Welcome to Nell Hodgson Woodruff School of Nursing from the Clinical Placement Team!

Transcription

1 Welcome to Nell Hodgson Woodruff School of Nursing from the Clinical Placement Team! Congratulations, you are about to take the first step of your clinical rotation journey. The clinical agencies we are contracted with require several health related documents noted in the attached checklist. You will submit these items to ESS, an online credentialing solution used to verify, track and store compliance documents. ESS login instructions are located on page 5 and on the admitted students pages. Please review the FAQs located on page 4 before you begin uploading documents. Compliance Deadlines: Summer Entry AMSN Students: May 15th Fall Entry ABSN and BSN Students: Orientation Fall Entry MSN, DNP, and Post Master s Certificate Students: Orientation Fall Entry Distance ABSN: Orientation **Don t forget, you must bring a copy of your ESS Report as your ticket to orientation!** Students who do not complete compliance requirements by the designated deadline may be placed on registration hold and dropped from clinical courses until compliant. We look forward to facilitating your clinical rotation journey and wish you the best in your educational endeavors. See you at orientation! Sincerely, Emory Kent MSN, RN Director, Clinical Partner Relations and Placement Jennifer Neely Program Coordinator, Clinical Placement and Credentialing 1

2 EMORY UNIVERSITY NELL HODGSON WOODRUFF SCHOOL OF NURSING CLINICAL COMPLIANCE REQUIREMENTS Bring a copy of your ESS Report as your ticket to orientation! Don t forget to review FAQs on page 4 before you begin submitting requirements! CHECK WHEN COMPLETE! HEPATITIS B VACCINES & TITER MEASLES, MUMPS AND RUBELLA (MMR) VACCINES & TITER VARICELLA VACCINES AND/OR TITER TDAP VACCINE POLIO VACCINE ANNUAL TB TESTING BASIC LIFE SUPPORT CARD (BLS/CPR) SUBMIT TO ESS BY DEADLINE ON COVER PAGE: ESS LOGIN INSTRUCTIONS ON PAGE 5 Submit proof of (3) Hepatitis B vaccines Submit proof of positive Quantitative Hepatitis B titer. Value and Result must be listed. Refer to guidance on page 10. If Hepatitis B titer is negative: If you are in the process of receiving vaccines and titers you will be clear to go to clinical. Submit proof of (2) MMR Vaccines Submit proof of positive MMR titer. Value and Result must be listed. Titer is required. Obtain 2 MMR vaccines 4 weeks apart If MMR titer is negative: Repeat the titer after completing 2 additional vaccines. Submit results If you have NOT had Varicella (Chicken Pox): Submit proof of (2) Varicella Vaccines If you HAVE contracted Varicella (Chicken Pox): Submit proof of positive Varicella titer Obtain 2 Varicella vaccines If Varicella titer is negative: Repeat the titer after completing 2 vaccines. Submit results. Submit proof of TDap vaccine within the last 10 years Submit proof of Polio vaccines or Polio Affidavit form found on page 15 Submit a negative 2 step TB Skin Test or T-spot test or Quantiferon Gold test each year. Test must be valid for the entire academic year. What is a 2 step test? Visit here: If the 1st or 2nd test is POSITIVE, the student will be referred for further evaluation and possible treatment If a student previously received the BCG vaccine, they should NOT get a 2 step TB skin test. Instead, submit proof of a negative TB blood test (Quantiferon Gold Test or T-Spot Test) or negative chest x- ray. If a student has tested positive for TB in the past, they must submit proof of treatment and a current chest x-ray. They must also follow up with Student Health and complete an annual symptom review. Submit current copy of card or electronic certificate with student signature (for cards) or verification code (for certificated). Students must be certified by the American Heart Association as a BLS Provider. Certification must be valid for the entire academic year. This may require recertification earlier than expiration date. Find classes near you here: 2

3 DRUG TESTING AND CRIMINAL BACKGROUND RELEASE FORM CONSENT TO RELEASE HEALTH INFORMATION FORM BLOOD BORNE PATHOGENS FOR RESEARCHERS AND CLINICIANS HIPAA IN A HURRY & HIPAA SECURITY PERSONAL HEALTH INSURANCE CARD DRIVERS LICENSE GEORGIA RN LICENSE *INSTRUCTORS, MSN STUDENTS & DNP STUDENTS ONLY* Complete and submit form on page 6 Complete and submit form on page 7 Complete modules and submit 1 certificate. See instructions on page 8. Complete modules and submit 2 certificates. See instructions on page 8. Submit a copy of the front and back of personal health insurance card. Submit a copy of the front and back of your driver s license. If you do not have a driver s license, submit a passport or other form of identification. Please note you are responsible for transportation to clinical sites. We do not accommodate personal travel to clinical. Submit a copy of your Georgia RN license OR Compact License. Submit actual license, not verification. Print GA license for free here: SUBMIT TO ESS AND STUDENT HEALTH PORTAL: PHYSICAL FORM IMMUNIZATION FORM Submit completed form (2 pages) found at end of this packet to ESS AND to Emory University Student Health Portal. Submit completed form found at end of this packet to ESS AND Emory University Student Health Portal. DUE BY SEPTEMBER 15th EACH YEAR (NOT ON ADMISSION) SUBMIT TO ESS: FLU VACCINE Submit proof of CURRENT seasonal flu vaccine. Must submit actual administration record, not prescription, with provider's signature. BACKGROUD AND DRUG SCREEN VIA ADVANTAGE STUDENTS (DO NOT SUBMIT TO ESS) BACKGROUND AND DRUG SCREEN *Do not drink too much water before the drug test. You will have to repeat the test if your result is dilute negative * *You must submit DRUG TESTING AND CRIMINAL BACKGROUND RELEASE FORM above before your order will be approved* Instructions: 1. Go to advantagestudents.com 2. Click Students 3. Click here to start your background check 4. Click Create new account 5. From the drop down box select Emory University Nursing Department Student 6. Click : a. Comprehensive Background Check with 12 Panel Drug Test for undergraduate students (AMSN, ABSN, BSN, D-ABSN) b. 'Graduate Student Package' for graduate students (MSN, DNP, PhD) 7. Follow directions and await approval from Emory University 8. After approval, an will be sent to you with a link that will direct you to a site to schedule your drug test, you can also click on the Schedule Drug Test link on the confirmation page you receive. You can also log into your account and link is also provided there. 3

4 COMPLIANCE FAQs 1. This is a lot, do I have to complete everything? A. Yes, because: i. Alignment with provisions in the clinical agency affiliation agreements related to student requirements. Upon request of an affiliate facility, the School of Nursing must provide evidence of student compliance with the requirements ii. The safety of patients and School of Nursing students, faculty and staff iii. Compliance with accreditation standards iv. Compliance with state regulations 2. I completed my background check online, but I have not receive an to complete my drug screen. A. You will receive an to complete your drug screen hours after you complete your background check 3. What is a 2 Step PPD test? A. Visit link: 4. What is a titer? A. A titer is a laboratory blood test that shows whether you are immune to a certain disease (ex. Hepatitis B, Varicella, MMR). 5. But I ve had the immunizations and I ve had chicken pox. Do I still need a titer? A. Yes, vaccinations and history of disease do not qualify for immunity. You will need titers as proof of immunity. 6. My Hepatitis B titer shows I am not immune. What should I do? A. See flowchart on page 9 7. Can I go to clinical while completing the repeat series of the Hepatitis B, Varicella or MMR vaccines? A. Yes! As long as you are in the process you are cleared to attend clinical. 8. My CPR expires in the middle of the semester. Do I need to renew early? A. Yes, your CPR certification needs to be in compliance for the entire school year. 9. Do I need a flu shot before the fall semester begins? A. No, you need to obtain a flu shot before September 15 th 10. When does my TDap expire? A. After 10 years 11. Can the School of Nursing access my Student Health patient portal record? A. No, only student health can see your portal record 12. How do I login to my Student Health patient portal? A. Visit link below and enter your Emory University OPUS username and password I feel like I m submitting duplicate information to the School of Nursing and Student Health. A. Unfortunately, the systems our clinical partners utilize do not communicate with the student health portal. Therefore, you must enter everything in ESS. 14. I ve heard about ACEMAPP. What is that? A. ACEMAPP is used for clinical agency specific credentialing. After you are added to your clinical rotation you will see agency specific paperwork populate. (ex. Computer login forms, agreements, etc.). You will not be added to ACEMAPP until orientation. 15. Do I get to choose my clinical placement (undergraduate students)? A. You will sign up for your clinical group sites when you register for classes. Please do not contact clinical agencies to arrange your own placement. We must abide by strict processes and procedures outlined by each clinical agency. If we violate these procedures we are in jeopardy of losing our privileges. 16. I have questions! A. SON Compliance: son-compliance@emory.edu B. ESS Questions: results@es2.com or C. Student Health Questions: immunizations-shs@emory.edu 4

