Health and Professional New Adjunct/Faculty Checklist Health Requirements: Healthcare Provider Immunization Verification
Agencies Offering Immunization (Information Sheet)
Current CPR/BLS: You must successfully complete an American Heart Association Health Care Provider Course and submit a copy of the wallet card or other proof of completion. CPR EXPIRATION DATE:______
Pre-Clinical Physical Exam
Professional Requirements:
Confidentiality Agreement
Criminal Background (the CON will reimburse cost.)
3 Letters of Professional Reference (nurse manager, faculty, colleague who have witnessed patient care or teaching/precepting.) These must be a hard copy on letterhead with a signature and sent to Laura Welborn (see contract information on business card)
Obtain official transcripts from all nursing programs that you have attended.
Copy of current RN Licence & Regulation information from OBN Website: https://license.ohio.gov/lookup/
Completion of the Core Competencies: Please go to www.lourdes.edu >Academics>College of Nursing>Current Students>Health Forms and Uniforms. You may submit an email attachment or submit a hard copy with your other documents. Other:
Review job description (note dates for Adjunct Development Day(s)) (includes: dress code, Responsibilities of faculty, teaching assistants, and preceptors in a clinical setting)
Review pay scale for professional contract based on Teaching Assistant (workload hours) rather than hourly. Contract includes: Adjunct meetings that are mandatory, clinical meetings, grading, evaluations, etc. Contract will be issued about 2-3 weeks into the semester.
Review syllabus of course you are teaching
Obtain contact information for Clinical Coordinator (plan on meeting)
Visit qsen.org website to prepare for teaching in the curriculum
Review "New Hire Packet" from Human Resources
______I agree to review and update any health and professional requirements as needed. Initial Here ______I understand that these requirements are non-negotiable in order to teach clinical. I further Initial Here acknowledge that if I do not complete these requirements by the established deadline, I will not be allowed to teach clinical.
______This acknowledgement indicates that I have reviewed the Ohio Board of Nursing rules and regulations, Initial Here including, but not limited to, §4723-5-20 and §5.8 Appearance/Dress Code.
R:\COMMON\Clinical\Health and Professional Requirements\ Health and Professional Packet 1 Revised 06.2016 Health Requirements Health and Professional Requirements Healthcare Provider Immunization Verification New Clinical Faculty and Clinical Adjunct
Name: ______(Please PRINT)
DOCUMENTATION NEEDS TO BE PROVIDED FOR ALL REQUIREMENTS A Physician waiver will not be accepted by clinical agencies as meeting the requirements 3 Dose Hepatitis B Immunization Series Negative Hepatitis B Antegen OR ______, ______, ______, Date: ______(Copy of lab report required)
2 MMR immunizations after age 2, at Rubella Titer date ______(Copy of lab report required) least 4 weeks apart #1 date______OR Rubeola Titer date______(Copy of lab report required)
#2 date______Mumps Titer date______(Copy of lab report required)
Tetanus/Diphtheria Immunization (within last ten years – date: ______)
Initial 2 step Tuberculin skin test (PPD) Negative yearly PPD for 2 Yearly physician T-Spot years prior to first clinical: statement of absence of Date #1: ______disease for positive Date: ______Result: ______Date #1______reactors. OR OR OR Date #2:______Date #2 ______Date: ______Result: ______Result: ______Note: date of second test to be initiated one to three weeks after first test read
Varicella Immunization OR Varicella Titer (Copy of lab report required) ______(date) ______(date)
Most Recent Seasonal Influenza Vaccination ______(date)
Healthcare Provider Signature: ______Date: ______Healthcare Provider Name: ______(PRINT or TYPE)
R:\COMMON\Clinical\Health and Professional Requirements\Health and Professional Packet Revised 02.2015 2 Healthcare Provider Form
PRE-CLINICAL PHYSICAL EXAMINATION
The individual whose name appears on this form is a faculty member in the Nursing Program at Lourdes University. To meet criteria to the clinical agencies the following examination is required.
Name: ______Last Name First Name MI Maiden/Other
Address: Street
City State Zip
Date of Birth: Month Date Year
______
Yearly PPD: ______Date Results: Positive Negative ______Date
Yes, Free of evidence of communicable disease No, not free of evidence of communicable disease If no, Comments/Recommendations:
TECHNICAL STANDARDS VERIFICATION BY HEALTHCARE PROVIDER* Check only one of the boxes below and sign where indicated:
I certify that I have examined the above named student and that the student has no physical or mental conditions that in my professional judgment would prevent him/her from meeting the Technical Standards for Nursing Students* outlined in the accompanying table.
I certify that I have examined the above named student and that I have found a condition(s) that would prevent him/her from meeting, without disability-related accommodations, the Technical Standards for Nursing Students* outlined in the accompanying table. I recommend that the student contact the Lourdes University Office of Accessibility Services to discuss disability-related accommodation options.
