Checklist for Nursing Program Students

Checklist for Nursing Program Students It is recommended that students make copies of all documents for your personal record prior to submitting. Complete and upload the following forms to CastleBranch by the November 15th (spring admission) or July 15th (fall admission) deadline. Failure to complete this task will result in the loss of your seat in the Nursing program. o Health/Immunization Form completed and signed by Health Care Provider (Parts A & B) o Copies of documentation of immunization status or copies of lab serology titer results o Important Notices for Nursing and Dental Hygiene Students in Clinical Training o Authorization for the Release of Educational Records to Clinical Facility o Student Accountability Verification Form o Faculty Authorization for Reference o CPR certification (American Heart Association Healthcare Provider ONLY) Attach copy of certification. (Front and back of current signed card) o LPN license number (LPNs only) o Background Study On the health/immunization form, please complete Part A yourself, including your signature at the bottom of Part A, and have your health-care provider complete Part B. Included is a letter you may use for your health-care provider explaining the Pre-Entrance Health/Immunization form. Immunization records and compliance can be a complicated issue, with multiple healthcare visits as most students need a two-step Mantoux test. Significant costs may be incurred. Students currently enrolled in classes can utilize the Health Clinic (2nd Floor of Campus Center) at no cost. Students are to upload an additional one-step Mantoux annually to CastleBranch. 1

This page intentionally left blank. 2

North Hennepin Community College Nursing Program Dear Health-Care Provider: The bearer of the attached Pre-Entrance Health/Immunization Record has met the academic admission qualifications for admission into the North Hennepin Community College Nursing Program. Eligibility for clinical experience in the Nursing Program includes completion of the attached form. The immunization record must be completed and up-to-date before the student can secure the position in the nursing program and start a clinical learning experience. Failure to submit the completed form by the designated due date may cause the student to forfeit his/her place in the class. Your assistance in certifying this student s health and immunization record is most appreciated. Sincerely, Traci Brakefield, MS, RN Associate Dean of Nursing & Allied Health North Hennepin Community College 7411 85th Avenue North Brooklyn Park, MN 763-424-0761 tbrakefield@nhcc.edu 3

This page intentionally left blank. 4

NORTH HENNEPIN COMMUNITY COLLEGE NURSING PROGRAM Pre-Entrance Health/Immunization Record Immunization Records: A completed immunization form must be on file. If a student does not have the required immunizations, a clinical site may refuse to accept the student at its facility. The Nursing Program does not guarantee an alternative facility placement, and if no alternative facility placement is available, the student cannot complete the clinical requirements of the program and therefore will be not be eligible to progress in the Nursing Program. This policy includes students who are conscientious objectors to immunizations. PART A: Personal Information (to be completed by the student) STUDENT NAME: ADDRESS: (Last) (First) (Middle) (Maiden) (Street) PHONE: (Home) (City) (State) (Zip Code) (Work/Cell) DATE OF BIRTH: IN CASE OF EMERGENCY: Person to be contacted NAME: RELATIONSHIP: ADDRESS: (Street) (City) (State) (Zip Code) PHONE: (Home) (Work/Cell) 5

This page intentionally left blank. 6

PART B: Healthcare Provider Signature Form All nursing students are required to submit documentation of the immunity requirements listed below. A signature from the MD, DO, PA or APRN who certifies the information provided by the student is required at the bottom of this form. These immunity requirements are designed to ensure that students meet not only the requirements determined by Minnesota s College Immunization Law (http://www.health.state.mn.us/divs/idepc/immunize/laws/ collegelaw.html) and recommended guidelines by the Centers for Disease Control and Prevention (www.cdc.gov) but also attempts to ensure that students meet the requirements of most clinical placement sites. Students please note: if you need vaccines and choose the Conscientious Exemption options, your progression in clinical and your ability to complete the program may be jeopardized. IMMUNITY REQUIREMENTS: Tuberculosis Screening Documentation of ONE of the following within the past 12 months: 1. Two-step tuberculin skin test (TST): a. Current TST and Date Given: Result: Previous TST (within the last 12 months of current) Date Given: Result: Students who have not had a TST in the past 12 months will need a full two-step TST 2. QuantiFERON (QFT) or T-spot blood test. Date Given: Result: Attach lab results 3. If your Tuberculosis test is positive, you also need to provide signed documentation from a clinic of one subsequent negative chest x-ray AND negative annual symptom survey since your chest x-ray. Mumps Immunity All students must have ONE of the following: - Two doses of vaccination against mumps after 12 months of age (attach documentation) - Mumps titer indicating immunity Date Given: Result: Rubeola (Red Measles) Immunity All students must have ONE of the following: - Two doses of vaccination against Rubeola after 12 months of age (attach documentation) - Rubeola titer indicating immunity Date Given: Result: Rubella (German Measles) Immunity All students must have ONE of the following: - Two doses of vaccination against Rubella after 12 months of age (attach documentation) - Rubella titer indicating immunity Date Given: Result: Hepatitis B Immunity All students must have completed the series of 3 vaccinations or have a Hepatitis B titer indicating immunity, OR have a signed Hepatitis B (HBV) Vaccine Waiver Form on file with the School of Nursing. Tetanus Diphtheria/TDaP (Adult Type) All students must have had a tetanus vaccination/booster in the past 10 years and an adult type TDaP. 7

Varicella (chicken pox) Immunity All students must have ONE of the following: Had chicken pox please check if applies. Approximate Age & Date - Two doses of Varicella vaccine (attach documentation) - Varicella titer indicating immunity Date Given: Result: *If any your titers indicate you do not have immunity, a booster vaccine is recommended. Seasonal Influenza Vaccine All students must have a seasonal flu vaccination or documentation of a medical contradiction or allergy as to why they cannot receive it. Immune Status: Nursing and dental hygiene students are assigned in clinical areas where exposure to infection and communicable diseases is common. The individual s immune response or status is sufficient to allow assignment in all clinical areas and to all patients (assuming use of protective measures ordered by the facility.) Yes No Please advise of necessary limitations. Allergies: Describe any allergies we should know about. Indicate symptoms experienced when exposed to the allergen. By signing below, I certify that I have reviewed the immunity information for this individual in relation to the requirements listed on this form and the information is complete and accurate, and that this individual has no health problems which would jeopardize his/her or an assigned patient s welfare. Student Name-Printed Signature of Health Care Provider Credential Date Name of Health Care Provider Printed Credential Printed Clinic Name and Address Clinic Telephone Number _ 8

STATE OF MINNESOTA MINNESOTA STATE COLLEGES AND UNIVERSITIES IMPORTANT NOTICES for Nursing and Dental Hygiene Students in Clinical Training REASONABLE ACCOMMODATIONS There are conditions for which accommodations may be appropriate under the Americans with Disabilities Act. The Nursing/Dental Hygiene Program will make all reasonable accommodations required by law for otherwise qualified individuals. To receive a reasonable accommodation during your clinical experience you must contact Access Services as far in advance as possible to discuss the matter. Students on clinical training who have questions about dealing with personal medical conditions other than disabilities for which they are seeking a reasonable accommodation should consult with the clinical facility. RESPONSIBILITY FOR HEALTH CARE COSTS Students are strongly encouraged to carry health insurance. If you choose not to carry health insurance and a medical issue should arise during the period of time you are a student in the Nursing/Dental Hygiene Program, you are solely responsible for any costs incurred. WORKERS' COMPENSATION The position of the clinical facilities and Minnesota State is that, as a nursing or dental hygiene student, you are not an employee of either the clinical facilities to which you are assigned or of Minnesota State for Workers' Compensation insurance purposes. CRIMINAL BACKGROUND CHECKS An integral part of the Nursing/Dental Hygiene Program is the clinical experience program. To provide this experience, Minnesota State contracts with local health care facilities. State law requires that any person who provides services which involve direct contact with patients and residents of a health care facility have a background study conducted by the State. A facility most likely will initiate a background study by asking you to complete a form so that a criminal background check can be conducted. If, as a result of the background study, you are disqualified from direct contact, it is highly unlikely that the facility will be able to allow you to participate in its clinical experience program. If you refuse to cooperate in the criminal background check, the clinical facility will refuse to allow you clinical experience program participation. The Nursing/Dental Hygiene Program does not guarantee an alternative facility placement. If no facility placement is available, you may not be able to continue in the Nursing/Dental Hygiene Program. HEALTH INFORMATION Some facilities also impose certain requirements regarding the health of persons working in their facilities and may require that health information (such as immunization records) about students in clinical site programs be made available to them. You may be asked to provide health information which will be used by the facility to determine whether you meet the clinical site's health requirements for care providers. Health information collected is your private data. The information provided will be maintained in a secure manner, refusal to provide the health information requested could mean that a clinical site may refuse to accept you at its facility. The Nursing/Dental Hygiene Program does not guarantee an alternative facility placement. If no alternative facility placement is available, you may be unable to continue in the Nursing/Dental Hygiene Program. CLINICAL PLACEMENT The Nursing and Dental Hygiene Programs endeavor to provide students with appropriate clinical training placements, but cannot guarantee placements in all circumstances. Students with personal circumstances that may limit their eligibility for participation in clinical experiences are encouraged to contact the Nursing/Dental Hygiene Program Director as soon as possible. The Nursing/Dental Hygiene Program does not guarantee an alternative facility placement. Students with these circumstances may be unable to continue in the Nursing or Dental Hygiene Program. By printing and signing my name below, I am verifying that I have read the notices above and understand that I can contact the Nursing or Dental Hygiene Program Director if I have additional questions. Print full name: Signature: Date: 9

TO WHOM IT MAY CONCERN: AUTHORIZATION FOR THE RELEASE OF EDUCATION RECORDS TO CLINICAL FACILITY I,, hereby authorize Minnesota State to release and/or orally discuss the education and health records described below about me to any hospital or health care facility where I will be participating in a clinical experience. This also includes, but is not limited to, reports, records and letters or copies regarding a background study performed by the Department of Human Services or a request to the Commission of Health for reconsideration of a disqualification. The specific records covered by this form that I give my permission to be released are noted below: Email Address Phone Number(s) Birthdate Background Study Results Immunization/Health Information Social Security number to establish access to electronic medical records system: The persons to whom the information may be released and their representatives may use this information for the following purposes: to establish my eligibility for the clinical experience and my access to the facility s electronic medical record system. I understand that the records information listed above includes information that is classified as private about me under Minn. Stat. 13.32, and the Federal Family Education Rights and Privacy Act. I understand that by signing this authorization, I am authorizing the university to release to the entities or persons named above and their representatives information that would otherwise be private and not accessible to them. I understand that without my informed consent, the university could not release the information described above because it is classified as private. I understand that, at my request, the university must provide me with a copy of any education records it releases to the persons named above pursuant to this authorization. I understand that I am not legally obligated to provide this information and that I may revoke this consent at any time. This consent expires upon completion of the above stated purpose or after one year, whichever comes first. However, if the above-stated purpose is not fulfilled after one year, I may renew this consent. A photocopy of this authorization may be used in the same manner and with the same effect as the original documents. I am giving this consent freely and voluntarily, and I understand the consequences of my giving this consent. I understand that if I do not give consent, that I may not be permitted to participate in clinical training at the hospital or health care facility which could result in my termination from the Nursing/Dental Hygiene program. Date: Print full name: Signature: 10

Name: Student Accountability Verification Form Please read each section and initial the box for each section. Statement of Student Responsibility/Confidentiality Initial I understand I have an obligation to conduct myself in a professional manner in all clinical areas, follow all facility policy and procedures, and hold confidential all information concerning the patients at clinical facilities. I understand any carelessness or thoughtlessness or release of any confidential information is not only ethically wrong, but may involve the individual and the clinical facility legally. This results in a failure to meet standards of professional and academic integrity. I agree to adhere to the professional standards of confidentiality while enrolled in the Nursing Program. I understand the unique and personal nature of patient care that is involved in the education of nurses and fully intend to safeguard the privacy of all patients for whom I give care as well as their families. I will not disclose information about my patients, their families or information about fellow students, and faculty that may be obtained during my studies in Nursing. I understand that this confidentiality is essential in the profession of nursing. Authorization for the Release of Background Information Initial I hereby authorize the MANE Representative Nursing Program to release information contained in its files (including but not limited to reports, records and letters or copies thereof) regarding a background study performed by the Department of Human Services, or a request to the Commissioner of Health for reconsideration of a disqualification, to determine my eligibility to participate in clinical placements to fulfill the requirements of the Nursing Program. This information may be released to any of the facilities used for clinical experience. I understand that the facility will review this information to assess whether I may be permitted to participate in a clinical placement for the Nursing Program. If background clearance is denied/not received by the Department of Human Services, I understand that I will be removed from clinical courses until a background clearance is obtained. I understand that I am not legally obligated to provide this information. However clinical sites require a background clearance prior to participation in clinical experiences involving direct patient care. If I do provide it, the data will be considered private data under state and federal law, and released only in accordance with those laws, or with my consent. I provide this information voluntarily and understand that I may revoke this consent at any time. A photocopy of this authorization may be used in the same manner and with the same effect as the original documents. This authorization is valid for the entirety of my student experience in the Nursing Program. Responsibility for Health Care Costs Initial Any health care costs incurred during the period of time I am a student in the Nursing Program will be my responsibility. Workers Compensation Initial It is the position of the clinical facilities and the College/University that, as a nursing student, I am not considered an employee of either the clinical facilities to which I am assigned or the College/University for purposes of Workers Compensation insurance. 11

Release of Health Information Initial I understand that there are conditions for which accommodations may be appropriate under the Americans with Disabilities Act and that the Nursing Program will make all reasonable accommodations required by law for otherwise qualified individuals. To receive accommodations, I must contact Access Services. Refer to the Access Services for types of accommodations. I grant the MANE Representative Nursing Program permission to share information contained in the Pre-clinical Health Form with those clinical institutions with whom I affiliate in my student role, should the clinical institution request or require it. I understand failure to sign this form or to provide the information requested could mean a clinical site may refuse me placement at their facility. The Nursing Program does not guarantee an alternative facility placement. I also understand that if no alternative facility placement is available, I may be unable to progress in the Nursing Program. Media Consent & Lecture Capture I hereby give North Hennepin Community College (NHCC) the right to use, edit, reproduce, and distribute my photograph, video, voice, and/or written testimonial for educational, publication, marketing, and/or online purposes without compensation to me or liability to NHCC. I understand that NHCC shall have total and exclusive control over these media, and I waive any right to inspect or approve any said usage. I state that I am at least 18 years of age and am competent to contract in my name; or if under the age of 18, a parent or guardian may sign on my behalf. I have read and understand this Media Consent Form. Simulation & Nursing Learning Resource Center Code of Conduct Initial I have read and understand the Simulation and Nursing Learning Resource Center code of conduct and agree to comply with the program. See the handbook for the entire code. Nursing Student Handbook Initial I verify that I have received the nursing program s Student Handbook and read it in its entirety. I agree that I am responsible for the content provided in the handbook, as well as updated program policies, throughout my enrollment in the Nursing Program. I understand that I am responsible for compliance with the statements and policies identified in the Nursing Student Handbook. Initial I have read, understand, and agree to comply with the Student Handbook. I acknowledge that this signed consent form will be in place throughout the course of time I am affiliated with the NHCC MANE nursing program. Student Printed Name Student Signature Date: 12

Nursing Student Authorization for Faculty Reference Student Name (Please print): I authorize all my nursing instructors that I have individually notified in writing, to release information and provide an evaluation about any and all aspects of my academic performance at to the following: (check all applicable spaces) 1. all prospective employers OR specific employers (list on reverse side) 2. all educational institutions OR specific educational institutions to which I seek admission (list on reverse side) 3. all organizations OR specific organizations considering (list on reverse side) me for an award or scholarship The reference may be given in the following form(s): (check one or both spaces) Written Oral This authorization to provide references is valid for one (1) year from the date of my signature below, unless I specify an earlier ending date as follows: Ending date: North Hennepin Community College NOTE: Under the Family Educational and Privacy Rights Act, 20 U.S.C. 1232(g), you may, but are not required, to waive your right of access to confidential references given for any of the purposes listed on this form above. If you waive your right of access, the waiver remains valid indefinitely. Check the appropriate space below: I waive my right of access to references about me. I do not waive my right of access to references about me. Name Student ID Number Date 13

