Student Clinical Clearance Form
TOP SECTION TO BE FILLED OUT BY THE STUDENT
First Name
Last Name
Date of Exam
Email
Phone Number
DOB
Sex
Address
City
State
Zip
The role of a professional nurse requires skills and abilities in the cognitive, social, affective, psychomotor, and
physical disciplines. Mastery of each of these skills is crucial to becoming a competent part of the healthcare
team. The student named above is a candidate for the Oakland University School of Nursing, and must be able
to demonstrate each of the following abilities:
Communication:
The role of the professional nurse requires the ability to communicate clearly and
effectively, both in writing and orally. This communication often requires the nurse to
speak to individuals as well as groups of family members and healthcare professionals,
who vary in emotional, cultural and spiritual backgrounds. The candidate must be able to
communicate timely, accurately and effectively.
Cognitive:
The use of written and spoken information must be able to be quickly received and then
analyzed for application as appropriate in the clinical setting. The candidate must exhibit
inductive/deductive reasoning skills sufficient for clinical judgment and decision making.
Behavioral/Emotional:
Clinical settings are often fast paced and can be perceived as stressful. The candidate must
be able to work effectively in a highly demanding and rapidly changing environment, while
demonstrating effectiveness, as well as professionalism, maturity, and empathy for
patients, family members and other healthcare professionals. The candidate must be able
to assume accountability for actions.
Motor Skills:
To successfully complete this nursing program, the candidate must have the ability to care
for patients in all clinical settings. The candidate must be able to move from place to place
and maneuver small places. The candidate must be able to perform basic life support, and
provide physical assistance to patients with repositioning, transfers and ambulation.
Sensory/Observation:
Professional nurses rely on their senses to detect changes in patient condition. For this
reason, this candidate must be able to hear heart and lung sounds or changes in voice.
The candidate must be able to palpate pulses or changes in skin temperature, as well as
see changes in skin tone.
I have given the student named above a complete physical examination. I feel that he/she is physically and
mentally capable of participating without hazard in clinical practice settings for the Oakland University School of
Nursing.
____________________________________________ _______________________________________
Healthcare Provider's Name and Title (Please Print) Healthcare Center/Facility Name and Address
________________________________________________ _______________________________________
Healthcare Provider's Signature Exam Date
Student Core Performance Standards
Standard
Inductive/deductive reasoning sufficient for clinical judgment and decision
making
Interpersonal abilities sufficient to interact with individuals, families, and
groups from a variety of social, emotional, cultural, spiritual and intellectual
backgrounds
Emotional stability sufficient to assume responsibility/accountability for
actions
Communication abilities sufficient for interaction with others in verbal and
written form
Gross and fine motor abilities sufficient to provide safe and effective nursing
care. Must be able to perform basic life support, provide physical assistance
to patients including repositioning, transfers and ambulation
Physical abilities sufficient to move from place to place and maneuver in small
places. Physical abilities sufficient to stand for extensive periods of time.
Visual ability sufficient to provide safe and effective nursing care
Auditory ability sufficient to provide safe and effective nursing care
Tactile ability sufficient for assessment and implementation of care
Characteristics that would not compromise health and safety of clients
Students must be able to demonstrate the above requirements while a student in the School of
Nursing (SON). Any student who believes that they may need assistance meeting the Core
Performance Standards should contact the OU Office of Disability Support Services (DSS), 202 Wilson
Hall, phone: (248)-370-3266; TTY (248)-370-3268.
I certify that I am capable of demonstrating the School of Nursing Student Core Performance
Standards on a regular basis, with or without a reasonable accommodation. If I experience difficulties
in performing the essential Student Core Performance Standards listed above, I agree to notify the
Director of Clinical Operations and Oakland University Office of Disability Support Services.
________________________________________________
Student Printed Name
_____________________________________________________ _______________________________________
Student Signature Date
Hepatitis B Vaccine Refusal and
Acknowledgment of Risk and Release
I understand that as part of my clinical experiences as a nursing student at Oakland University, 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 education, 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.
By signing this form, I understand that I may be subject to exclusion from clinical placements if the
clinical agency advises exclusion as a disease control measure. This may affect the timing of and/or
my ability to graduate from the School of Nursing program. In consideration for being allowed to
participate in the clinical experience without the Hepatitis B vaccination, I fully, unconditionally and
forever release and discharge, and agree to, indemnify (including without limitation attorney’s fees
and costs of litigation) and hold harmless, Oakland University, its trustees, officers, employees,
representative and agents, in their official and personal capacities, and the facility where I receive my
clinical education, from any and all costs, liabilities, expenses, claims, demands, or causes of action
of any kind, nature or description, actually or allegedly arising out of or resulting from my declining
the Hepatitis B vaccination, including without limitation those relating to bodily injury, emotional
injury, risk associated with exposure to and/or potential contraction of infectious/contagious diseases
and/or conditions, and death.
________________________________________________
Student Printed Name
_____________________________________________________ _______________________________________
Student Signature Date
Health Screening Questionnaire for History of Positive TB Skin Test
The current CDC guidelines do not require biannual chest x-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:______________
Undergraduate Program: Yes / No Graduate Program: FN, FNP, AGNP, AGACNP, CNL, DNP-NA
…………………………………(circle one)……………………………… (circle one)
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.
________________________________________________
Student Printed Name
_____________________________________________________ _______________________________________
Student Signature Date
This form was developed jointly by the Oakland University School of Nursing, Graham Health Center, and the Oakland County Health Department.