STUDENT NAME: Date Completed:

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1 WINONA STATE UNIVERSITY College of Nursing and Health Sciences Graduate Programs in Nursing HEALTH INFORMATION AND REQUIREMENTS FOR PARTICIPATION IN THE GRADUATE PROGRAMS IN NURSING STUDENT NAME: Date Completed: Graduate Nursing students should send this form (completed and signed) and any required supporting documentation (already photocopied) to the Graduate Programs in Nursing Office, th Avenue SE, Rochester, MN PLEASE MAKE A COPY OF THIS COMPLETED DOCUMENT FOR YOUR FILES. NOTE: Students will NOT be allowed to start nursing clinicals without this form or any of the required supportingdocumentation! WSU Health Services offers Mantoux tests, Tetanus/Diphtheria, influenza vaccination, and Hepatitis B. UCR Student Health offers Mantoux tests, but does not offer immunizations. Clinics or public health departments are possible sources for remaining required tests, immunizations, or titer laboratory work. For clinical experiences, students are expected to be in compliance with the vaccines required by the clinical facility/agency. If you have questions about any of this information, please contact the WSU Graduate Nursing Department as soon as possible. ELECTRONIC MEDICAL RECORD (EMR) If an Electronic Medical Record (EMR) of your immunizations is available through your healthcare provider, please attach a copy to this form. FREEDOM FROM TUBERCULOSIS (TB) You must provide evidence of freedom from tuberculosis through Mantoux test(s) or chest x-ray. Please see the decision tree on page 5 to determine sequence of testing to meet requirement. MANTOUX TEST: Positive Negative Date mantoux test was read: CHEST X-RAY (if needed): Date: Positive Negative MEASLE, MUMPS, and RUBELLA (MMR) IMMUNITY The MMR vaccine affords protection against the infections of measles (rubeola), mumps (parotitis), and rubella (German measles). A second MMR dose is recommended at years of age. Nursing students must: 1) provide dates for their last two MMR immunizations (which must be after 12 months of age); or 2) specify the date they had the rubella disease; or 3) have a rubella titer done (a blood test that assesses the presence of antibodies against the rebella virus). 1) Dates of last two MMR immunizations (must be after 12 months of age): 2) Date of rubella disease: 3) Rubella titer results: Immune Not Immune (MMR vaccination required) Date of titer: TETANUS/DIPHTHERIA/PERTUSSIS IMMUNIZATION (Tdap) The tetanus/diphtheria vaccine meets the minimum requirement. However, the tetanus/diphtheria/pertussis is strongly recommended due to recent pertussis outbreaks. Boosters are required every 10 years. Most recent booster: Tetanus/Diphtheria Tetanus/Diphtheria/Pertussis Date: (must be within last 10 years) Updated: 11/18/15 Page 1 of 5

2 POLIO IMMUNIZATION The Minnesota Department of Health s recommendation for the polio vaccine is a minimum of 3 doses. If you do not have a minimum of 3 polio immunizations, please contact your health care provider to complete this series. Dates: HEPATITIS B VACCINE The Hepatitis B vaccine affords protection against acute inflammation of the liver caused by the hepatitis B virus. Vaccination is HIGHLY recommended for nurses because they are part of a high-risk group of workers who are exposed to contaminated blood products and body fluids. Nursing students are strongly encouraged to be immunized. Immunizations are given in a series of 3 doses, and are available through public health departments, clinics, some hospital health services, and campus health centers. Dates of Series: (1) (2) (3) INFLUENZA VACCINATION The Centers for Disease Control recommends influenza vaccination for all health care personnel. Nursing students are strongly encouraged to be vaccinated to protect their patients and themselves. Date of your seasonal influenza vaccination: (to be completed as soon as seasonal influenza vaccine becomes available) CHICKENPOX (VARICELLA) As a nursing student, you must: 1) provide dates for two chickenpox immunizations, or 2) specify the date you had chickenpox (varicella) disease, or 3) have a chickenpox titer done (a blood test that assesses the presence of antibodies against the chickenpox virus). 1) Dates of two chickenpox immunizations: 2) Date of chickenpox (Varicella) Infection: 3) Chickenpox titer results: immune not immune (Chickenpox vaccination required) Date of titer: MEDICAL/HOSPITALIZATION INSURANCE COVERAGE All nursing students must be covered by health insurance: Nursing students may purchase a student health insurance plan. More information is available through Health Services ( , IWC 222, A photocopy of your health insurance card or policy would be helpful, but is not required. Please indicate: Name of Company: Policy Number: Effective Date: Expiration Date: Page 2 of 5

