WESTMORELAND COUNTY COMMUNITY COLLEGE
PHARMACY TECHNICIAN PROGRAM
HEALTH REQUIREMENTS
As a Pharmacy Technician student, you will be assisting clients in a variety of health care facilities. Westmoreland County
Community College has established a policy regarding the health requirements of the program for your protection as well
as that of others.
Students entering the Westmoreland County Community College Pharmacy Technician Program must meet certain health
requirements. Any fee(s) in connection with the examination is the responsibility of the student.
The Health Requirements must include:
Complete Physical Examination and:
1.
Complete Blood Count
2.
Chemistry Profile
3.
Urine Routine & Microscopic
4.
Serology (RPR)
5.
Rubella Titre (if previously unprotected, proof of immunization is required)
6.
Rubeola Titre (if previously unprotected, proof of immunization is required)
7.
Varicella Titre (if previously unprotected, proof of immunization is required)
8.
Two Step PPD* (Form attached)
*If PPD is positive, full Chest X-ray is required.
9.
Urine Drug Screen – complete prior to internship (Urine Drug Screen Form attached)
It is required that the applicant meets Center for Disease Control recommendations and is immunized against:
Diphtheria
Tetanus
Pertussis
Poliomyelitis
Measles
Individuals born after 1957 who have not received (2) MMR's and who
Mumps
do not have documented cases of Measles, Mumps, and Rubella need
Rubella
to be reimmunized.
Varicella
Hepatitis B Vaccine is required unless contraindicated
Hepatitis B Surface Antibody Titre follows immunization
Influenza Vaccine is strongly recommended – to be given during the influenza season annually.
The Physical Examination may be scheduled with a Pennsylvania Licensed Physician (M.D. or D.O.) or a Certified
Licensed Nurse Practitioner.
ALL COMPLETED FORMS FROM YOUR EXAMINER(S) MUST BE RETURNED BY PRIOR TO THE FIRST DAY ON
CLASS.
ANY STUDENT WHO DOES NOT SUBMIT THE COMPLETED HEALTH FORMS PRIOR TO THE FIRST DAY OF
CLASS WILL NOT BE PERMITTED TO ATTEND CLASSES OR INTERNSHIPS, AND THE COURSE REGISTRATION
WILL BE CANCELED.
FOR THE URINE DRUG SCREEN (see Urine Drug Screen Policy).
TWO 2 X 2 PASSPORT PHOTOGRAPHS MUST BE ATTACHED TO THIS FORM (print name on the back)
DO NOT STAPLE
MAIL ALL FORMS TO:
Becky Lauffer, RN, BSN, coordinator
Westmoreland County Community College
Continuing Education Division
145 Pavilion Lane
Youngwood, PA 15697-1895
Phone: (724) 925-4082 – FAX: (724) 925-4294
WESTMORELAND COUNTY COMMUNITY COLLEGE
PHARMACY TECHNICIAN PROGRAM
HEALTH EXAMINATION
I.
GENERAL INFORMATION (To be completed by applicant)
Applicant's Name____________________________________________________________________________
Address____________________________________________________________________________________
Phone ___________________________
Date of Birth __________________________________
Social Security Number___________________
In case of accident or illness, notify ______________________________________________________________
Relationship____________________________
Telephone number(s) ___________________________
Address____________________________________________________________________________________
The student presenting this form is entering the Westmoreland County Community College Pharmacy Technician
Program and is required to have a physical examination and various laboratory tests to complete his/her admission
process.
Any fee in connection with this examination is the responsibility of the student.
II.
FAMILY HEALTH HISTORY (To be completed by applicant prior to physical exam)
Member of Family
Year of Birth
Health
Status
History of tuberculosis, mental or nervous disease,
epilepsy, hypertension, heart disease, cancer, diabetes
Father
Mother
Brother(s)
Sister(s)
Spouse
Children
2
III.
HEALTH PRACTICES (To be completed by applicant prior to physical exam)
Smoking History:
Do you use tobacco products?
Yes
If yes, indicate type:
Cigarettes
Cigars
Snuff
Marijuana
Pipe
No
Never
Number/Day________ Years________
If you quit smoking: Number of years since you quit__________
Alcohol History:
Never
Beer_____
Occasionally
Wine_____
Weekly
Liquor_____
Have you ever been treated for alcohol abuse?
Drug History:
Never
Daily
Occasionally
Yes
Weekly
No
Daily
Substance used:_______________________
Have you ever been treated for substance abuse?
