Health and Professional Returning Clinical Faculty/Adjunct Checklist

Transcription

1 Health and Professional Returning Clinical Faculty/Adjunct Checklist Name: Health Requirements: Other: Healthcare Provider Immunization Verification Agencies Offering Immunization (Information Sheet) Current CPR/BLS: You must successfully complete an American Heart Association Health Care Provider Course and submit a copy of the wallet card or other proof of completion. CPR EXPIRATION DATE: Pre-Clinical Physical Exam Professional Requirements: Completion of the Core Competencies: Please go to >Academics>College of Nursing>Current Students>Health Forms and Uniforms. You may submit an attachment or submit a hard copy with your other documents. Review pay scale for professional contract based on Teaching Assistant (workload hours) rather than hourly. Contract includes: Adjunct meetings that are mandatory, clinical meetings, grading, evaluations, etc. Contract will be issued about 2-3 weeks into the semester. NOTE: If your degree has changed, you are responsible for informing us of that change so it will reflect in your pay. Review syllabus of course you are teaching Obtain contact information for Clinical Coordinator (plan on meeting) Continue education by visiting qsen.org website to prepare for teaching in the curriculum I agree to review and update any health and professional requirements as needed. (initial here) I understand that these requirements are non-negotiable in order to teach clinical. I further (initial here) acknowledge that if I do not complete these requirements by the established deadline, I will not be allowed to teach clinical. This acknowledgement indicates that I have reviewed the Ohio Board of Nursing rules and regulations, (initial here) including, but not limited to, and 5.8 Appearance/Dress Code. R:\COMMON\Clinical\Health and Professional Requirements\ Health and Professional Packet Revised

2 Health Requirements Health and Professional Requirements Healthcare Provider Immunization Verification Returning Clinical Faculty and Clinical Adjunct Name: (Please PRINT) DOCUMENTATION NEEDS TO BE PROVIDED F ALL REQUIREMENTS A Physician waiver will not be accepted by clinical agencies as meeting the requirements Tetanus/Diphtheria Immunization (within last ten years date: ) Most Recent Seasonal Influenza Vaccination (date) Initial 2 step Tuberculin skin test (PPD) Date #1: Result: Date #2: Result: Note: date of second test to be initiated one to three weeks after first test read Negative yearly PPD for 2 years prior to first clinical: Date #1 Date #2 Yearly physician statement of absence of disease for positive reactors. Date: T-Spot Date: Result: Healthcare Provider Signature: Healthcare Provider Name: (PRINT or TYPE) Date: R:\COMMON\Clinical\Health and Professional Requirements\Health and Professional Packet Revised

3 Health Requirements PRE-CLINICAL PHYSICAL EXAMINATION Returning Clinical Faculty & Adjunct The individual whose name appears on this form is a faculty member in the Nursing Program at Lourdes University. To meet criteria to the clinical agencies the following examination is required. Name: Last Name First Name MI Maiden/Other Address: Street City State Zip Date of Birth: Month Date Year Only Required for Faculty teaching in a Long Term Care Facility: Yearly PPD: Date Results: Positive Negative Date Yes, Free of evidence of communicable disease No, not free of evidence of communicable disease If no, Comments/Recommendations: Date of Physical Examination: Name of Health Care Provider (Print or Type): Address of Health Care Provider: Signature of Health Care Provider: 6832 Convent Blvd., Sylvania, Ohio PHONE: FAX: R:\COMMON\Clinical\Health and Professional Requirements\ Health and Professional Packet 3 Revised

4 Information Sheet CPR Training Requirement (CPR/BLS Information) In preparation for your clinical experiences, it is required that you obtain and maintain current Training in BLS (CPR), according to the guidelines set forth by the American Heart Association for Healthcare Providers (AHA HCP). To find an American Heart Association Training Center near you please call (1-877-AHA-4CPR) or go to the AHA web site at You will be prompted to enter your zip code and then be directed to AHA Training Centers near you. Many hospitals, fire departments and rescue agencies are designated AHA Training Centers. Because schedules and availability vary, you should call early and follow their registration instructions. Fees vary from place to place* For your convenience a list of local AHA Training Centers are listed here: Flower Hospital Toledo Hospital University of Toledo Medical Center Mercy St. Anne s Hospital Mercy St. Vincent Medical Center St. Luke s Hospital In addition, there are instructors, affiliated with these training centers, who will offer on-site classes. Please call us for their names and contact information. *The American Heart Association strongly promotes knowledge and proficiency in BLS, ACLS, and PALS and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course sponsorship by the AHA and any fees charged for such courses do not represent income to the AHA. R:\COMMON\Clinical\Health and Professional Requirements\ Health and Professional Packet 4 Revised

5 Information Sheet AGENCIES OFFERING IMMUNIZATIONS ALLEN COUNTY Allen County Combined Health District 219 E. Market St., Lima, Ohio (419) DEFIANCE COUNTY Defiance County General Health District 1300 E. Second St., Defiance, Ohio (419) ERIE COUNTY Erie County General Health District 420 Superior St., Sandusky, Ohio (419) FULTON COUNTY Fulton County Health Department 606 S. Shoop Ave., Wauseon, Ohio (419) FINDLAY CITY HEALTH DEPARTMENT 1644 Tiffin Ave., Suite A, Findlay, Ohio (419) HENRY COUNTY Henry County General Health District 1843 Oakwood Ave., Napoleon, Ohio (419) HURON COUNTY Huron County General Health District 180 Milan Ave., Norwalk, Ohio (419) LUCAS COUNTY Toledo-Lucas County Health Department 635 N. Erie Street, Toledo, Ohio (419) Adult/Travel Immunization Clinic (419) By appointment only Western Lucas County Clinic 330 Oak Terrace, Holland, Ohio (419) THE TOLEDO HOSPITAL Occu Health Center 2150 W. Central Ave., Toledo, Ohio (419) REYNOLDS CLINIC 2450 N. Reynolds Rd., Toledo, Ohio (419) NW OHIO URGENT CARE CENTER (formerly Industrial Medical Center) 1155 E. Alexis, Toledo, Ohio (419) OTTAWA COUNTY Ottawa County Health Department 1856 E. Perry St., Port Clinton, Ohio (419) PUTNAM COUNTY Putnam County Health Department 256 Williamstown Rd., Ottawa, Ohio (419) SANDUSKY COUNTY Sandusky County Combined General Health District 2000 Countryside Dr., Fremont, Ohio (419) SENECA COUNTY Seneca County General Health District 71 S. Washington St., Tiffin, Ohio (419) WILLIAMS COUNTY Williams County Combined Health District 310 Lincoln Ave., Montpelier, Ohio (419) WOOD COUNTY Wood County Combined General Health District 1840 E. Gypsy Lane Rd., Bowling Green, Ohio (419) R:\COMMON\Clinical\Health and Professional Requirements\Packet 5