Health Requirements Instructions - Updated 6-18-14-akp
OAKLAND UNIVERSITY SCHOOL OF NURSING
3016 HUMAN HEALTH BUILDING, ROCHESTER HILLS, MI 48309
FNP/AGNP/CRNA
REQUIREMENTS TO PARTICIPATE IN NURSING COURSES
Semester Admitted to Begin
Deadline Dates
Fall
July 1
st
– (September 1
st
in 2014 only)
Requirements for New FNP/AGNP/CRNA
1. Student completes all of the health requirements (refer to Clinical Requirements Submission
Checklist), marks that they were completed, and signs the form. Student then enters the actual
dates that the health requirements were satisfied on the Student Health Requirements
Satisfied Form, signs the form, and attaches a copy of all health requirements. The health
requirements that each student needs to submit are:
A. Proof of inoculation for tetanus (T-DAP); skin testing for tuberculosis (possibly chest x-ray if
TB skin test is positive and then student will need to also submit Health Screening
Questionnaire for History of Positive TB Skin Test) required YEARLY; and proof of
immunity to Rubella, Rubeola, Mumps (MMR), Varicella, and Hepatitis B. If student elects
to not take the Hepatitis B vaccines, then he/she will need to submit the Hepatitis B Vaccine
Refusal and Acknowledgment of Risk and Release form.
B. Submission of completed approved CPR course (BLS + ACLS required for CRNA – BLS
only for FNP, AGNP students)
*If a student has a current TB test and/or CPR card, he/she can choose to use either of
those documents as part of their clinical health requirements. The student will be
responsible for submitting proof of updated test/card results prior to the current one’s
expiration date. If your updates do not arrive prior to the expiration date, your clinical
attendance will be affected.
C. Submission of criminal background check result (done through American Databank).
D. Submission of drug screen result (done through American Databank).
NOTE: The criminal background check and drug screen must be done within the 45 days prior
to the submission deadline date (see table above-after May 15
th
), and they must be done
through American Databank at www.oaklandunivcompliance.com, A receipt showing the
results for both the drug screen and the criminal background check is required (e.g. one
page stating “no flags at this time” unless a record is found). The criminal background
check and the drug screen are required at the beginning of the program. Note:
Individual clinical agencies may require additional background checks or drug
screens prior to starting clinical rotations.
2. Student has a health examination performed by a qualified health care provider (HCP) (e.g.
physician, nurse practitioner, physician’s assistant). Have the HCP complete the Clinical
Experience Student Clearance Form. Health examinations may be obtained through your
own HCP or at the Oakland University Graham Health Center (GHC). To schedule an
appointment at the GHC, call (248) 370-2341; identify yourself as a nursing student when you
make the appointment.
Health Requirements Instructions - Updated 6-18-14-akp
3. Do not submit your clinical health requirements to the School of Nursing until you have all of
the documents completed. The health requirements will only be accepted by the School of
Nursing if submitted via trackable mail. Trackable mail (certified, registered, or priority)
includes the United States Postal Service, United Parcel Service (UPS), or Fed-Ex. The
clinical health requirements MUST be postmarked by no later than the submission deadline
date (see above) to be considered “on time”.
4. Send all of the clinical health requirement documents to the School of Nursing address below:
Andrea Patton
Oakland University School of Nursing
3016 Human Health Building
Rochester, MI 48309-4401
Requirements for Continuing FNP/AGNP/CRNA
When you are admitted to the School of Nursing in the Fall semester, your clinical health
requirements will be due July 1st every year you are a student in the School of Nursing.
1. The student completes the Clinical Requirements Submission Checklist,
enters the date(s) the requirements were satisfied, signs the form, and attaches a copy of
the updated materials (e.g. updated TB skin test and CPR card (ACLS required for
CRNA)
2. Send all of the updated health requirement documents to the School of Nursing via
trackable mail (refer to #4 above) to the School of Nursing address listed above.
