anemia
Eye trouble besides
need glasses
Bone, joint, or other
deformity
Knee problems
Sexually transmitted
disease
Blood transfusion
Alcohol use
Recurrent back pain
Drug use
Neck injury
Anorexia/Bulimia
Thyroid trouble
Excessive worry or
anxiety
Ulcer (duodenal or
stomach)
Intestinal trouble
Back injury
Diabetes
Pilonidal cyst
Serious skin disease
Mononucleosis
Frequent vomiting
Gall bladder trouble
or gallstones
Broken bones
(specify)
Kidney infection
Bladder infection
Smoke 1+ pack
cigarettes/week
Regularly
Exercise
Wear Seat Belt
Other (specify)
Please list any drugs, medicines, birth control pills, vitamins and minerals (prescription and nonprescription) you use and indicate how often you use them.
Name
Use
Dosage Name
Name
Use
Dosage
Name
Use
Dosage
Use
Dosage
Name
Use
Dosage
Name
Medform/4-00
Use
Dosage
Revised lkp11/13
9
CPCC Nurse Aide/Phlebotomy
STUDENT NAME______________________________________________ PROGRAM
__________________
PART II: FAMILY AND PERSONAL HEALTH HISTORY - CONTINUED (Please print in black ink) To be completed by student
Check each item “Yes” or “No.” Every item checked “Yes” must be fully explained in the space on the right (or on an attached sheet).
Have you ever experienced adverse reactions (hypersensitivities, allergies, upset stomach, rash hives, etc.) to any of the following? If
yes, please explain fully the type of reaction, your age when the reaction occurred, and if the experience has occurred more than once.
Adverse Reactions to:
Yes
No
If Yes, Explanation With Type Of Reactions Required
Yes
No
If Yes, Explanation and Dates Required
Penicillin
Sulfa
Other antibiotics (name)
Aspirin
Codeine or other pain relievers
Other drugs, medicines,
Chemicals, Latex (specify)
Insect bites
Food allergies (name)
Do you have any conditions or
disabilities that limit your physical
activities? (if yes, please describe)
Have you ever been a patient
in any type of hospital? (Specify
when, where, and why.)
Has your academic career been
interrupted due to physical or
emotional problems?(Please explain)
Is there loss or seriously
impaired function of any paired
organs? (Please describe)
Other than for a routine check-up, have
you seen a physician
or health-care professional in the past
six months? (Please describe.)
Have you ever had any serious
illness or injuries other than those
already noted? (Specify when and where
and give details.)
IMPORTANT INFORMATION....PLEASE READ AND COMPLETE
STATEMENT BY STUDENT (OR PARENT/GUARDIAN, IF STUDENT UNDER AGE 18):
(A) I have personally supplied (reviewed) the above information and attest that it is true and complete to the best of my
knowledge. I understand that the information is strictly confidential and will not be released to anyone without my
written consent, unless otherwise permitted by Court order and/or law.
(B) If I should be ill or injured or otherwise unable to sign the appropriate forms, I hereby give my permission to the
institution to release information from my medical record to a physician, hospital, or other medical professional
involved in providing me (him/her) with emergency treatment and/or medical care.
Signature of Student
__________________________________________________
Signature of Parent/Guardian, if student under age 18
Date
____________________
Date
PLEASE ATTACH COPY OF HEALTH INSURANCE CARD
Revised lkp 3/12
10
CPCC Nurse Aide/Phlebotomy
PARTIII: PHYSICAL EXAMINATION (Please print in black ink) To be completed and signed by
physician or clinic
(* )Must Be Completed.
.
*
*
Last Name
First
Middle
*
Date of Birth
*
Student ID Number
*
Permanent Address
City
*Height
*Weight
*Vision:
*TPR
*Corrected
Right 20/
*Uncorrected Right 20/
*Color
Left 20/
Vision
*Hearing:
* 15 ft.
* (gross)
Right
State
Zip code
/
/
Area Code/Phone Number
*BP
/
Urinalysis:
Sugar:____ Albumin
Micro
Left 20/
Hgb or Hct (if indicated)
STS (if indicated)Date
Results
13 PANEL DRUG SCREEN Results __________
Right
___
_Left_____
Left
To include Ecstasy, methaqualone, oxycodone,
and propoxyphene
Please mail lab report to address provided by student.
*Are there abnormalities? If so, describe fully Normal
Abnormal
DESCRIPTION (attach additional sheets)
*1. Head, Ears, Nose, Throat
*2. Eyes
*3. Respiratory
*4. Cardiovascular
*5. Gastrointestinal
*6. Hernia
*7. Genitourinary
*8. Musculoskeletal
*9. Metabolic/Endocrine
*10. Neuropsychiatric
*11. Skin
*12. Mammary
*A. Is there loss or seriously impaired function of any paired organs?
Yes
No
Explain
*B. Is student under treatment for any medical or emotional condition?
Yes
No
Explain
*C. Recommendation for physical activity (physical education, intramurals, etc.) Unlimited__Limited ____
Explain
*D. Is student physically and emotionally healthy?
Yes
No
Explain
* REQUIRED: HEALTH ASSESSMENT MUST BE COMPLETED BY THE MD, PAC, OR FNP DOING THE
PHYSICAL EXAMINATION.
Based on my assessment of this student’s physical and emotional health on ______________(date),
he/she appears able to participate in the activities of a health professional in a clinical setting.
Yes____ No___
If no, please explain:
*Signature of Physician/Physician Assistant/Nurse Practitioner (Include Title)
*Print Name of Physician/Physician Assistant/Nurse Practitioner
*Office
Address
OR FACILITY STAMP
* Date
*Area Code/Phone Number
City
_____________________________
State
Zip Code
Revised 3/14lkp
11
CPCC Nurse Aide/Phlebotomy
STUDENT NAME ____________________________________________ PROGRAM__________________
PART IV: IMMUNIZATION RECORD
Please print in black ink. To be completed and signed by physician or clinic. A complete immunization record
from a physician or clinic should be attached to this form.
SECTION A REQUIRED IMMUNIZATIONS

mo./day/year mo./day/year mo./day/year
(#1)
(#2)
(#3)
mo./day/year
(#4)
DPT or Td (Must have total of 3)

Tdap (if due update after July, 2008 and have
not received a Tdap or Td within 10 years)
OR
Td booster




Polio (Optional If 18 or older)
Measles (2 MMR) (After first birthday)
MR (after first birthday)
Measles (after first birthday)

Mumps

Rubella
SECTION B
(Disease date
Not Accepted)
(Disease date
NOT Accepted
(Disease date
not accepted)
ATTACH TITER LAB REPORTS
Titer Date & Result
Titer Date & Result
Titer Date & Result
RECOMMENDED IMMUNIZATIONS
(The following immunizations are recommended for all students and
may be REQUIRED by certain colleges or departments)
REQUIRED By CPCC
•
Hepatitis B Series REQUIRED
for all Students In Health Programs at
CPCC. HepB titer test required
uon completion of series.
Date
(#1)
Date
(#2)
Date
(#3)
HepB Surface Antibody
titer Date/results
ATTACH LAB REPORT
Titer/Date/Lab report
OR: Hepatitis A/B Combination Series
•Varicella IgG Titer Test REQUIRED
(Disease date
not accepted)
for all students In Health Programs
at CPCC. Varicella series of two doses
REQUIRED if not immune to chicken pox
and must repeat Varicella IgG titer test.
Varicella IG titer
Date/results
ATTACH LAB REPORT
2-STEP PPD is required
PPD#1 Date
PPD#1Results
PPD#2 Date
PPD#2 Results
Chest x-ray required, if positive PPD
CXR Date
CXR Results
CXR Date
CXR Results
TB Screening every 12 months after
Chest x-ray
TB Screening
Date
Results
TB Screening
Date
Results
ANNUAL PPDs
Annual PPD Date
Results
Annual PPD Date
Results
Date rec’d
Date rec’d
Date rec’d
Date rec’d
SECTION C
Optional Immunizations

Hemophilus Influenzae

Pneumococcal

Hepatitis A series only

Typhoid (specify type)

Other
Signature or Clinic Stamp REQUIRED:
_______________________________________________________
_________________________________
Signature of Physician/Physician Assistant/Nurse Practitioner
Date
_______________________________________________________________
Print Name of Physician/Physician Assistant/Nurse Practitioner
______________________________________
Phone Number
________________________________________________________________________________________________________________
Office Address
OR FACILITY STAMP
City
State
Zip Code
Revised 3/14
12
CPCC Nurse Aide/Phlebotomy
Recommended places for the 13 panel Drug Screening for CPCC Students:
Novant Health Urgent Care (2 locations) Cost $50

1918 Randolph Rd Suite 175

9600 E. Independence Blvd.
Matthews, NC 28105 704-384-8441
(Located near Independence Blvd and Sam Newell Rd.)
Charlotte, NC 28270
Total Screening Solutions

