RDA Registered Dental Assisting

Transcription

1 Verified by Dawn Brewster, RDA Coordinator: RDA Registered Dental Assisting HEALTH SCIENCES PROGRAM HEALTH REQUIREMENTS To be filled out by Health Care Provider (HCP) STUDENT NAME: DATE OF BIRTH: Applicants must show proof of Immunization Records and document it on the table below. If no records are available, student must get the following titers completed below. If a result of a titer shows Non-Immune status, a vaccination must be completed or a series started. IMMUNIZATIONS (Required) MMR #1 #2 Hepatitis B or Twinrix* #1 #2 #3 TITER (If applicable) DATE DRAWN RESULT # REFERENCE RANGE RESULTS OF TITERS Rubeola (Measles) AB (IGG) Mumps AB (IGG) Rubella AB (IGG) Hepatitis B (HepBsAb) Quantitative PAGE 1 OF 2

2 Date of Physical Exam: Known Allergies: PHYSICAL EXAMINATION (Required) WNL = Within Normal Limits HEENT Lungs Cardiac Extremities Spine Neuro Height Weight Pulse BP Provider Comments: ESSENTIAL FUNCTIONS All applicants are required, throughout the program, to meet the following essential functions for entry and Programs. continuation in Health Sciences PHYSICAL DEMANDS: Perform prolonged, extensive, or considerable standing/walking, lifting, positioning, pushing, and/or transferring patients; Possess the ability to perform fine motor movements with hands and fingers; SENSORY DEMANDS: Depth perception: ability to judge distance and space relationships; Near vision: ability to see clearly 20 inches or less; Hearing: able to recognize a full range of tones. WORKING ENVIRONMENT: Exposed to infectious and contagious disease, without prior notification; Exposed to the risk of blood borne diseases; Exposed to hazardous agents, body fluids and wastes; Exposed to odorous chemicals and specimens; Subject to hazards of flammable, explosive gases; Contact with patients having different religious, culture, ethnicity, race, sexual orientation, psychological and physical disabilities, and under Possess the ability for extremely heavy effort (lift/carry 50 lbs. or more); Perform considerable reaching, stooping, bending, kneeling and crouching. Color vision: ability to distinguish and identify colors (may be corrected with adaptive devices); Distance vision: ability to see clearly 20 feet or more; a wide variety of circumstances; Subject to burns/cuts; Handle emergency or crisis; Subject to many interruptions; Requires judgment/action in life/death situations; Exposed to products containing latex. ENGLISH LANGUAGE SKILLS: Although proficiency in English is not a criterion for admission into the RDA Program, students are encouraged to be able to speak, write and read English to complete classes successfully and to ensure safety for themselves and for others. NOTES Prior to admission to the RDA Program, students demonstrate physical health as determined by a health history and physical examination. Entry and continuation in the program requires the student to submit a history and physical exam and meet required immunizations, titers, TB clearance (PPD/Chest X-ray), and any other testing required by college, program and clinical partner contractual requirements, including drug testing. A current BLS Provider CPR must be in possession of the student; renewed annually while enrolled. The college does not provide transportation to and from required clinical facility rotations. Entry and continuation in the RDAA Program requires that students must earn a minimum grade of C. **After this examination, I believe this applicant meets wellness criteria for Health Sciences Programs, which includes the ability to perform all the Essential Functions listed above. There is no evidence of communicable disease or health condition that would prohibit this applicant from undertaking any Health Science Program. Provider Signature Print Name City State Zip Telephone I verify that the above information is correct and I understand that any falsification of any information may result in my being dropped from the Health Sciences Program. I also give my permission for my health files to be kept in my folder, which is secured within the Health Sciences Department. Student Signature Date PAGE 2 OF 2

3 Verified by Dawn Brewster, RDA Coordinator: RDA Registered Dental Assisting Citrus College 1000 W. Foothill Blvd. Glendora, CA (626) RDA PROGRAM TB Test STUDENT NAME: DATE OF BIRTH: *This exam must be completed within one (1) month of the RDA Program start date. It is due by the RDA Mandatory Orientation. TB SKIN TEST Date Given Mantoux Signature/Title (PPD) Date Read mm induration Signature/Title Chest X-Ray [ ] Normal [ ] Abnormal [ ] Free from Communicable Tuberculosis Film Date* Impression *Chest X-Ray Film date must be within two year range of RDA Program start date. (If required due to prior positive reaction.) Provider Signature Print Name City State Zip Telephone I verify that the above information is correct and I understand that any falsification of any information may result in my being dropped from the Health Sciences Program. I also give my permission for my health files to be kept in my folder, which is secured within the Health Sciences Department. Student Signature Date

4 Citrus College 1000 W. Foothill Blvd. Glendora, CA (626) RDA PROGRAM Dentist s Record of Pre-Entrance Dental Health Exam It is the intention of the Citrus College Registered Dental Assisting Program that each student maintains good oral health and a disease-free dentition. Student s Name: Street : DATE OF INITIAL EXAMINATION: Type of Dental Care provided (please check what treatment was provided) Exam Complete Prophylaxis Full mouth x-rays (If radiographs can be deferred, that will allow the student to sit as a patient when enrolled in Radiology) Periodontal Exam All restorative charted with next appointment scheduled (if needed) Recall visit scheduled: [ ] 3 months [ ] 4 months [ ] 6 months All dental work is completed (date) The following dental work is in progress: Restorative (filling/crown/bridge, etc) Periodontal (root planning/curettage/corrective procedure) Next appointment: (date) Comments Print Name: Signature City, State, Zip Phone D.D.S/D.M.D.

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