College of Nursing
Undergraduate Nursing Department
Nursing Student Handbook
Appendix
A - Forms: Health Status Report and Immunizations |
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APPENDIX-A
FORMS: HEALTH STATUS
REPORT AND IMMUNIZATIONS
South Dakota State University
College of Nursing
Department of Undergraduate Nursing
STUDENT IMMUNIZATION AND TESTING RECORD
(RETURN TO NURSING STUDENT SERVICES, COLLEGE OF NURSING)
Name:______________________________________ Date of Birth:______/______/______
(Print) First Last
Middle
Student ID #_________________________________ Social Security # ______-______-______
I certify that the information I have provided below is true and accurate.
Student Signature:___________________________________ Date:______/______/______
This information is based on Center of Disease Control and Prevention.
Immunization of Health-Care Workers: recommendations of the Advisory Committee
on Immunization Practices (ACIP) and the Hospital Infection Control Practices
Advisory Committee (HICPAC). MMWR1997; 46(No. RR-18):[inclusive page
numbers].
Provide month and year for immunizations requested below. The
corresponding information in Section D is required ONLY if student cannot
be immunized with vaccine or cannot perform CPR. NOTE: A health care
provider (nurse practitioner or physician) is REQUIRED to sign this form
to verify that all immunizations have been properly completed.
Section A. This section must be completed UNLESS you were born
before January 1, 1957.
The below immunizations can be taken as an MMR immunization.
Measles (Rubeola) Immunity
Immunized with live-measles vaccine. First dose must be
Dose1:______/______
on or after first birthday, and second dose must be at least
30
Month Year
days after first dose. Both doses must have been received
after Dose2:______/______
December 31, 1967 or you must be re-vaccinated.
Month Year
-
Contraindicated (See Section D) ______/______
-
Month Year
Rubella (German Measles) Immunity
Immunized with live-virus vaccine (must be on or after first
birthday)
q Contraindicated (See Section D) ______/______
Month
Year
Mumps Immunity
Immunized with live-virus vaccine (must be on or after first
birthday.)
q Contraindicated (See Section D) ______/______
Month
Year
Section B. This section must be completed by ALL students
and is related to CHILDHOOD immunization guidelines or current recommendations
issued by the Center for Disease Control for Health Care Workers.
If you are being immunized for the FIRST time as an ADULT, guidelines may
differ. If you have been immunized and have no record, please talk
with Nursing Student Service Coordinator and Student Health Services Coordinator
before getting re-immunized.
Tetanus, Diphtheria, Pertussis Immunity
Childhood series of four. A fifth does before entry into
Kindergarten may have been recommended if fourth dose was before age 4.
A booster is required every ten years.
Date of Each Injection: 1.____ 2.____ 3.____ 4.____ 5.____
if given.
Date of Last Booster: ____/____
Month Year
G Contraindicated (See Section D)
Poliomyelitis Immunity
Childhood series of three required; a booster before entry into
Kindergarten may have been recommended.
Date of Each Vaccination & Type: 1.____2.____3.____4.____(maybe)
G Contraindicated (See Section D)
Hepatitis B Immunity (recombinant vaccine)
Required to have two (2) immunizations prior to midterm of the
first semester of the nursing major with the third immunization five (5)
months after the second immunization, which should be before the second
semester of the Nursing major.
Date of Vaccination: 1.____2.____3.____
G Contraindicated (See Section D)
Influenza Immunity
This vaccination is available only during Influenza season and
will be made available to students through Student Health Services or the
Student can choose to have the vaccination done by primary care provider.
G Contraindicated (See Section D)
Section C. This section must be completed by ALL students
on an annual basis.
Tuberculin Skin Testing
A tuberculin skin test is required annually. Prior positive
or converters must be evaluated by a physician to determine active disease
and a letter must be on file from the primary care provider indicating
the student is cleared to care for patients.
Date of Skin Tests:________Results:_______ Chest X-ray (if positive
skin test)_______
If chest X-ray necessary, student must have written documentation
from primary care provider that student does not have active disease and
is cleared to care for patients.
q Letter on file
q Contraindicated (See Section D)
Cardiopulmonary Resuscitation Certification/Testing (CPR)
Indicate which certification and the date completed.
G American Red Cross-Professional Rescuer
G American Heart Association - BLS Health Care Provider, Course C
or Proof of CPR that states (1 & 2 Man Rescue, Infant &
Child Choking, Infant & Child CPR)
Date Completed:______/______/______
NOTE: You must turn in a copy of your card to Nursing Student
Services
q Contraindicated (See Section D)
SECTION THAT DEALS WITH CONTRAINDICATIONS
Section D. This section to be completed by physician, nurse
practitioner, or clinic ONLY if student cannot be immunized with vaccine
or cannot be CPR certified for health reasons.
1. Measles (Rubeola) Immunity (Check One)
G Date of physician-diagnosed Rubeola disease Date:___/___/___
G Has an immune titer (Specify date of test & results) Date:___/___/___
Results of test________________
G ____________________________ __________________________
(Medical contraindication*to Rubeola vaccine)
(Probable duration of contraindication)
2. Rubella (German Measles) Immunity (Check One)
G Date of physician-diagnosed Rubella disease Date:___/___/___
G Has an immune titer (date of test and results) Date:___/___/___
Results of test________________
G ____________________________ ___________________________
(Medical Contraindication*Rubella vaccine)
(Probable duration of contraindication)
3. Mumps Immunity (Check One)
G Date of physician-diagnosed mumps disease Date:___/___/___
G Has an immune titer (specify date of test results) Date:___/___/___
Results of test________________
G __________________________________ ________________________________
(Medical contraindication*to mumps vaccine)
(Probable duration of contraindication)
4. Tetanus, Diphtheria, Pertussis Immunity
G ___________________________________ _______________________________
(Medical contraindication*to TD or Pertussis Vaccine)
(Probable duration of contraindication)
5. Hepatitis B Immunity
G ___________________________________ _______________________________
(Medical contraindication * to Hepatitis B Vaccine)
(Probable duration of contraindication)
6. Varicella Immunity
G Date of physician-diagnosed varicella disease Date:___/___/___
G Has an immune titer (date of test and results) Date:___/___/___
Results of test___________________
G ___________________________________ _______________________________
(Medical contraindication * to Varicella Vaccine)
(Probable duration of contraindication)
7. Tuberculin Skin Testing and/or Chest X-ray
G ___________________________________ _______________________________
(Medical contraindication * to skin testing or Chest
X-ray) (Probable duration of contraindication)
G ____________________________________________________________________
(Under Medical Care if results indicate positive
tuberculin skin test and/or positive chest x-ray)
8. Poliomyelitis Immunity
G __________________________________ ________________________________
(Medical contraindication * to Poliomyelitis Vaccine)
(Probable duration of contraindication)
9. Influenza Immunity
G __________________________________ ________________________________
(Medical contraindication * to Influenza Vaccine)
(Probable duration of contraindication)
10. CPR Certification/Testing
G __________________________________ ________________________________
(Medical contraindication to CPR Certification)
(Probable duration of contraindication)
Signature and address of PHYSICIAN, NURSE PRACTITIONER, or CLINIC
providing information for this Immunization and Testing Record.
Name:______________________________ Telephone: (___) _________-_________________
Address:______________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Signature of Health Care Provider:_________________________________________________
Date of Signature:____/____/____
*Medical Contraindication to Vaccine must be in accordance with
the most recent recommendations of Advisory Committee on Immunizations
Practices (ACIP)
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