5 EMPLOYMENT SCREENING SERVICES (ESS) COMPLIANCE TRACKING INSTRUCTIONS Please contact ESS Client Care should you have questions or concerns about your uploaded documents at or 1. You will receive an ESS invitation to your emory.edu address. Read the instructions and click on the link at the bottom of the . The SON pays for your compliance tracking account. If you are newly deposited, please wait up to 3 business days for an invite. 2. Agree to terms of use, create your profile and start submitting documents! a. From the account landing page, you will be able to upload your documents. If you upload an attachment that includes multiple documents, be sure to notate which documents are included. (ex. A shot record may have multiple immunizations, be sure to notate this!) 3. Once the documents are uploaded, a new status of REVIEW will appear. Once the ESS analyst team has reviewed your documents, this status will change to one of the following: a. Complete = You re done! b. Expired = Uh oh! Upload a new document c. Invalid = Yikes! Something was wrong with your document. There will be a note next to the rejected document. Try again! 4. Once all documents have been verified, you will receive a copy of the completed report via . If a status shows as Invalid there will be a note to let you know why it is invalid. You will need to upload a valid document and update your account. 5. Communicate with ESS from your Account! Easily communicate with the ESS Document Review team concerning your documents. Do not contact SON compliance regarding expired or invalid document uploads. a. Status Request a status request will send a notification to ESS Client Care to review and update. b. Add Note notes are visible to ESS staff, namely the ESS Document Review Team. Make internal notes to provide additional information. 6. I need to login again and I forgot the website! a. To log into your account, go to and click the Credentialing Log In link and use the credentials you used when creating your account Don t forget to bring your completely valid ESS report with you to orientation! 5

