BScN Scholar Practitioner Program

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BScN Scholar Practitioner Program

STUDENT NAME: DATE:

STUDENT NUMBER: DATE OF BIRTH: Student Authorization:

I give my consent that the information on this form may be shared as required with Nipissing University, Clinical Faculty and Administrative/Support Staff

Signature: ____________________________________________ Date:______________________________________

Communicable Disease Screening Requirements

Dear Student,

The Scholar Practioner Program includes clinical placements as an essential component of the program. In order to protect yourself and the patients you will be interacting with, you must complete all required immunizations upon admission and annually as indicated. You may also be required to update any necessary immunizations during your enrollment in the program. It is your responsibility to carefully review the following instructions and ensure that you comply with all of the requirements.

1. General Instructions

• Failure to submit a signed and duly completed Communicable Disease Screening Form to the School of Nursing will result in ineligibility to register for clinical courses. Please ensure your personal health care provider understands that the form must be completed as indicated. Every page and section MUST be filled out. Failure to comply may lead to repeat testing/immunization. Incomplete documents will be discarded.

• The following requirements may differ from your workplace, but these are the requirements that must be met for Nipissing’s School of Nursing.

• Agencies have reserved the right to refuse access to students who do not meet their clinical placement requirements. Agencies may also have additional requirements that are separate from the School of Nursing requirements.

• The clinical placement requirements are not subject to accommodations for personal reasons and only a medical exemption can be accepted.

• Documents that will be accepted as proof of immunization include the provincial Immunization Record, documentation signed by your health care provider (Registered Nurse, Nurse Practitioner or Physician), or laboratory evidence (report). All information from the aforementioned records must be recorded on the form. • Forms can be filled out by the student and then approved and endorsed by a qualified healthcare provider OR

completed by a qualified healthcare providor (physician, NP,RN). Please ensure document is signed and designation of healthcare provider is included.

• The Communicable Disease Screening Form is available at www.nipissingu.ca

The completed form can be returned via mail, email or fax (705-474-6111) or a duplicate copy submitted on the Orientation day in September. Students must keep their original. The form should be updated as needed and resubmitted to meet annual

requirements. Questions regarding these instructions, the form and/or the requirements, should be directed to the School of Nursing at 705-474-3450, ext 4090.

Kind Regards,

Baiba Zarins,

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INSTRUCTIONS

IMMUNIZATION/SEROLOGIC STATUS

TUBERCULOSIS

Tuberculin Skin Test (TST) Proof of a baseline two-step Tuberculin Skin Test (TST)

is mandatory in addition to a yearly one-step TST. Two step TST should be 1-3 weeks apart

10mm or more induration is considered positive Positive Result:

If either TST (2-step or 1-step) is positive, the student will be required to submit the following documentation with their Communicable Disease Screening form:

1. Copy of recent chest x-ray report (x-ray must be less than 1 year old from current date)

2. Annual TB Surveillance Letter. A copy of this letter can be found at:

www.nipissingu.ca/blendednursingforms ***Future TST is not required but the TB

Surveillance Letter must be completed on an annual basis.

***Repeat chest x-ray only required if there has been a risk of exposure.

**Please note that a One Step TST is required on an annual basis for those students whose results are negative** Multiple spaces are provided to the left so

that annual One Step (TST) updates may be added to this form.

Please keep the original form for your record keeping and only submit copies to the School of Nursing.

Two Step (TST) Documentation Required

Step 1 Date Given (mm/dd/yy)______________________ Step 1 Date Read (mm/dd/yy)_______________________

Result/Induration________________mm Signature & Designation:___________________________ Step 2 Date Given (mm/dd/yy)________________________ Step 2 Date Read (mm/dd/yy)________________________

Result/Induration_________________mm Signature & Designation:___________________________

One Step Tuberculin Skin Test (TST)

Date Given (mm/dd/yy)___________________________ Date Read (mm/dd/yy)____________________________ mm Induration________________

Signature & Designation:__________________________ Date Given (mm/dd/yy)___________________________ Date Read (mm/dd/yy)____________________________ mm Induration________________

Signature & Designation:__________________________ Date Given (mm/dd/yy)__________________________ Date Read (mm/dd/yy)___________________________ mm Induration________________

Signature & Designation:_________________________ Date Given (mm/dd/yy)___________________________ Date Read (mm/dd/yy)___________________________ mm Induration________________

Signature & Designation:__________________________ Date Given (mm/dd/yy)___________________________ Date Read (mm/dd/yy)___________________________ mm Induration________________

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VARICELLA

Laboratory evidence of immunity required.

If non-reactive/non-immune, proof of immunization with documentation is required by the School of Nursing. Titre Results

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Reactive/Immune (+)

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Non-Reactive/Non-Immune (-)

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Indeterminate If Non-Reactive/Non-Immune (-) Varicella Immunization:

Dose #1 Date (mm/dd/yy)_____________________ Dose #2 Date (mm/dd/yy)_____________________

MEASLES, MUMPS, RUBELLA (MMR)

Students must provide documentation of immunity via serologic testing(Titres) to Measles, Mumps and Rubella.

If any titre result for Measles, Mumps or Rubella is Non-Reactive, the student must provide documentation of immunization.

**Students whose titre results are non-reactive to Measles, Mumps or Rubella and have provided complete documentation of vaccination against Measles, Mumps & Rubella will not be required to receive additional vaccinations. **

Titre Results Measles Date (mm/dd/yy)_______________________________

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Reactive/Immune (+)

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Indeterminate Mumps Date (mm/dd/yy)_______________________________

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Reactive/Immune (+)

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Indeterminate Rubella Date (mm/dd/yy)_______________________________

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Reactive/Immune (+)

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Indeterminate MMR Vaccination

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TETANUS/DIPHTHERIA

Students must show proof of vaccination for Tetanus &

Diphtheria every 10 years. It will be the responsibility of the student to ensure that these boosters remain up to date after admittance into the RPN to BScN Blended Program.

Primary Series or Booster received within the last 10 years: Vaccine Name:___________________________

Date (mm/dd/yy)_________________________ Booster Name:____________________________ Date (mm/dd/yy)__________________________

POLIO

Proof of childhood immunization (5 dose series) or adult primary immunization (3 dose series)

Students are required to provide documentation of a completed series of polio vaccinations either as a child or as an adult. Polio vaccination consists of a 5 dose series for children under the age of 6 (child dose) and a 3 dose series if the primary series is started after the age of 7 (adult dose).

Students requiring the adult dose should receive two doses of Polio Vaccination given 4 to 8 weeks apart, followed by a third dose 6 to 12 months after the second dose.

If you do not have proof of polio vaccination, a note from a Healthcare provider is required affirming that vaccinations did occur, but documentation does not exist; or a note from a Healthcare provider stating unclear status and reason for not re-immunizing.

1. Primary Series Vaccination (Child)

Dose #1 Date (mm/dd/yy) ____________________ Dose #2 Date (mm/dd/yy) ____________________ Dose #3 Date (mm/dd/yy) ____________________ Dose #4 Date (mm/dd/yy) ____________________ Dose #5 Date (mm/dd/yy) ____________________

OR

2. Primary Series Vaccination (Adult)

Dose #1 Date (mm/dd/yy) _____________________ Dose #2 Date (mm/dd/yy) _____________________ Dose #3 Date (mm/dd/yy) _____________________

INFLUENZA

*Please note that influenza vaccination is required on an

annual basis*

The vaccine is available beginning in October and will take 2 weeks to become effective after the injection.

Influenza vaccination is required for all students attending clinical placement. Vaccination against influenza should be obtained as soon as the vaccine becomes available. If for any medical reason, you are not able to receive the influenza vaccination, you will be required to provide the School of Nursing with annual documentation outlining the reason you cannot receive the vaccination. You will also be required to obtain proof of an alternate form of defense for influenza (i.e. Tamiflu prescription).

Multiple spaces are provided so that annual updates may be added.

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HEPATITIS B

Proof of vaccination and serology for Hepatitis B Surface Antibody is mandatory.

Surface Antibody Level (Anti-HBs Titre)

**Antibody titre must be done at least 1 month following completion of vaccination series** Date (mm/dd/yy)_____________________

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Reactive/Immune (+)

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Students who are non-reactive (-) for anti-HBs after completing a Hepatitis B vaccination series are required to have a second series of Hepatitis B vaccination and provide documentation of a second anti-HBs titre one month after completion of the second vaccination series.

Repeat Vaccine Series (3 Doses or Accelerated Series)

Dose #1 Date (mm/dd/yy)___________________________ Dose #2 (1 month following Dose #1) Date (mm/dd/yy)___________________________ Dose #3 (6 months following Dose #2) Date (mm/dd/yy)___________________________ Repeat Surface Antibody Level (Anti-HBs Titre)

**Antibody titre must be done at least 1 month following completion of vaccination series** Date (mm/dd/yy)_______________________________

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Reactive/Immune (+)

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Students who continue to be non-reactive after a second series of Hepatitis B vaccination are considered to be “non-responders” and will be referred to the Clinical Placement Officer for further instruction.

Physician/Registered Nurse/Nurse Practitioner Declaration: I confirm that the information provided on this form is correct: