Childrens Hospital Los Angeles

CHILDRENS HOSPITAL LOS ANGELES STUDENT/OBSERVER and NON EMPLOYEE HEALTH CLEARANCE REQUIREMENTS FOR PLACEMENT AT CHLA

This form must be COMPLETED AND INCLUDE ALL CURRENT DATES where indicated. This MUST be submitted to the CHLA Program Coordinator no later than the student’s, non- employee, non-volunteer’s 1st day at CHLA. If this form is incomplete or not received, then the students, observers, non-employee, non-volunteer will not be allowed to begin his or her rotation at CHLA. Incomplete forms will result in a delay in placement.

Please complete the following with the appropriate dates where indicated, and an “X” to indicate Verified: Student Name PHYSICAL Flu IZ.: Dates Required: Verified: Verified: Date of: Expiration Verified: EXAM TB Testing Measles, Mumps, Positive Varicella HBV Vaccine Date: Malpractice Date of MUST have a negative TB PPD in the past 12 months. If no test Rubella Titers Verification Series or Current Insurance and in past 12 months needs a 2-Step TB PPD Test. Immunization Positive History or Declination CPR Card (If Not DATE where If 2-Step was done more than 1 year ago, it is still valid as long (two doses given at written documentation of Form Provided PHYSICAL given as follow up PPD testing was done annually and a single TB any age) or two varicella vaccine (positive titer *Put N/A if By School) EXAM PPD test was done in the past 12 months. A negative IGRA in Immunity verified injections at 6 weeks or evidence not PASSED or the past 12 months may be substituted. by positive titers or apart. of receiving required *Put N/A if *Put N/A if Signed written medical series not required Physical Exam Declinati CXR if PPD or IGRA is Positive. documentation of Consider two twice if titer is not required on Illness vaccinations at 6 weeks negative). Form (Verification of apart if no written illness does not documentation or Students who have to be written positive titers are cannot documentation if provided. provide proof If born before of immunity Dates of Initial 2 Step Date of Last CXR (if 1957). Students who cannot may decline TB Tests: A negative positive TB Test or provide proof or cannot the series but Date of IGRA such as the T- positive IGRA. Tdap given one recall having immunity they are Last Spot or Quantiferon Annual time as an adult. may decline, but they advised Annual Gold may be Questionnaire: are advised against against doing TB Test: substituted for any  to confirm no active Students who doing so. Please refer to so. Please skin test requirement. disease thereafter. cannot show proof EHS. refer to EHS may formally decline MMR or Tdap, but they are advised against doing so. Please refer to EHS.

Affiliate School: Instructor Name: Rotation Dates: Unit(s): *Any individual who has not had Varicella/Titers Verification/Vaccine and is exposed will not be allowed to enter CHLA from the 10th day through the 21st day. (Updated 5/17/1) ** If PPD expires before end date the end date becomes the date the PPD expires. Individual must show proof of new PPD and submit to HR for extension.