This page intentionally left blank. 14

APPLICANT BACKGROUND STUDY You received this form because you applied for a position that requires a Minnesota Department of Human Services (DHS) background study. Follow the instructions below to submit your background study request to the provider. The provider will review and may submit your background study request to DHS. Provider means a facility, program, or agency initiating background study requests under Minnesota Statutes, chapter 245C. Provider Name and License Number NORTH HENNEPIN COMM COLL-NURSING DEPT. (900200) 900200 Provider Number N6RT3Q Instructions 1. Go to NETStudy 2.0 Applicant Portal https://netstudy2.dhs.state.mn.us/applicant 2. Create an Account If you have not created an account before: a. Click Register as a new user. b. Enter your account information. Click Register. c. Check your email for the temporary password. 3. Login Your username is your email address. A temporary password was sent to the email account you used to register. When you login, you will be prompted to change your password and choose a security question. 4. Enter Application Information a. Click Create Application on the home screen b. Enter N6RT3Q in the provider number field. Click Search. If the correct provider is displayed, click Continue Application. If an incorrect provider is displayed, contact the provider that gave you this form. c. Enter your demographic information. Click Next after you have completed all required fields. After you have reviewed the information from the registry screen, click Finish. Clicking Finish will submit your application to the provider. d. Be careful to enter the information correctly. You will not be able to change it unless you contact the provider. Frequently Asked Questions Will I be notified when I can be fingerprinted and photographed? Yes. You will be notified by email that the provider submitted the background study to DHS. Log into NETStudy 2.0 to retrieve the Fingerprint and Photo Authorization Form on the home screen under Forms for the applicable provider. You cannot be fingerprinted and photographed until the provider submits the background study request to DHS. What happens next? The provider will review and verify your background study information. If the provider chooses to submit the background study request, you and the provider will receive a notice of your background study status. The notice will be mailed to you within three days of your fingerprints and photo being taken. The provider will receive the notice electronically. Where do I find more information? You can find information on the Background Study website at www.dhs.state.mn.us, select General Public; Office of Inspector General; Background Studies. What if I have questions? If you have questions about your background study status call (651) 431-6620. If you have questions about this notice or technical issues registering an account call (651) 431-6625. 5. Retrieve the Fingerprint and Photo Authorization Form After the provider submits your background study to DHS, you will receive an email that the Fingerprint and Photo Authorization Form is available. Login to NETStudy 2.0. On the home screen, locate the Fingerprint and Photo Authorization Form under Forms for the applicable provider. Version: 03212016 15

BACKGROUND STUDY NOTICE OF PRIVACY PRACTICES Because the Department of Human Services (DHS) is asking you to provide private information, you have privacy rights under the Minnesota Government Data Practices Act. This law protects your privacy, but also allows DHS to give information about you to others when the law requires it. This notice describes how your private information may be used and disclosed, and how you may access your information. Why is DHS asking me for my private information? A background study from the Department of Human Services (DHS) is required for your job or position. The private information is needed to conduct the background study. How will I be notified that a background study was submitted on me? DHS will mail you a notice within three working days after a request for a background study is submitted on you. The notice will contain the background study result or let you know that more time is needed to complete the background study. The notice will also identify the entity that submitted the background study request. What information must I provide to complete the background study? You are required to provide enough information to ensure an accurate and complete background study. This includes your: first, middle, and last name and all names you have ever been known by or used; current home address, city, zip code, and state of residence; previous home addresses, city, county, and states of residence for the last five years; sex and date of birth; driver s license or other identification number, and; fingerprints and a photograph. How will the information that I give be used? The information will be used to perform a background study that will include a check to determine whether you have any criminal records and/or have been found responsible for substantiated maltreatment of a vulnerable adult or child. Background study data is classified as private data and cannot be shared without your consent except as explained in this notice. What may happen if I provide the information? You could be disqualified from positions that require a DHS background study if you are found to have committed certain crimes, been determined responsible for maltreatment of a vulnerable adult or child, or have other records that require a disqualification. If you do not have a disqualifying record, you will be cleared to work. What if I refuse to provide the information? You will be disqualified if you refuse to provide information to complete an accurate background study. You will not be able to work in a position that requires a DHS background study. Who will DHS give my information to? DHS will only share information about you as needed and as allowed or required by law. The identifying information you provide will be shared with the Minnesota Bureau of Criminal Apprehension and in some cases the Federal Bureau of Investigation (FBI). If there is reasonable cause to believe that other agencies may have information related to a disqualification, your identifying information may also be shared with: county attorneys, sheriffs, and agencies; courts and juvenile courts; local police; the Office of the Attorney General, and; agencies with criminal record information systems in other states. What information will DHS share with the entity that requested my background study? The entity that requested the background study will be notified of your background study determination. If you are disqualified, the entity will not be told the reason unless you were disqualified for refusing to cooperate with the background study or for substantiated maltreatment of a minor or vulnerable adult. What other entities might DHS share information with? Information about your Background study may be shared with: the Minnesota Department of Health; the Minnesota Department of Corrections; the Office of the Attorney General, and; health-related licensing boards. 16