Lastly, it is important for students to maintain their own health insurance for illness or injury.
Student health insurance is available through the Graham Health Center. Clinical agencies are
not required to provide free treatment for students and will bill individuals for use of their
emergency department or employee health service. OU does not cover any costs associated with
student injuries or accidents.
Any questions regarding the clinical health requirements should be directed to Andrea Patton at
[email protected] Please do not call the School of Nursing or contact Ms. Patton to request
delivery confirmation. You can use your trackable mail receipt to find out when the clinical
health requirements were delivered to OU.
Oakland University School of Nursing
Clinical Requirements Submission Checklist
__________________________________________ _____________________________ ______________________ ________________
Student Name (Oakland) email address phone (cell or home) (Circle one) G#
Graduate track: FNP AGNP CRNA (circle one) Nursing License expiration date______________
New students who do not submit all health requirements by the deadline date will not be allowed to start the nursing curriculum and will need to re-apply. Continuing students who do not
submit all of the clinical/health requirements by the deadline date will not be allowed to register for clinical courses that semester, and their graduation date may be affected.
REQUIREMENT
ACCEPTABLE PROOF REQUIREMENT MET
The items listed below are due upon Admission
COMPLETED
(Place X in box when satisfied)
Health Examination
Health examination by qualified health care provider (must be within 4 months of admission). Have health care provider
complete the Clinical Experience Student Clearance Form.
Hepatitis B
Hepatitis B titer indicating immunity or documented dates of 3 Hepatitis B vaccinations or signed Hepatitis B Vaccine
Refusal and Acknowledgement of Risk and Release if hepatitis vaccination series not completed by deadline date.
Mumps
IGG titer indicating immunity (include lab work from Titer if not done at Graham Health Center) or documented
dates of 2 Mumps vaccinations.
Rubella
IGG titer indicating immunity (include lab work from Titer if not done at Graham Health Center) or documented
dates of 2 Rubella vaccinations.
Rubeola
IGG titer indicating immunity (include lab work from Titer if not done at Graham Health Center) or documented
dates of 2 Rubeola vaccinations.
Tetanus (T-dap only)
Documentation of T-dap injection (expires after 10 years)
Varicella
IGG titer indicating immunity (include lab work from Titer if not done at Graham Health Center) or documented
date of 1 (one) Varicella vaccination.
Drug Screen
Follow directions provided for obtaining through American Databank – www.oaklandunivcompliance.com
Copy of results page must be included in packet. It is not necessary to include payment information
Criminal Background
Check
Follow directions provided for obtaining through American Databank – www.oaklandunivcompliance.com
Copy of results page must be included in packet. It is not necessary to include payment information
The items listed below are due upon Admission and each consecutive year for continuing students.
CPR Course
Copy of CPR card with expiration date; AHA-Health Care Provider or American Red Cross Professional Rescuer,
only (Two year expiration). ACLS is required for CRNA.
TB (PPD)
Date and result of PPD (or negative chest x-ray and completed Health Screening Questionnaire for History of Positive
TB test) TB tests are required annually.
______________________________________________________________________ ____________________________________________________
Student signature Date
Oakland University School of Nursing Student Health Requirements Satisfied Form
Student Name _________________________________ Oakland University G# ________________ Oakland email address______________________
TUBERCULIN SKIN TEST (PPD) (required annually)
CHEST X-RAY (If history of positive skin test)
CPR requirement (two year expiration)
______ ____ ________
month day year
______ ____ ________
month day year
_______MM
ACLS is required for CRNA students
TETANUS (T-dap - within last 10 years)
______ ____ ________
month day year
Drug Screen & Criminal Background Check
Follow directions provided for obtaining through American Databank –
www.oaklandunivcompliance.com - Copy of results page only must be included in packet. It
is not necessary to include payment information
ATTACH LAB REPORT WITH RESULTS OF TITER OR
IMMUNIZATION RECORD OF THE FOLLOWING. Positive history of
disease is not acceptable documentation of immunity.
