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Health and Professional New Adjunct/Faculty Checklist Health Requirements: Healthcare Provider Immunization Verification

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Health and Professional New Adjunct/Faculty Checklist Health Requirements: Healthcare Provider Immunization Verification 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
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