I certify that I have examined the above named student and that I have found a condition that would prevent him/her from meeting, the Technical Standards for Nursing Students* with or without disability- related accommodations outlined in the accompanying table.
List condition(s) (use back of form if additional space is required): ______
______* Please review Technical Standards for Nursing Students form attached.
Date of Physical Examination:
Name of Health Care Provider (Print or Type):
Address of Health Care Provider:
Signature of Health Care Provider:
6832 Convent Blvd., Sylvania, Ohio 43560 PHONE: 419-824-3789 FAX: 419-824-3985
R:\COMMON\Clinical\Health and Professional Requirements\Health and Professional Packet 3 Revised 02.2015 Information Sheet
AGENCIES OFFERING IMMUNIZATIONS
ALLEN COUNTY HURON COUNTY OTTAWA COUNTY Allen County Combined Health District Huron County General Health District Ottawa County Health Department 219 E. Market St., Lima, Ohio 45802 180 Milan Ave., Norwalk, Ohio 44857 1856 E. Perry St., Port Clinton, Ohio 43524 (419) 228-4457 (419) 668-1652 (419) 734-6800 [email protected] [email protected] [email protected]
DEFIANCE COUNTY PUTNAM COUNTY Defiance County General Health District LUCAS COUNTY Putnam County Health Department 1300 E. Second St., Defiance, Ohio 43512 Toledo-Lucas County Health Department 256 Williamstown Rd., Ottawa, Ohio 45875 (419) 784-3818 635 N. Erie Street, Toledo, Ohio 43604 (419) 523-5608 [email protected] (419) 213-4100 [email protected] [email protected] ERIE COUNTY SANDUSKY COUNTY Erie County General Health District Sandusky County Combined General Health 420 Superior St., Sandusky, Ohio 44870 Adult/Travel Immunization Clinic – District (419) 626-5623 (419) 213-4163 2000 Countryside Dr., Fremont, Ohio 43420 [email protected] By appointment only (419) 334-6377 [email protected] FULTON COUNTY Western Lucas County Clinic SENECA COUNTY Fulton County Health Department 330 Oak Terrace, Holland, Ohio 43528 Seneca County General Health District 606 S. Shoop Ave., Wauseon, Ohio 43567 (419) 213-6255 71 S. Washington St., Tiffin, Ohio 44883 (419) 337-0915 (419) 447-3691 [email protected] THE TOLEDO HOSPITAL – [email protected] Occu Health Center FINDLAY CITY HEALTH 2150 W. Central Ave., Toledo, Ohio 43506 WILLIAMS COUNTY DEPARTMENT (419) 291-5517 Williams County Combined Health District 1644 Tiffin Ave., Suite A, Findlay, Ohio 310 Lincoln Ave., Montpelier, Ohio 43543 45840 REYNOLDS CLINIC (419) 485-3141 (419) 424-7105 2450 N. Reynolds Rd., Toledo, Ohio 43615 [email protected] [email protected] (419) 535-3214
HENRY COUNTY NW OHIO URGENT CARE CENTER WOOD COUNTY Henry County General Health District (formerly Industrial Medical Center) Wood County Combined General Health 1843 Oakwood Ave., Napoleon, Ohio 43545 1155 E. Alexis, Toledo, Ohio 43612 District (419) 599-5545 (419) 726-6500 1840 E. Gypsy Lane Rd., Bowling Green, [email protected] Ohio 43402 (419) 352-8402 [email protected]
R:\COMMON\Clinical\Health and Professional Requirements\Packet 4 Information Sheet
CPR Training Requirement (CPR/BLS Information)
In preparation for your clinical experiences, it is required that you obtain and maintain current Training in BLS (CPR), according to the guidelines set forth by the American Heart Association for Healthcare Providers (AHA HCP). To find an American Heart Association Training Center near you please call 1- 877-242-4277 (1-877-AHA-4CPR) or go to the AHA web site at www.americanheart.org. You will be prompted to enter your zip code and then be directed to AHA Training Centers near you. Many hospitals, fire departments and rescue agencies are designated AHA Training Centers. Because schedules and availability vary, you should call early and follow their registration instructions. Fees vary from place to place*
For your convenience a list of local AHA Training Centers are listed here:
Flower Hospital Mercy St. Anne’s Hospital 419-824-1283 419-407-2410
Toledo Hospital Mercy St. Vincent Medical Center 419-291-4528 419-251-4397
University of Toledo Medical Center St. Luke’s Hospital 419-383-5204 419-897-8331
In addition, there are instructors, affiliated with these training centers, who will offer on-site classes. Please call us for their names and contact information.
*The American Heart Association strongly promotes knowledge and proficiency in BLS, ACLS, and PALS and has developed instructional materials for this purpose. Use of these materials in an educational course does not represent course sponsorship by the AHA and any fees charged for such courses do not represent income to the AHA.
