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