BOROUGH OF MANHATTAN COMMUNITY COLLEGE OF THE CITY UNIVERSITY OF NEW YORK DEPARTMENT OF NURSING

Dear Provider: The Nursing Student listed below is entering their clinical rotations and is being held to these Health Care Provider Standards by the hospitals where he/she will be doing their clinical rotation. They will NOT be allowed to start clinical until the health requirements are met EXACTLY as listed. Thank you for your assistance.

Name: __________________________________________

Date of Birth: ___________________

Tuberculin Skin Test (TST) If you do not have documentation of a TST done in the past 12 months, then you will need to have a 2-Step test done a week apart. Date #1 ___________________ Result __________mm (No more than 12 months) Date #2 ___________________ Result __________mm Or.. If you have a Positive TST (past or present), Chest X-ray is required every 3 years. Copy of chest X-ray report MUST be submitted X-ray - Date ____________________ Immunizations Required Titers Tdap NEED Adult Pertussis vaccine Tdap Date ______________________

***MUST attach copies of lab results of Varicella & MMR***

Varicella Date___________ Titer # ____________ Immune / Non-Immune / Equivocal (History of Disease no longer adequate) Measles Mumps Rubella Date___________ Date___________ Date___________ Titer # ____________ Immune / Non-Immune / Equivocal Titer # ____________ Immune / Non-Immune / Equivocal Titer # ____________ Immune / Non-Immune / Equivocal

NOTE: For Varicella & MMR, if currently Non-immune/Equivocal then MUST revaccinate if appropriate and repeat titer level 4-6 weeks after revaccination. Equivocal is considered Non-Immune. Hepatitis B Date #1 __________ Titer # ____________ Date #2 __________ Date #3 __________ (Or sign declination form) Immune / Non-Immune / Equivocal

Providers Name (print): ________________________________ Date: _________________________ Signature and Title: ___________________________________ Phone#:_______________________ Address: _____________________________________________________________________________ Provider STAMP with LICENSE#:
___________________________________________________ Note: *Multiple clinical agencies are also requiring a drug screen. Please appropriately counsel the student concerning foods/substances to avoid prior to drug screening. **All necessary immunizations (as requirements and/or recommendations) and Tuberculosis protocol are based on the latest guidelines of the NYC Department of Health and Mental Hygiene. June 2011 Page 2