R:\COMMON\Clinical\Health and Professional Requirements\ Health and Professional Packet 5 Revised 02.2015 Professional Requirements
CONFIDENTIALITY AGREEMENT
As an adjunct, I understand that certain information to which I have access contains confidential client, patient, and management information. With references to this information, I agree to the following:
1. To abide by all laws, regulations, and agency policy and procedures relating to the confidentiality of client’s business, patient, and management information;
2. To use client business, patient, and management information only as it relates to my nursing duties;
3. I understand that I cannot copy, record, or use in any manner any information that could be connected to agency clients, patients, or business matters:
4. To continue to maintain the confidentiality of all client, patient, business, and management information after the termination of my adjunct clinical placement and to refrain from accessing the same records or computer systems after the termination of my education; and
5. To permit this Confidentiality Agreement to be kept as part of my adjunct file.
I have completed core concepts education in client and management information confidentiality and understand that my signature constitutes acceptance of the terms of this Agreement and compliance with the core concepts standards. I understand that any violation of this Agreement during my clinical placements will result in disciplinary action. Any violation of this Agreement at any time may result in legal action taken against me.
Name (please print) Date
Signature
R:\COMMON\Clinical\Health and Professional Requirements\Health and Professional Packet 6 Revised 04.2015 Professional Requirements
CRIMINAL BACKGROUND CHECK POLICY AND ACKNOWLEDGEMENT
The required curriculum for nursing involves completion of clinical nursing courses. Students and faculty participating in nursing courses with clinical components must meet the requirements mandated by the clinical agencies, which includes a satisfactory criminal background check consistent with the agencies’ screening requirements for their employees.
It is the student’s responsibility to initiate the background check and have results sent directly to: Lourdes University College of Nursing 6832 Convent Blvd. Sylvania, OH 43560
Residents outside of Ohio must submit a BCI background check and an FBI background check.
If you have not lived within the state of Ohio for at least five (5) years, you need to submit a BCI background check and an FBI background check.
If the results of the criminal background check show any potentially disqualifying or questionable information, Lourdes University may require the student to obtain and provide additional information to verify or clarify the background check’s results. The failure to provide additional information as requested will render the student unable to participate in clinicals.
Cost: The student is responsible for the cost of the criminal background check and the cost of obtaining additional information to verify or clarify potentially disqualifying or questionable results.
Processing Time: It may take 30 to 90 days to receive the results of the background check. It is the student’s and faculty’s responsibility to allow sufficient processing time in advance of the beginning of the clinical course.
Use of Results: the criminal background check results are not approved as satisfactory by the nursing department before the first clinical class, the student’s admission to the clinical course will be deferred until the following semester unless it is determined from the results that the student will be unable participate in clinicals. If the criminal background check results are not approved as satisfactory by the nursing department before the first clinical class, the faculty will not be able to teach in the clinical course. If the results of the background check and any necessary follow-up are inconsistent with criminal records check requirements such that the student or faculty member would be limited or barred from participating in clinicals, Lourdes University will not approve the student or faculty for participation in clinicals. Without clinical experience, the student cannot complete all aspects of the nursing program and will not be able to receive regular admission or continue in the program; in such instances, the student will be dismissed from the program and will not be entitled to any tuition refund. Lourdes University is not liable for any damages arising out of or related to the results of the criminal background check, the student’s non-approval for clinicals, or the student’s dismissal from the program.
Confidentiality: Lourdes University will store the results of the background check in a separate confidential file apart from the student’s other records. Lourdes University may disclose the results as needed or as required by law.
Self-Disclosure: The student or faculty member must report within 10 business days any criminal conviction (excluding minor traffic violations) that occurs after submitting the information for the background check. Failure to report the required information to the Dean of the College of Nursing may constitute grounds for immediate dismissal from clinicals.
ACKNOWLEDGEMENT
I, ______, understand and acknowledge that decisions regarding my participation in the Lourdes University nursing program will be made based, in part, upon the results of my required criminal background check(s) and the additional information I provide to comply with this policy.
Signature: Date: ______
Print Name:
R:\COMMON\Clinical\Health and Professional Requirements\ Health and Professional Packet 7 Revised 04.2015 Professional Requirements
Suggested Background Check Location (This is most convenient to the University, however; you may also visit the locations in your area.)
* A BCI criminal background check is required. * If you are resident outside of Ohio, you need to submit a BCI background check and an FBI background check. * If you have not lived within the state of Ohio for at least five years, you need to submit a BCI background check and an FBI background check. * If you have had your background check done within the last six months, a copy of that report will be acceptable.
Sylvania Deputy Registrar License Bureau 4900 North McCord Road Sylvania, OH 43560 (419) 885‐0201 (Please call for current hours of operation and background check pricing.) ADA Accessible
The report MUST be sent to: Lourdes University College of Nursing 6832 Convent Blvd. Sylvania, OH 43560
R:\COMMON\Clinical\Health and Professional Requirements\ Health and Professional Packet 8 Revised 04.2015