Caffeinated Beverages:
Never
Occasionally
Yes
No
Daily
Number/Day________
Exercise:
Weight:
Jog______
Aerobics______ Weight Training______ Walking______
Other______
Times/Week _____
Current weight ________
Do you diet? _____
Number/Years____________
Usual weight ________
Type of Diet/Program:___________________________
Hobbies: _____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Forms of Relaxation: ____________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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IV.
EXAMINER'S REPORT - To be completed by the examiner - Pennsylvania Licensed Physician (M.D. or D.O.) or
a Certified Licensed Nurse Practitioner.
A.
DISEASE HISTORY:
Check if finding is positive and comment below:
Check
Check
Check
Ear Disease
Metabolic Disorder
Eye Problems
Menstrual Problems
Foot Problems
Musculoskeletal Disorder
Headaches
Nervous System Disorder
Heart Disease
Rheumatic Fever
Hemorrhoids
Respiratory Disease
Hepatitis
Skin Disorders
Hernia
Sore Throat
Infectious Disease
Tuberculosis
Jaundice
Vascular Disorders
Emotional/Mental
Illness
Vertigo
Allergies
Anemia
Arthritis
Asthma
Backaches
Colitis
Colds-Frequent
Cysts or Tumors
Diabetes
Digestive Disorder
Epilepsy Disorder
Other
Comments or Recommendations Concerning Checked Item(s) or Other:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
If any illness is checked, please indicate current treatment, including medications:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Additional Comments:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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IV.
EXAMINER'S REPORT (CONT'D)
B.
PHYSICAL EXAMINATION -
Please indicate findings as normal or abnormal.
Enter measurement where appropriate.
Normal
Abnormal
Height
Weight
B/P and Pulse
Ears
Nose & Throat
Head & Neck
Teeth, Lips & Mouth
Chest & Respiratory
Breasts
Heart
Back
Abdomen
Extremities
Reflexes
Rectum
Kidneys & Bladder
Pelvic
C.
OPERATIONS AND INJURIES
Operation or Injury (Specify)
Approximate Age
6
IMMUNIZATIONS:
Indicate immunization for each of the conditions listed by recording date of immunization.
If not current, it is required that the applicant be immunized.
Date Immunized
Reason for Not Immunizing
A. Diphtheria
* Date of Tetanus Booster
B. Tetanus*
(Adult - within last 10 years)____________
Tdap should also be given to adults who will have close
contact with an infant less than 12 months of age, ideally at
least one month before beginning close contact with infants.
In situations when it is important to protect against pertussis,
intervals shorter than 10 years since the last Td vaccination
may be used. A 2 year interval between Td and Tdap is
suggested to reduce the risk of reactions following
vaccination.
C. Pertussis
D. Poliomyelitis
** Individuals born after 1957 who have not received (2)
MMR's and who do not have documented cases of Measles,
Mumps, and Rubella need to be reimmunized.
E. Measles**
Mumps**
Rubella**
F Varicella***
*** Varicella: If varicella vaccine was not received prior to
age 13, susceptible persons 13 years of age or older should
receive 2 doses, given at least 4 weeks apart.
G. Hepatitis B
(If unprotected, proof of Immunization
is required)
Vaccine Injection
Date Received
#1
One month after 1st injection
#2
#3
Five months after 2nd injection
but within six months of 1st injection
All tests listed below are REQUIRED and RESULTS should be available to the examiner at the time of
examination. EXAMINER - please DOCUMENT test results below:
TEST
DATE
RESULT
1.
Complete Blood Count ______________
Normal
Abnormal
2.
Chemistry Profile
______________
Normal
Abnormal
3.
Urine R&M
______________
Normal
Abnormal
4.
Serology (RPR)
______________
Positive
Negative
5.
Rubella Titre
______________
Protected
Unprotected
6.
Rubeola Titre
______________
Protected
Unprotected
7.
Varicella Titre
______________
Protected
Unprotected
8. BASELINE TWO STEP PPD required for all persons who do not have a documented negative PPD test
result during the previous twelve month period. Each test should be read within 48 to 72 hours.
(Document the results of the Baseline Two-Step PPD on the PPD Form attached)
If PPD positive:
Full Chest X-Ray Required and a copy of the X-ray Report must be attached
Date ___________
Normal
Abnormal
A single PPD can only be administered if documentation of the results of a Two-Step PPD within the past
12 months is provided.
9. Urine Drug Screen - (Copy of Actual Lab Report to be attached to Urine Drug Screen Policy Form)
(To be done within 10 days of start of internships. Obtain order from physician at this time.)
10. Hepatitis B Surface Antibody Titre - must be drawn six weeks after the last Hepatitis B vaccine injection in
order to verify immunity.
Hepatitis B Surface - Antibody Titre
Date _____________
Protected
Unprotected
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REPORT OF PHYSICAL EXAMINATION
Physician's Pertinent Remarks Concerning Student's Health Status:
A.