6 DRUG TESTING & CRIMINAL BACKGROUND INVESTIGATION RELEASE FORM By signature below, I authorize the School of Nursing to conduct a Criminal History Background Check for the purpose of complying with contractual requirements of clinical agencies seeking to identify and evaluate care providers who have been convicted of one or more criminal offenses before they participate in patient care or who fail to pass a drug test as detailed in this policy. I further agree to report any adverse event, including felony or misdemeanor charges and convictions (excluding minor traffic related violations), which occur during my enrollment in the School of Nursing within 10 business days of occurrence. The School of Nursing will be responsible for the ordering of and payment for the initial student Criminal Background Check and drug test. Clinical sites may have additional requirements or other required vendors; the student will be responsible for these additional expenses. Results of previously conducted investigations or drug tests will not be accepted by the School; Drug test panels will include: Marijuana, Cocaine, Opiates, Phencyclidine, Barbiturates, Benzodiazepines, Amphetamines, Propoxyphene, Methadone, Oxycodone and meperedine; The database check must cover the past seven (7) years or the time period since the student s 18th birthday, whichever is less and will cover all states of prior residence. The following checks will be conducted: Social Security Verification, Residency History (all states), Employment History, Georgia Statewide Criminal Search, Nationwide Sex Offender Search, Nationwide Healthcare Fraud & Abuse Scan, United States Patriot Act Search; The student s failure to consent to the background checks and/or drug screen may prevent the School of Nursing from securing suitable clinical placement for the student, thus rendering the admitted student unable to matriculate or the enrolled student unable to complete the nursing degree program NHWSN; The staff of the Office of the Dean will convey the status of the background check to the healthcare or community agency per contractual obligations as necessary Adverse results of the background checks and/or drug screens may prevent the School of Nursing from securing suitable clinical placement for the student, thus rendering the student unable to complete the nursing degree program which may result in either the revocation of admission prior to matriculation or dismissal from the program for enrolled students. Adverse results include, but are not limited to: Felony convictions, weapons possession, history of Medicaid fraud, terrorist activities, pedophilia, sex offender crimes, assault and battery and patterns of misdemeanors (for example, but not limited to, charges of driving under the influence (DWI, DUI) driving with suspended license, shoplifting, fraud, trespassing; Students must report felony or misdemeanor convictions (excluding minor traffic violations) which occur during enrollment within 10 business days of occurrence to the Office of the Dean or designee. Failure to report requisite information may constitute grounds for immediate dismissal; Students will have the opportunity to investigate and correct adverse findings with certified court documents with the assistance of the background check vendor. Students may appeal administrative actions of revocation of admission or dismissal taken as a result of information obtained in the criminal background search by submitting a written statement of appeal and supporting documents to the Office of the Dean within 10 business days of the receipt of the administrative action. I consent to follow and participate fully in Emory s drug testing and criminal background check requirements. Name (please print): Signature: Date:

7 CONSENT TO RELEASE HEALTH INFORMATION I hereby give my permission for the following health information to be shared by Emory University Nell Hodgson Woodruff School of Nursing, Office of Education with all clinical sites. Demographic information (name, Emory ID number, social security number, school of nursing class affiliation, health insurance company and policy number) Immunization information (measles/mumps/rubella (MMR), tetanus/diphtheria/pertussis (Tdap), polio, chicken pox (varicella), hepatitis B, PPD status, influenza vaccine, other) Test results and name of physician providing follow-up (hepatitis B serology, chicken pox (varicella) serology, PPD tuberculin skin tests and results, chest xrays and laboratory work for positive PPD skin tests) I understand that the immunization information will be contained in a separate student folder to be retained in the Office of Education. I hereby authorize Emory University School of Nursing to release this information to any facility that requests verification of my immunization status prior to my participation in a clinical experience at the facility. I consent to the release of this information for these specific purposes. I understand that I have the right to revoke this Consent at any time in writing. I understand that revocation of this Consent will only apply to future uses and disclosures. In addition, if I revoke Consent, this may prevent me from going to a clinical experience; which will affect my progression in the program. Name (please print): Signature: Date:

8 BLOOD BORNE PATHOGENS & HIPAA INSTRUCTIONS: Be sure to use a Windows PC or MAC computer. DO NOT use Chromebook as ELMS does not recognize that computer system. Also, the online courses are viewed best in Mozilla FireFox or Google Chrome browsers. If you try to launch the course in Internet Explorer, you will get a blank screen. Make sure your browser is up to date with plug-ins such as adobe flash or java needed to launch the course content. 1. Login to ELMS: 2. Click on My Learning tile to select your training session. If your training sessions are not listed, then click on the Find Learning 3. Enter the course code listed below to search and launch your course. EHSO BBP for Researchers and Clinicians: HIPAA in a Hurry: HIPAA Security: If you missed it or do not see your certificate upon completion, go back to the dashboard, by clicking on the Home icon located at the top right of the webpage 5. Click on My Learning tile. 6. You will see a list of the courses completed. Click on the printer icon to the right of the course to view your certificates of completion. 7. Save as a pdf file to your computer and then upload to the designated areas in ESS. ELMS TROUBLESHOOTING: 1. Check the url. The correct url iselmprod9.emory.edu. 2. If you get a duplicate course error, the course is already in your learning history in either enrolled, in progress or planned status. You need to access the course from My Learning tile. When you click on the arrow, you will be taken to the next page where you click on the launch or Re-launch in situations where the course has been launched. 3. Online classes are viewed best in FireFox, Chrome, or IE11 browsers. If you are trying to launch a course in an earlier version of IE and you get a blank screen, please try a different browser. 4. Online courses require that pop up blockers be turned off and that cookies be enabled. It may help to clear cache as well. 5. Make sure your browser version is up to-date. For example, there may be certain plug-in updates that are required for your browser to launch the content such as Adobe Flash, JavaScript,etc. 6. The HIPAA courses require Adobe Flash and you may need administrator rights to download Flash. The system may display a Flash icon when you launch. If so, click that icon and Flash will open. For Emory owned computers, Desktop support should be able to help you download Adobe Flash if the icon does not appear. 7. Chromebooks run an operating system that is not supported by the ELMS. Students will need to find a Windows or Mac computer to take the training. 8. If the course will not launch, try launching the course from another computer. There are several computers in the computing center above Cox hall that are freely available to students. They should have no trouble running the training, as well as any computers available in the libraries etc. 9. If you encounter scoring issues, please contact the class administrator. You may find the administrator s name by clicking on the course Title on the My Learning landing page. Look for the Contact line under Class Details. 10. Contact support at if you continue to have problems. 8

9 WHAT TO DO IF YOUR HEPATITIS B TITER IS NEGATIVE (CDC, 2018) 9

10 INCOMING STUDENT PHYSICAL EXAMINATION FORM All incoming medical students must return this completed, signed form PRIOR TO MATRICULATION through one of the following methods: Student s Name: Street Address: Upload the form to your Patient Portal (preferred) or a pdf to immunizations-shs@emory.eduor Fax to: or Mail to: Emory University Student HealthServices Attention: Immunization Department 1525 Clifton Road NE, Atlanta, GA Emory ID#: City: State: ZIP: Country: Gender: Male Female Transgender(please elaborate): Date of Birth (mm/dd/yyyy): / / Medical School Student Allied Health Student (Allied Health Program: ) School of Nursing Do you now have or have you ever had: No Yes No Yes No Yes Allergies/Asthma Epilepsy/Seizures Positive PPD Test/Tuberculosis Cancer Gastrointestinal Disorder Psychiatric/Behavior Disorder Cardiovascular Disease Hepatitis/Jaundice Pulmonary/Lung Disease Diabetes High Blood Pressure Skin Problems/Disease Drug/Alcohol Abuse Kidney/Urinary Disorder Tobacco use (current or past) Endocrine Disorder Musculoskeletal Disorder Other: Other: Comments (please explain any YES answers above): List all allergies: Surgeries (with dates): Previous hospitalizations (with dates): Current medications: I attest that the information shown above is true and accurate to the best of my knowledge. Student s Signature: Date:

11 PHYSICAL EXAMINATION (This page must be completed and signed by your physician, nurse practitioner or physician assistant.) Patient s Name: Height: Weight: BMI: Temp: BP: _ Pulse: RR: Vision: OD OD OS OS OU OU Without correction: With correction: Normal Abnormal Comments HEENT Neck Lungs Heart Abdomen GU (if indicated) Extremities Neurologic Adenopathy Vascular Skin Psychiatric How long and on what basis have you known this patient? Months: Years: This visit only Professional basis Personal basis To your knowledge, does this patient have any significant medical problems? Yes Explain: No To your knowledge, does this patient have any emotional, psychological or psychiatric problems? Yes Explain: No Do you know of any physical or psychological reason why this student would not be able to withstand the rigors of his/her program of study? Yes No Explain: Labs (if indicated): CXR CBC or H/H Other U/A PAP Other Physician/NP/PA Name: Phone: ( ) Address: Physician/NP/PA Signature: Date: Update