4730 – C Park Road
704-316-1050
Cost $35
704-561-0081
(Located behind Supercuts on Park Rd between Tyvola Rd. and Woodlawn Rd.)
13
CPCC Nurse Aide/Phlebotomy
Randolph
1918 Randolph Rd
Suite 175
Charlotte, NC 28270
704-316-1050
No appointment needed!
Matthews
9600 E. Independence Blvd.
Matthews, NC 28105
704-384-8441
(Located near Independence Blvd and Sam Newell Rd.)
Office hours:
Monday through Friday: 8 a.m. until 8 p.m.
Saturday: 10 a.m. until 6 p.m.
Sunday: 1 p.m. until 6 p.m.
Please take CPCC Student ID and this form with you.
Fee schedule
Fee Schedule
Physical Exam
$45.00
Will include:
Height, Weight, Snellen vision,
Color vision, Whisper hearing
and dipstick urine.
Vaccines:
Varicella Vaccine
$110.00
Hepatitis B Vaccine
$75.00 each
(series of 3 injections)
MMR Vaccine
$90.00
TD Booster
$20.00
Tdap
$79.00
PPD (2 step)
$8.00 each
**2 step requires 2 PPDs completed
2-4 weeks apart**
If positive PPD:
TB Assessment form
$25.00
**must complete this form, yearly
if you have had a positive
PPD**
PA Chest
(unless
Tetanus received within 10 years or have no record of DPT
vaccinations)
Drug Testing:
UDS 13 panel
$49.00
$65.00
**Every 5 years if you have had
a positive PPD**
Titers:
Hepatitis B Surface Antibody
Measles(Rubeola) IGG AB
Mumps Antibody
Rubella Titer
Varicella IGG Titer
Pertussis IGG Titer
_____________________________________
$25.00
$25.00
$25.00
$25.00
$25.00
$56.00
LABS: ONLY for students with a history of jaundice and/or
hepatitis
_________________________________________________
Hepatitis B Surface Antigen
Hepatitis B Core Antibody
Hepatitis B Surface Antibody
Hepatitis A Antibody
Hepatitis C Antibody
$39.00
$49.00
$25.00
$48.00
$60.00
PRICES SUBJECT TO CHANGE WITHOUT NOTICE.
Revised 2.14
14
CPCC Nurse Aide/Phlebotomy
CRIMINAL BACKGROUND CHECK
Central Piedmont Community College Nurse Aide and Phlebotomy Programs adhere to the policies and procedures of
all clinical facilities with which the department is affiliated for student clinical learning experiences. Many clinical
facilities are now requiring criminal background screening of all students.
Central Piedmont Community College will designate the company selected to do the criminal background screening.
Nurse Aide and Phlebotomy Program personnel will not accept criminal background screening results from any
company other than the one designated by the College. The student will pay the cost of the criminal background
screening at the time of the screening. The cost is $42 to be paid by credit card. If a student's background check
prevents participation in the clinical experience, the cost is non-refundable.
Criminal Background screenings will be performed by an external vendor and will review the student’s criminal history.
The check will include sex offender registry checks and verification that the student is not excluded from providing
services under federal healthcare programs. The check will also include the cities and counties of all known
residence. Criminal background checks will include the student’s criminal history for the seven years prior to entry into
a Health Educational Program. Consumer or investigative consumer reports which may contain public record
information may be requested including, but not limited to consumer credit and criminal records. Information from
various Federal, State and Local agency regarding past activities will be obtained.
All positive findings on the student background check will be given to the clinical facility. The decision of
acceptance or denial of student access to the clinical facility is made by the clinical facility. The clinical
facility decision is final.
Notes:
Verification information will be filed in a secured area to ensure confidentiality. In the event that the
student feels an error has been made in the results of the report, it is the responsibility of the student
to contact the external vendor for a verification check and the student is responsible for any cost
associated with this check. Other than error relative to identity, there will be no appeal to this policy.
***Criminal background checks from any other outside agency will not be accepted. All background
checks will be done IN CLASS within the first week of class***
STUDENT INSTRUCTIONS FOR CENTRAL PIEDMONT COMMUNITY COLLEGE
About CertifiedProfile.com - CertifiedProfile is a secure platform that allows you to order your background check
online. Once you have placed your order, you may use your login to access additional features of CertifiedProfile,
including document storage, portfolio builders and reference tools. Background check results are posted to
CertifiedProfile upon completion. Before placing your order make sure you have the required personal
information; in addition to entering your full name and date of birth, you will be asked for your Social Security
Number, current address, phone number and e-mail address. Payment Information: During the online order
process, you will be prompted to enter your Visa or MasterCard information.
Place Your Order: Go to: www.CertifiedBackground.com and click on “Students” then enter package code:
CG09. You will then be directed to set up your CertifiedProfile account. View Your Results: Results will be posted
directly to your CertifiedProfile account. To log in after you have already placed your order, go to
www.CertifiedBackground.com and enter your email address on the right-hand side of the screen under “View
Your Results.” You will be notified if there is any missing information needed in order to process your order. Although