Does this student have any activity limitations? If so,
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
B.
Pregnancy: __________________________________________________________________________
____________________________________________________________________________________
C.
Do the examination or diagnostic test results indicate a need for follow up treatment?
YES ____________________
NO ___________________
If yes, please specify: __________________________________________________________________
____________________________________________________________________________________
I HAVE OBTAINED A HEALTH HISTORY, PERFORMED A PHYSICAL EXAMINATION AND REVIEWED
IMMUNIZATION STATUS AND REQUIRED LABORATORY TESTS. IN MY ESTIMATION THIS STUDENT IS
ABLE TO PARTICIPATE FULLY IN CLINICAL STUDENT PHARMACY TECHNICIAN EXPERIENCES IN
HEALTH CARE AGENCIES.
YES ____________________
NO ___________________
Comments:__________________________________________________________________________
___________________________________________________________________________________
EXAMINER'S NAME:_________________________________________________________________________
(Please Print)
Address:___________________________________________________________________________________
Phone Number:______________________________________ Date:__________________________________
Signature:__________________________________________________________________________________
(Physician)
RETURN FORM TO:
Becky Lauffer, RN, BSN
coordinator, Emergency Medical Services & Health Care Continuing Education Programs
Westmoreland County Community College
145 Pavilion Lane
Youngwood, PA 15697-1895
Phone: (724) 925-4082 – FAX: (724) 925-4294
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WESTMORELAND COUNTY COMMUNITY COLLEGE
PHARMACY TECHNICIAN PROGRAM
BASELINE TWO-STEP PPD
Facility Name :_____________________________________________
Phone:__________________________
Facility Address: _____________________________________________________________________________
Student Name:________________________________________________ Date:_________________________
Social Security #:______________________________________ Date of Birth:__________________________
HAVE YOU PREVIOUSLY HAD A POSITIVE RESULT FROM A PPD SKIN TEST: YES
(IF YES, A CHEST X-RAY IS REQUIRED)
NO
UNLESS DOCUMENTATION CAN BE PROVIDED TO INDICATE A NEGATIVE BASELINE TWO-STEP PPD WITHIN
THE PAST TWELVE MONTHS, A BASELINE TWO-STEP PPD IS REQUIRED.
#1 PPD skin test/annual PPD skin test given:
Site: Left:
Manufacturer:
Lot #:
Expiration Date:
Administered by:
(Full signature)
Date/time:
Right
PPD READINGS: 48-72 HOURS AFTER ADMINISTRATION
M – T – W – TH – F – S (Circle day/s for reading)
PPD skin test result
mm in duration
NOTE—Positive test: Must be referred to a physician since a full chest X-ray is required.
______________________________________________________________
Full Signature of PPD Reader
Date/time
#2 PPD skin test/annual PPD skin test given:
Site: Left:
Manufacturer:
Lot #:
Expiration Date:
Administered by:
(Full signature)
Date/time:
Right
PPD READINGS: 48-72 HOURS AFTER ADMINISTRATION
M – T – W – TH – F – S (Circle day/s for reading)
PPD skin test result
mm induration
NOTE—Positive test: Must be referred to a physician since a full chest X-ray is required.
______________________________________________________________
Full Signature of PPD Reader
Date/time
Please return this form to:
Becky Lauffer, RN, BSN
coordinator, Emergency Medical Services & Health Care Continuing Education Programs
Westmoreland County Community College
145 Pavilion Lane
Youngwood, PA 15697-1895
Phone: (724) 925-4082 – FAX: (724) 925-4294
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WESTMORELAND COUNTY COMMUNITY COLLEGE
PHARMACY TECHNICIAN PROGRAM
SUBSEQUENT PPD
IF YOU HAVE NOT PREVIOUSLY HAD A POSITIVE PPD SKIN TEST AND YOU CAN PROVIDE DOCUMENTATION
OF A TWO-STEP PPD WITHIN THE PAST TWELVE MONTHS, THIS FORM CAN BE USED FOR A SUBSEQUENT
ANNUAL PPD REPORT.
Please Note: You must also submit the Baseline Two-Step PPD results on the Baseline Two-Step PPD
form.
Facility Name :_____________________________________________
Phone:__________________________
Facility Address: _____________________________________________________________________________
Student Name:________________________________________________ Date:_________________________
Social Security #:______________________________________ Date of Birth:__________________________
HAVE YOU PREVIOUSLY HAD A POSITIVE RESULT FROM A PPD SKIN TEST: YES
NO
IF YES, A CHEST X-RAY IS REQUIRED AND A COPY OF THE REPORT MUST BE SUBMITTED WITH THIS FORM TO:
Becky Lauffer, RN, BSN
coordinator, Emergency Medical Services & Health Care Continuing Education Programs
Westmoreland County Community College
145 Pavilion Lane
Youngwood, PA 15697-1895
Phone: (724) 925-4082 – FAX: (724) 925-4294
Annual PPD skin test given:
Site: Left:
Manufacturer:
Lot #:
Expiration Date:
Administered by:
(Full signature)
Date/time:
Right
PPD READINGS: 48-72 HOURS AFTER ADMINISTRATION
M – T – W – TH – F – S (Circle day/s for reading)
PPD skin test result
mm induration
NOTE—Positive test: Must be referred to a physician since a full chest X-ray is required.
______________________________________________________________
Full Signature of PPD Reader
Date/time
Please return this form to:
Becky Lauffer, RN, BSN
coordinator, Emergency Medical Services & Health Care Continuing Education Programs
Westmoreland County Community College
145 Pavilion Lane
Youngwood, PA 15697-1895
Phone: (724) 925-4082 – FAX: (724) 925-4294
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WESTMORELAND COUNTY COMMUNITY COLLEGE
PHARMACY TECHNICIAN PROGRAM
WAIVER FOR RELEASE OF HEALTH RECORDS FORM
I hereby authorize release of my Health Records to all clinical sites as requested and
for Becky Lauffer, lead instructor and/or program director to discuss my health condition with
my physician.
PRINT STUDENT NAME
STUDENT’S SIGNATURE
SOCIAL SECURITY #
Student’s Address:
Phone :____________________________________
DATE
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WESTMORELAND COUNTY COMMUNITY COLLEGE
PHARMACY TECHNICIAN PROGRAM
URINE DRUG SCREEN POLICY/FORM
A Urine Drug Screen will be required as a part of the health requirements. The report of the drug screen must be dated within
(10) days of the first internship and submitted to the coordinator of Emergency Medical Services & Health Care Continuing
Education on or before the first day of internship. Failure to meet this due date for submission of the Urine Drug Screen
report will result in cancellation of all internships.
YOUNGWOOD STUDENTS:
The Urine Drug Screen can be obtained at: Tri-County Occupational and Physical Medicine, 4000 Hempfield Plaza
Boulevard, Suite 991, Greensburg, PA 15601. Phone: (724)925-6050. The cost will be approximately $45.00 at the student’s
expense. Hours: Monday – Friday 8 a.m. – 11:30 a.m.
Monday – Thursday 1 p.m. – 3:30 p.m.
Friday – 1 p.m. – 2:30 p.m.
INDIANA STUDENTS:
The Urine Drug Screen can be obtained at: The Urgicare and Occupational Health 875 Hospital Road, Indiana, PA 15701.
Phone: (724) 357-7493. The cost will be approximately $24.00 at the student’s expense.
Hours: Monday – Friday 8 a.m. – 8 p.m.
Saturday & Sunday 9 a.m. – 5 p.m.
BLAIRSVILLE STUDENTS:
The Urine Drug Screen can be obtained at: The Urgicare and Occupational Health- Indiana @ Chestnut Ridge 25 Colony
Blvd., Suite 101, Blairsville, PA 15701. Phone: (724) 459 – 1700 . The cost will be approximately $24.00 at the student’s
expense.
Hours: Monday – Friday 8 a.m. – 8 p.m.
Saturday & Sunday 9 a.m. – 5 p.m.
GREENE COUNTY STUDENTS:
The Urine Drug Screen can be obtained at: SRMC Instacare & Occupational Medicine, 220 Greene Plaza, , Waynesburg, PA
15370. Phone: (724) 627-1950 before the start of each course. The cost will be approximately $24.25 at the student’s
expense.
Hours: Monday – Friday 9 a.m. – 6 .m.
Saturday and Sunday 10 a.m. – 3 p.m.
CALL TO SET UP APPOINTMENTS
POSITIVE SCREENS COULD RESULT IN ADDITIONAL COSTS.
SERVICES CANNOT BE BILLED TO INSURANCE.
PAYMENT IS REQUIRED AT THE TIME OF SERVICE.
Student's Name
Date Urine Screen Obtained
(Please Print)
Name of Testing Facility
Facility Contact Person
MAIL ALL FORMS MARKED
“CONFIDENTIAL” TO:
Phone
Becky Lauffer, RN, BSN, coordinator
Emergency Medical Services & Health Care Continuing Education Programs
Westmoreland County Community College
145 Pavilion Lane
Youngwood, PA 15697-1895
Phone: (724) 925-4082 – FAX: (724) 925-4294
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