MUMPS IGG TITER
RUBELLA IGG TITER
RUBEOLA IGG TITER
VARICELLA IGG TITER
----------- OR ----------
MMR Immunization
Varicella Immunization
_____ Immune _____ Non-Immune
month day year
_____ Immune _____ Non-Immune
month day year
_____ Immune _____ Non-Immune
month day year
_____ Immune _____ Non-Immune
month day year
MMR # 1 MMR # 2
_______ _______ _______ _______ _______ _______
month day year month day year
Varicella #1
_______ _______ ________ Note: Lab report with results needed for titers
month day year
HEPATITIS B VACCINE – 3 required
------------ OR ----------
Hepatitis B Titer:
_______ _____ ______ _____ immune _____non-immune
month day year
Inj. #1 ______ _______ ________
month day year
Inj. # 2 ______ _______ ________
month day year
Inj. #3 _______ ______ ________
month day year
Influenza vaccine
Date received: ____________
(Given October – April)
__________________________________________ ____________________________
Student signature Date
Oakland University School of Nursing
Student Clinical Experience Clearance Form
____________________________________________________________________
Student name
who is a student in the Oakland University School of Nursing undergraduate program
has been cleared/has not been cleared (circle one) to participate in School of Nursing
clinical experiences.
________________________________ _____________________________
Health care provider signature Date
Restrictions/Comments:
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
SEN-Fall-2014
Oakland University School of Nursing
HEPATITIS B VACCINE REFUSAL AND
ACKNOWLEDGMENT OF RISK AND RELEASE
I understand that as part of my clinical experiences as a nursing student, I may be
exposed to blood or other potentially infectious materials and that, as a result, I may be
at risk of being infected by the Hepatitis B virus. I understand that Hepatitis B is a
severe and potentially life threatening illness and that taking the Hepatitis B vaccination
series would significantly reduce my risk of being infected by the Hepatitis B virus.
Nevertheless, I have elected not to take the Hepatitis B vaccination series and assume
responsibility for all arrangements, costs, and complications arising from not taking the
Hepatitis B vaccination series. I agree to release, discharge, indemnify and hold
harmless Oakland University, its trustees, officers, employees, representative and
agents, and the facility where I receive my clinical training, from any and all costs,
liabilities, expenses, claims, demands, or causes of action arising out of or resulting
from my declining the Hepatitis B vaccination series.
Student Name:
Student Signature:
Date: __________________________________________
Updated 4-9-14-akp
Oakland University School of Nursing
Health Screening Questionnaire for History of Positive TB Skin Test
The current CDC guidelines do not require biannual chest c-ray screening. It is believed that once a normal chest x-ray has been
achieved, and documented, it is more important to review common signs and symptoms of pulmonary tuberculosis and assess for risk
factors.
Student Name: __________________________________________ G#________________________________
Date: _____________________________________ Program: Undergraduate/Master’s________________
When did you convert to a positive PPD? _____________
When was your last chest x-ray?_____________________ Result: _______________________________
Have you previously been treated for active or inactive TB? Yes ____ No ____ Date _________________
Are you experiencing any of the following:
Ongoing night sweats: Yes ______ No _______
If yes, are you under treatment? __________With whom______________ Diagnosis_________________
Unexplained weight loss: Yes ______ No _______
If yes, are you under treatment? __________With whom______________ Diagnosis_________________
Chronic fatigue: Yes ______ No _______
If yes, are you under treatment? __________With whom______________ Diagnosis_________________
Persistent Cough: Yes ______ No _______
If yes, are you under treatment? __________With whom______________ Diagnosis_________________
I declare that my answers and statements are correctly recorded, complete, and true to the best of my
knowledge.
Signature_________________________________________ Date ______________________________
This form was developed jointly by the Oakland University School of Nursing, Graham Health Center, and the Oakland County Health Department.