12 Immunization Form 1525 Clifton Road NE Atlanta, Georgia Phone # Fax # For School of Medicine, Allied Health, and School of Nursing Last Name: First Name: MI: Emory Student ID #: Date of Birth: / / Please select your degree program (circle one): AA DPT Gen Counseling Med Imaging MD Nursing PA All incoming Emory students must meet the CDC and American College Health Association immunization guidelines. If relevant, you may also provide copies of other official, signed immunization records. ALL VACCINATIONS AND ANY NEEDED LAB WORK ARE TO BE COMPLETED PRIOR TO MATRICULATION. (Due dates to be determined by each degree program.) If necessary, multi-dose vaccination series started prior to arrival at Emory can be completed at EUSHS. BE SURE YOUR HEALTHCARE PROVIDER SIGNS THE FINAL PAGE OF THIS FORM. For more information about the required immunizations listed below, please visit our web site at: MMR (Measles, Mumps Rubella) -- 2 doses of MMR vaccine or two (2) doses of Measles, two (2) doses of Mumps, and one (1) dose of Rubella; or serologic proof of immunity for Measles, Mumps, and/or Rubella Option 1 Vaccine Date MMR MMR Dose #1 / / 2 doses of MMR vaccine MMR Dose #2 / / Option 2 Vaccine or Test Date Measles Measles Dose #1 / / 2 doses of vaccine or positive Measles Dose #2 / / serology Serologic Immunity (IgG, antibodies, titer) / / Attach copy Mumps Mumps Dose #1 / / 2 doses of vaccine or positive Mumps Dose #2 / / serology Serologic Immunity (IgG, antibodies, titer) / / Attach copy Rubella Rubella Dose #1 / / 1 dose of vaccine or positive serology Serologic Immunity (IgG, antibodies, titer) / / Attach copy Hepatitis B Vaccination -- 3 doses of vaccine followed by a QUANTITATIVE Hepatitis B Surface Antibody (titer). Primary Hepatitis B Series Hepatitis B Vaccine Dose #1 / / Hepatitis B Vaccine Dose #2 / / Hepatitis B Vaccine Dose #3 / / QUANTITATIVE Hep B Surface Antibody / / Result miu/ml Hepatitis B Vaccine Dose #4 / / Secondary Hepatitis B Series Hepatitis B Vaccine Dose #5 (if nonimmune after primary / / series) Hepatitis B Vaccine Dose #6 / / QUANTITATIVE Hep B Surface Antibody / / Result miu/ml Hepatitis B Vaccine Non- Hepatitis B Surface Antigen responder (if Hep B surface / / Attach copy antibody neg after primary & Hepatitis B Core Antibody secondary series) / / Attach copy Hepatitis B Surface Antigen / / Attach copy Attach copy Attach copy Version: Page 1

13 Chronic Active Hepatitis B Hepatitis B Viral Load / / Attach copy Version: Page 1

14 Immunization Form, Emory School of Medicine, Allied Health, and School of Nursing Last Name: First Name: MI: Emory Student ID #: Date of Birth: / / Tetanus-Diphtheria-Pertussis (Tdap) -- One (1) dose of adult Tdap. If last Tdap is more than 10 years old, provide date of last Td and Tdap. Vaccine Date Tdap Vaccine / / Td Vaccine / / Varicella (Chicken Pox) -- 2 doses of vaccine or positive serology Vaccine Date Varicella Dose #1 / / Varicella Dose #2 / / Serologic Immunity (IgG, antibodies, titer) / / Attach copy Influenza -- required for entrance between September and April, inclusive / / Vaccinations Recommended but not Required Polio Immunization: It is recommended that all students have a documented primary series of polio immunization. Completed primary series of polio immunization. Type: Oral Inactivated Completion Date: / / Meningococcal (Meningitis ACWY) Vaccination: Date of last dose: / / HPV (Human Papillomavirus) -- Indicate which preparation, if known. HPV2 HPV4 HPV9 Dates: Dose #1 / / Dose #2 / / Dose #3 / / Other vaccinations, such as meningococcal B, hepatitis A, pneumococcal, typhoid, yellow fever, rabies (include month, day, year) : _ TUBERCULOSIS SCREENING-Emory Schools of Medicine, Nursing and Allied Health require Tuberculosis(TB) screening (one PPD skin test, a chest x-ray, or an IGRA blood test) within 6 months prior to matriculation for all students. (For School of Medicine and Allied Health, a second PPD is also required and will be administered after matriculation. For Nursing, both PPDs must be completed prior to matriculation.) If you have received BCG vaccine, an IGRA test is preferred. If you have a history of a positive TST (PPD) 10mm or IGRA please supply information regarding any evaluation and/or treatment below. You only need to complete ONE section. Emory s guidelines are based upon the recommendations of the CDC and the American College Health Association. Section A Date Placed Date Read Reading Negative Skin Test, Blood Test, or Chest X-ray TST #1 / / / / mm TST #2 / / / / mm IGRA Blood Test T-Spot Date / / Attach copy Quantiferon Gold Chest X-ray Date / / Attach copy Please continue TB screening on page 3 Version: Page 2

15 Immunization Form, Emory School of Medicine, Allied Health, and School of Nursing Last Name: First Name: MI: Emory Student ID #: Date of Birth: / / TUBERCULOSIS SCREENING, CONTINUED Section B Date Placed Date Read Reading Positive TST / / / / mm Postive IGRA Blood Test / / T-Spot History of Latent Attach copy Quantiferon Gold Tuberculosis, Positive Skin Chest X-ray / / Attach copy Test, or Positive Blood Test Prophylactic medications for latent TB taken? Yes No Section C Total duration of prophylaxis? Date Date of last annual TB symptom questionnaire (if applicable) Type test Date of Diagnosis / / months / / Attach copy History of Active Tuberculosis Date Treatment Completed / / Attach copy Date of last annual TB symptom questionnaire (if applicable) / / Attach copy Date of last Chest X-ray / / Attach copy FORM MUST BE COMPLETED AND SIGNED BY YOUR HEATHCARE PROVIDER Authorized Signature: Date: / / Printed Name and Title: Address Line 1: Address Line 2: City / State / Zip/Phone: This paper form serves to provide verification of your immunization information. Two steps are required: Step1: please enter the information on this form electronically into your Patient Portal at Step 2: please submit a copy of this form. Please be certain that all sections and signatures have been completed (including the signature of your healthcare provider) and that you have met all applicable Emory University immunization requirements. To submit the completed and verified immunization document, the preferred method is to upload a PDF version of the form through your Patient Portal at If you are unable to upload this form, then choose one of the following: - Scan and to immunizations-shs@emory.edu. We advise you to use your emory.edu address (e.g., lord.dooley@emory.edu). - Fax to: Mail to: Emory University Student Health Services, ATTN: Immunization Department, 1525 Clifton Road NE, Atlanta, Georgia, Thank you! Version: Page 3

16 NELL HODGSON WOODRUFF SCHOOL OF NURSING EMORY UNIVERSITY AFFIDAVIT OF POLIO VACCINE Students who are certain they have received the Polio Vaccine, but who are unable to obtain documentation from their physician are required to use this form to report acknowledgement of the receipt of the polio vaccination. Without the required documentation of immune status on file, (either proof from a physician or by personal verification) students may be unable to continue in the program or may be prevented to train at some clinical sites. Name: SS#: Student ID# : Date of Birth: Entered current degree program: Semester: Year: BSN, ABSN, D-ABSN - Anticipated Graduation: AMSN - Anticipated Graduation: MSN - Specialty: Anticipated Graduation: DNP - Anticipated Graduation: Other: I have a consulted a reliable source who has verified that I received the Polio vaccine series or I remember receiving the Polio vaccine series. I understand that if I provide false information on this document and have not received the Polio vaccine, as a health care worker, I continue to be at a greater than average risk of acquiring Polio, a serious disease. Signature: Date: