Health & Professional Requirement Semesters 2-5 Student Checklist

Student Form

Health & Professional Requirement Semesters 2‐5 Student Checklist

Name: ______ID#______

*This list should be used as a checklist for your H&P requirements and MUST be turned in

All students enrolled in a clinical nursing course must meet all College of Nursing Health and Professional Requirements as described in Section 5.3 of the Nursing Student Handbook. All documentation must be submitted as soon as possible in order to register for classes or remain registered. The student should retain the original documentation and submit copies to the College of Nursing’s Administrative Assistant.

Healthcare Provider Form:

Healthcare Provider Immunization Verification

Pre-Clinical Physical Exam

Technical Standards Table Student Form:

Completion of the Core Competencies: Please go to www.lourdes.edu > Current Students>Nursing Lab>Health Forms and Uniforms. You may submit an email attachment or submit a hard copy with your other documents.

Student 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:______

Agencies Offering Immunization

Technical Standards Table

Technical Standards Policy

Technical Standards Certification Statement

______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 enroll for clinical. I further (initial here) acknowledge that if I do not complete these requirements by the established deadline, I will not be allowed to attend clinical.

R:\COMMON\Clinical\Health and Professional Requirements\Health and Professional Packet 1 Revised 04.2015 Healthcare Provider Form

Health and Professional Requirements Healthcare Provider Immunization Verification - Semesters 2 - 5

Name: ______ID#: ______(Please PRINT)

DOCUMENTATION NEEDS TO BE PROVIDED FOR ALL REQUIREMENTS A Physician waiver will not be accepted by clinical agencies as meeting the requirements

T-Spot Negative yearly PPD: Yearly physician statement of absence of disease for positive Date: ______reactors. Date #1______Yearly Tuberculin skin OR OR test (PPD) or T-Spot Date: ______Result: ______

Most recent Tetanus/Diphtheria Immunization Date: ______(Confirm within the last 10 years)

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 2 Revised 07.2016 Healthcare Provider Form

PRE-CLINICAL PHYSICAL EXAMINATION Semesters 2 – 5 Nursing Students

The individual whose name appears on this form is a student or faculty member in the Nursing Program at Lourdes University.

To meet admission 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

 Yes, Free of evidence of communicable disease

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:

R:\COMMON\Clinical\Health and Professional Requirements\Health and Professional Packet 3 Revised 04.2015 Healthcare Provider & Student Information Sheet

Technical Standards for Nursing Students Table

The Lourdes University College of Nursing is committed to equal access for all qualified program applicants and students. The College of Nursing faculty has identified specific technical standards essential to the delivery of safe, effective nursing care during clinical education activities. These standards determine the students’ ability to acquire knowledge and develop the clinical skills required by the curriculum. Clinical education is a major focus throughout the program involving considerations, such as patient safety, that are not present for classroom activities. Therefore, the student must meet these standards and maintain satisfactory demonstration of them for successful program progression and graduation. Nursing students, with or without reasonable accommodation, must satisfy the performance standards described below.

Technical Standard Definition Examples Senses Have functional use of the senses of Hear, observe and speak to patients; detect skin vision, touch, hearing, and smell so that color changes, anatomical abnormalities such data received by the senses may be as edema, sounds related to bodily functions quickly integrated, analyzed, and using a stethoscope, and odor associated with a synthesized in an accurate manner. wound infection. Physical Abilities Perform gross and fine motor movements Perform CPR, safely transfer and control fall of with reasonable endurance, strength, a patient, and manipulate equipment such as flexibility, balance, mobility, and syringes and medication packages. precision as required to provide holistic nursing care. Cognitive Collect, analyze, and integrate Measure, calculate, reason, and understand information and knowledge to make information and graphs; identify priorities; clinical judgments and decisions that problem-solve in a timely manner; select, promote positive patient outcomes. implement and evaluate interventions; and teach patients and families. Communication Communicate effectively and sensitively Speak, read, write, and comprehend English at with patients and families, other a level that meets the need for accurate, clear, professionals, and groups to elicit and effective communication; perceive information and transmit that information patients’ nonverbal communication; maintain to others. Possess sufficient accurate patient records; obtain accurate health interpersonal skills to interact positively history; establish rapport with patients, faculty, with people from all levels of society, all peers, and agency staff; and accept constructive ethnic backgrounds, and all belief feedback on performance. systems. Mental/Emotional Have sufficient emotional health to fully Function under stress, problem solves, adapt to Stability use intellectual ability, exercise good changing situations, and follow through on judgment, and complete all assigned patient care responsibilities. responsibilities necessary to the care of patients. Professional Engage in activities consistent with safe Does not demonstrate behaviors of addiction Behavior nursing practice and display responsibility to, abuse of, or dependence on alcohol or other and accountability for actions as a student drugs that may impair judgment; displays and as a developing nurse. compassion, nonjudgmental attitude, consciousness of social values, honesty, integrity and confidentiality; displays appropriate dress and appearance in clinical- related activities; and demonstrates motivation, appropriate attitude, and professional behavior.

R:\COMMON\Clinical\Health and Professional Requirements\Health and Professional Packet 4 Revised 04.2015 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\Health and Professional Packet 5 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 6 Revised 02.2015 Healthcare Provider & Student Information Sheet

Technical Standards for Nursing Students Table

R:\COMMON\Clinical\Health and Professional Requirements\Health and Professional Packet 7 Revised 04.2015 Student Information Sheet

Technical Standards for Nursing Students Policy

Policy: The Lourdes University College of Nursing is committed to equal access for all qualified program applicants and students. Nursing students must be able to perform certain mental, physical, and other tasks that are essential in providing care for their patients. These requirements are outlined in the School’s Technical Standards for Nursing Students and Technical Standards Certification Statement.

Procedure: After being admitted to the Nursing Major, nursing students must submit a signed Technical Standards Certification Statement stating that they believe that they can meet these standards with or without reasonable accommodation. The student’s statement must also be confirmed through a physical examination by a licensed healthcare provider of the student’s choosing who also signs a statement on the form. Students are responsible for the cost of the physical examination and must provide the healthcare provider with the Technical Standards for Nursing Students table on the following page. The executed certification form must be on file before beginning the clinical nursing courses of the program. If a student believes that he or she needs disability-related accommodation(s) in order to meet these requirements, the student must request them by contacting the Office of Accessibility Services. Accommodations may not be reasonable in some cases.  Any student who cannot meet each of the Technical Standards with or without reasonable accommodation can no longer be enrolled in the Nursing major.  Students requesting disability-related accommodations must have their need for reasonable accommodation validated through the Office of Accessibility Services before beginning clinical nursing courses in order to permit adequate time to arrange the accommodation. It may not be possible to provide some accommodations on short notice.  Accessibility Services works jointly with the student and the College of Nursing to explore accommodation options.  Students are responsible for informing their instructors about needs for accommodation for courses or clinical experience.

Note: Student medical information will be kept confidential. Lourdes University may disclose as needed or required by law.

R:\COMMON\Clinical\Health and Professional Requirements\Health and Professional Packet 8 Revised 04.2015 Student Form

TECHNICAL STANDARDS CERTIFICATION STATEMENT – CONFIDENTIAL

Student Name: ______Student ID#: ______

This form is a companion to the Technical Standards for Nursing Students* document. After being accepted for admission to the College of Nursing, students must complete and submit this certification form to the Lourdes University College of Nursing prior to beginning the program’s clinical courses. The Lourdes University College of Nursing is committed to equal access for all qualified program applicants and students.

Enrollment of accepted students in the College of Nursing is contingent, in part, upon: 1. Submission of this completed Technical Standards for Nursing Students Certification Statement to the College of Nursing. 2. The ability to meet the Technical Standards for Nursing Students either with or without accommodation(s). 3. The verification of the physical aspects of this ability as determined through a routine physical examination by a health care provider licensed and qualified to perform such routine physical examinations (typically a physician, physician assistant or advanced nurse practitioner).

Students are responsible for: a. The cost of the physical examination.

b. Providing a copy of the Technical Standards for Nursing Students table to the health care provider completing the physical exam.

STUDENT STATEMENT: After you have been accepted into the College of Nursing, check only one of the statements below and sign where indicated:

I certify that I have read and understand the Technical Standards for Nursing Students documents, and I believe to the best of my knowledge that I meet each of these standards without accommodation(s). I also understand that if I am unable or become unable to meet these standards with or without accommodation(s), I cannot enroll or remain enrolled in the College of Nursing.

I certify that I have read and understand the Technical Standards for Nursing Students documents, and I believe to the best of my knowledge that I meet each of these standards with accommodations. I will contact the Office of Accessibility Services to have my need(s) for accommodation(s) validated. I will work with both the Office of Accessibility Services and the College of Nursing to examine reasonable accommodation options. I understand that in some cases, accommodation(s) might not be reasonable. I also understand that if I am unable or become unable to meet these technical standards with or without accommodation(s), I cannot enroll or remain enrolled in the College of Nursing.

I certify that I have read and understand the Technical Standards for Nursing Students, and I believe to the best of my knowledge that I do not meet each of these standards with or without disability-related accommodations. I also understand that if I am unable to meet these standards with or without accommodation(s), I cannot enroll or remain enrolled in the College of Nursing.

Signature of Student: ______Date: ______

R:\COMMON\Clinical\Health and Professional Requirements\Health and Professional Packet 9 Revised 04.2015