3 Student Name: HEALTH HISTORY & PHYSICAL EXAMINATION All students must have a completed health history on file with their health care provider. Nursing students are required to have a physical examination and have the functional abilities statement form completed and signed by their health care provider. CPR CERTIFICATION Nursing students must be certified in CPR for ONE & TWO PERSON, INFANT, CHILD AND ADULT from ONLY the following organizations (check all that apply): American Heart Association (Basic Life Support for Healthcare Providers); or American Red Cross (CPR/AED for Professional Rescuers and Health Care Providers) ACLS (Advanced Cardiac Life Support) (ACNP Students Only) Attach a photocopy (front and back) of your current CPR card, including date issued, expiration date, and instructor s signature. *CPR Certification will be valid until the expiration date shown on your card. You are responsible for keeping track of your CPR expiration date and for getting recertified in CPR before the expiration. VERIFICATION OF CURRENT RN LICENSURE All students must have evidence of a current, unencumbered Minnesota license as a Registered Nurse. Minnesota licensure required for all clinical courses. Other state RN licenses are also required for clinical experiences in those states. Please attach a copy of your Current RN Licensure verification. (Current RN licensure will be validated by the graduate nursing department via online public registry.) PROFESSIONAL LIABILITY INSURANCE (Rates subject to change) GRADUTE CERTIFICATE PSYCHIATRIC-MENTAL HEALTH NURSE PRACTITIONER STUDENTS ONLY: You will need to purchase your own occurrence-based professional liability insurance. (Employer coverage is not adequate.) The amount of coverage must be at least $2,000,000/$3,000,000. When notified of coverage, submit a photocopy of the portion of the policy that includes the insurance company's name, policy number, evidence of occurrence-based insurance and the effective and expiration dates. The copy should show coverage for both your professional and student roles. HIPAA CERTIFICATION All students must have evidence of HIPAA Certification on file with the Graduate Programs in Nursing office. I have attended a HIPAA training session and received certification regarding HIPAA Privacy and confidentiality Requirements. Signature Date If you are not certified, you must complete three (3) modules of the MN Department of Human Services (DHS) Protecting Data and Information Privacy training. To start the DHS HIPAA training, please visit the following website You may choose the option Login As Guest. No course code or ID number is required. The three modules to complete are: Data Security & Privacy, How to Protect Health Information, and Protected Health Information. Allow 1-2 hours to complete the training, print the result pages and submit them with this form. Attach a photocopy of your HIPAA Training participation/certification(s). ACUTE CARE NURSE PRACTITIONERS ONLY ACNP students need to provide proof of completing an ECG interpretation course PRIOR to beginning Clinicals. Attach documentation of having completed an ECG interpretation course. HUMAN SUBJECTS QUIZ Graduate Nursing students take the Human Subjects Quiz in N612, N613, or N614. After taking the Human Subjects Quiz, please submit a photocopy of your training participation/certificate to the Graduate Nursing Office. Page 3 of 5

4 NURSING STUDENT STATEMENT OF CONTINUED HEALTH RESPONSIBILITY If there is a change in my health status, I understand a subsequent health examination may be required by the Department of Nursing. I understand it is my responsibility throughout the program of study to inform my clinical instructor(s) or the Director of any condition that could possibly affect my performance or the welfare of my patients in the clinical area(s). I understand this is necessary to make appropriate arrangements for me to participate in my nursing courses. I understand that this disclosure is necessary to protect my health and well-being, as well as, the health and well-being of patients for whom I may provide care. All information contained in this document must be retrievable from a health care provider (i.e., physician, nurse practitioner, or physician assistant) upon request from the Department of Nursing faculty or staff within one (1) business day. I declare the information contained on this form to be accurate, current and complete. I further understand any falsification of this information is sufficient cause for dismissal from the Graduate Programs in Nursing. Student Signature: Date: Page 4 of 5

5 Decision Tree for Mantoux Testing Based on CDC Recommendations, Centers for Disease Control and Prevention. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, MMWR 2005;54(No. RR-17): * A two step Mantoux test consists of two separate negative tuberculin skin tests. The second test can be done as early as 1 week after the first test is read. Exception: If first test is positive, do not repeat Mantoux skin test. A chest x-ray is required. Note: Mantoux test results must be read hours after injection. Page 5 of 5