95% of orders are completed within 3-5 business days, some may take longer. Your order will show as “In Process”
until it has been completed in its entirety. Your school's administrators can also securely view your results online with
their unique usernames and passwords.
Need Help?: If you need assistance, please contact CertifiedProfile.com at [email protected]
or 888-666-7788 and a Student Support Representative will be available Monday-Thursday 8am-8pm, Friday 8am6pm & Sunday 12pm-8pm EST.
15
CPCC Nurse Aide/Phlebotomy
CENTRAL PIEDMONT COMMUNITY COLLEGE
AUTHORIZATION FOR CRIMINAL BACKGROUND CHECK
Healthcare facilities which provide educational experience for students enrolled in health programs at Central
Piedmont Community College require criminal background checks prior to clinical placement. CPCC has arranged for
Certified Background (certifiedbackground.com) to conduct these background searches for our students. These
background checks include sex offender registry checks and verification that the student is not excluded from
providing services under federal health care programs.
Results of criminal background checks may be shared with affiliating healthcare facilities. Results will be maintained
in confidential CPCC files and reviewed by authorized CPCC employees only.
The cost is $42 paid by credit card. The review will extend to the past seven years.
A student who declines to have the background check done, or to have results reviewed if necessary by authorized
CPCC personnel to include administrators, Division Directors, Program Chairs and other college officials, or to have
the results released to a healthcare facility will become ineligible for enrollment in all courses requiring experience
in a healthcare facility and will become ineligible for program completion.
A criminal record, when reported to an affiliating healthcare facility, may result in the student’s ineligibility to
complete the program.
Please read, sign, and date one of the following statements:
Authorization for Criminal Background Check
As indicated by my signature, I authorize the release of my criminal background report to CPCC personnel, if deemed
necessary, to include administrators, Division Directors, Program Chairs and other college officials. I have read and
understand the above-stated information and hereby agree to have a criminal background check completed, results
reviewed by authorized the authorized CPCC personnel, and results shared with affiliating healthcare facilities.
________________________________________________
STUDENT SIGNATURE
______________________________________________
STUDENT’S NAME PRINTED
__________________________
DATE
_________________
STUDENT NUMBER
___________________________PROGRAM
Rev. 3/14
16
CPCC Nurse Aide/Phlebotomy
EXHIDITD
HIPAA Student Training Orientation
Confidentiality and Privacy mean that the patients have the right to control who will see their protected
health information. With the enactment of the Health Insurance Portability and Accountability Act of 1996
(HIPAA), a patient's right to have his/her health information kept private, secure and confidential became
more than just an ethical obligation of healthcare providers; it became a federal law.
Protected Health Information (PHI) includes patient identity, address, age, social security number and any other
personal information that patients are asked to provide. In addition, protected health information includes why a
person is sick or in the facility, what treatments and medications he/she may receive, and other observations about
his/her condition or past health conditions.
Healthcare providers use information about patients to determine what services they should
receive. Ask yourself before looking at any protected health information:
* Do I need this in order to do my job and provide quality care?
* What is the least amount of information I need to do my job?
Depending on your task, if you do not need to know confidential patient information, then you should not access it.
Ways to protect a patient's privacy include:

Keep discussions about patient care private if reasonably possible by closing doors, pulling curtains
and conducting discussions so that others cannot over hear.
 Keep medical records locked and out of public areas.
 If you find that you are overhearing someone else discuss patient information, politely remind the
individual of the privacy policies and let them know they can be overheard.
 Do not release any patient information, unless authorized by the patient.
 Do not leave messages on answering machines regarding patient condition or test results. If there are
persistent problems regarding the breach of confidentiality or you have any
questions, please notify or contact your supervisor.
As a student at the Facility, Irecognize the patient's right to confidentiality and agree to abide by the Patient's Bill of
Rights as posted within the facility.
Additionally, I agree that information relating to a patient's physical and/or emotional status will not be released or
discussed except as needed for the care of that patient.
I also understand that breaking HIPAA's rules and regulations can mean either a civil or criminal sanction (penalty).
My signature below indicates that I have read the above information and understand the above
information and will abide by the policies and procedures of the facility.
Date
Student Signature
_______________
Employee Signature
Student Name
Employee Name
17
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