What if my disqualification is set aside? If you request reconsideration of your disqualification and your disqualification is set aside, the entity that requested the background study will be informed of the reason(s) for your disqualification unless the law states otherwise. DHS will provide information about the decision to set aside your disqualification if the entity requests it. Unless prohibited by law, your name and the reason(s) for your disqualification will become public data if your set aside is for: a child care center or a family child care provider licensed under chapter 245A, or; an offense identified in section 245C.15, subdivision 2. For future background studies submitted by entities that provide the same type of services as the services you were set aside for, the set aside will apply unless: you were disqualified for an offense in section 245C.15, subdivision 1 or 2, or; DHS receives additional information indicating that you pose a risk of harm, or; your set aside was limited to a specific person receiving services. In addition, those entities will be informed of the reason(s) for your disqualification unless prohibited by law. Will my fingerprints be kept? DHS and the Bureau of Criminal Apprehension will not keep your fingerprints. However, if an FBI check is required for your background study, the Federal Bureau of Investigation (FBI) will keep your fingerprints and may use them for other purposes. What information can the fingerprint and photo site view and keep? The fingerprint and photo site can view identifying information to verify your identify. The fingerprint and photo site will not keep your fingerprints, photo, or most other information. The fingerprint and photo site can keep your name and the date and time your fingerprints were recorded and sent, for auditing and billing purposes. Who can see my photo? Your photo will be kept by DHS. If you provide your social security number to allow your background study to be transferable to future entities, your photo will be available to those entities to verify your identity. What are my rights about the information you have about me? You may ask if we have information about you and request in writing to get copies. You may have to pay for copies. You may give other people permission to see and have copies of private information about you. You may ask in writing a report that lists the entities that submitted a background study request on you. You may ask in writing that the information used to complete your background study be destroyed. The information will be destroyed if you have: (1) not been affiliated with any entity for the previous two years, and; (2) no current disqualifying characteristic(s). Please send all written requests to: Minnesota Department of Human Services Background Studies Division NETStudy 2.0 Coordinator PO Box 64242 St. Paul, MN 55164-0242 How long will DHS keep my background study information? DHS will destroy: your photo when you have not been affiliated with an entity for two years. any background data collected on a you after two years following your death or 90 years after your date of birth, except when readily available data indicates that you are still living. What is the legal authority for DHS to conduct background studies? Background studies are completed by DHS according to the requirements in Minnesota Statutes, chapter 245C. Background studies are authorized under Minnesota Statutes, sections 256B.0943, subdivision 5a; 256B.0659, subdivision 11(a)(3); 241.021, subdivision 6(a);144.057, subdivision 1; 518.165, subdivision 4, and 524.5-118; What if I think my privacy rights have been violated? You may report a complaint if you believe your privacy rights have been violated. If you think that the Minnesota Department of Human Services violated your privacy rights, you may send a written complaint to the Minnesota Department of Human Services, Privacy Official at: Minnesota Department of Human Services Privacy Official PO Box 64998 St. Paul, MN 55164-0998 17 Updated: 02/12/2015