Gaston College Student Health Records - Requirements and Accommodations






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Welcome to Gaston College! We are so glad that you have chosen to complete your education in one of our outstanding health programs.

All Health Program students are required to submit to the college a student Health Record. Below are detailed instructions and more information for your understanding.


• Students must retain a copy of all documentation submitted to the Compliance Specialist. • All records must be verifi ed with a healthcare provider’s signature or stamp.

• Students will be ineligible to participate in Clinicals until the Health Record is completed.


Submission Deadline When applying to your chosen program, please submit the completed Health Form on or before the designated due date.

Three Ways to Submit Health Record:

1. Deliver to the Dallas Campus 1. Hand deliver your health records to the Dallas Campus (David Belk CannonBuilding) Compliance Specialist, Danielle Kahne, office # 205 2. Mail to the Dallas Campus 2. Danielle Kahne, Compliance Specialist

Gaston College

201 Highway 321 South Dallas, NC 28034 3. Scan Documents and Email to

the Compliance Specialist

3. Email to:

If you have questions, Contact Danielle Kahne, Compliance Specialist at 704-922-2275.


Please note that all students must

complete a criminal background check.

As a requirement from our clinical agencies, we must ensure this is completed for every student.

Instructions Gaston College endorses the following source for obtaining a criminal background history:

1) Go to

2) In “Place Order” enter package code for your school ( ) 3) Click “Go” and follow instructions.

4) ANY allegations or charges of a misdemeanor or felony that occur after the Criminal Background History results have been submitted must be report-ed immreport-ediately to the Compliance Specialist, Danielle Kahne. Clinical Sites have the right to deny students access based on criminal background. This denial would result in the student’s inability to complete theprogram of study successfully.

Failure to Report Failure to report any change may result in withdrawal or removal from the program.



Health Insurance • All students are required to have health insurance coverage. • Coverage is required throughout enrollment in the program. Acceptable Sources to Obtain Health

Insurance There are many sources from which to obtain health insurance coverage, a few examples include: Medicaid, Affordable Care Act, Military Insurance, BCBS, Aetna, Cigna, United Healthcare, etc. Healthcare coverage is also offered by the NC Community College System

Malpractice Insurance (Tuition Fee) Malpractice Insurance (required for Nursing and Health Services program students): $13 per year

CURRENT American Heart Association

CPR (Adult, Child, Infant) Proof of current American Heart Association Healthcare Provider CPR certification must be on file and current at all times.


Examination by Healthcare Provider (Using Form A – Student Health Evaluation)

Only a physician, physician assistant, or nurse practitioner shall perform the physical examination.

Hearing and Color Vision Tests Hearing and vision tests must be included as part of the physical examination. Vision test must include a color vision test due to clinical skills where

visualization of color is necessary to patient care.

Signatures/Facility Stamp The Physical Examination and Immunization Record forms must include the healthcare provider’s signature and the address/phone number of the



Program Essential Functions (Form B) Each Program has a list of competencies which students must be able to per-form in order to successfully complete the learning outcomes. Only a

physician, physician assistant, or nurse practitioner shall perform this section. IT MUS BE SIGNED BY A QUALIFIED HEALTHCARE PROVIDER!

Submission of the Program Essential

Functions Form The Essential Functions Form will need to be sent to our Compliance Specialist, Danielle Kahne, by any of the following means: 1. Hand deliver


3. Mail

Danielle Kahne, Compliance Specialist Gaston College

201 Highway 321 South Dallas, NC 28034


North Carolina State Law Section 15A NCAC 19A.0207 (POSITIVE HIV and HEP B infected). This law addresses HIV and HEP B infected healthcare workers (THIS INCLUDES STUDENTS IN HEALTH PROGRAMS.)

Excerpt: “(b) All health care workers who perform surgical or obstetrical procedures or dental procedures and who know themselves to be infected with HIV or Hepatitis B shall notify the State Health Director. The notification shall be made in



Disability Services:

If a Gaston College Health Services Program Applicant or current student believes that he or she cannot meet one or more of the essential standards without accommodations or modifications, the college must determine, on an individual basis, whether or not the necessary accommodations or modifications can be reasonably accommodated.

Requests for accommodations should first be directed to the program chairperson and/or coordinator. From there the Counseling and Career Development Center at Gaston College will assist and advise studentswith documented disabilities, arranging academic support and reasonable accommodations. Accommodations are arranged on an individual basis, specific to the student’s needs. Students must provide all necessary

documentation prior to receiving any special accommodations.

Change/Altered State of Student Health after Admission to a Health Program:

A change in the student’s health during the program of learning, so that the essential functions cannot be met, with or without reasonable accommodations, may result in withdrawal from the Health Sciences Program. The chairperson/coordinator of the program must be informed when there is any change in condition/health of

students (for example: pregnancy, injury, extended illness, hospitalization). An additional medical examination at the student’s expense may be required in order to assist with evaluation of the student’s ability to perform the essential functions of the Health Sciences Programs at Gaston College.


All Programs EXCEPT VET TECH will need to provide proof of the following vaccines/immunizations.

(Form C)

• DPT or TD (must have a total of 3) OR Tdap within 10 years • Polio

• MMR (Measles, Mumps and Rubella) 2 doses or titers • Hepatitis B (3 shot series) or declination

• Varicella Titer (Chicken Pox) • 2 step PPD (on admission) • Annual TB test

• Seasonal Flu Vaccine (mandatory in most clinical sites) VET Tech Student Immunizations - Rabies Vaccine

- Tetanus & Pertussis Vaccine (Tdap within 10 years)

To learn more information about these vaccines and the benefits/potential risks, please visit the Center for Disease Control and Prevention website at

NOTE: Vaccine requirements may change based upon industry standard and/or Center for Disease Control recommendations. All students will be informed in a timely manner about any changes in required immunizations for admittance and/or progression in a health program at Gaston College.



Drug Screen Requirements Gaston College adheres to the policies and procedures of all clinical facilities with which the health programs are affiliated for student clinical learning experiences. These policies and procedures address the requirement for a drug screen and circumstances when policies are not followed.

12 Panel Drug Screen *THC Marijuana * PCP (Phencyclicline) *BAR (Barbituates) *BZP (Benzodiazepines) *PPX (Propoxphene) *COC (Cocaine)

*MTD (Methadone) *OPt (Opiates/Including Heroin *OXY (Oxycodone) *AMP (Amphetamines)

*MDMA (Ecstasy) *METH (Methamphetamines)

Positive Drug Screen Due to

Prescribed Medications A POSITIVE drug screen due to prescribed medications must be substantiated by documentation from the prescribing physician. Positive Drug Screen Due to

Non-prescribed Medications and/or


A POSTIVIE drug screen due to non-prescribed drugs will result in the student being ineligible to participate in a clinical experience. The student will be with-drawn from the program.

Sources for Drug Screen Testing • Drug Testing is offered in coordination with an outside laboratory. • You will be given information of how to obtain drug sceening through

our Compliance Specialist, Danielle Kahne.

Results of Drug Screens Results will be kept onsite at Gaston College and available for review in order to be in compliance with our clinical facilities, policies and


Student Name: _____________________________________________________________________________

Last First Middle

Gaston College Student ID # ______________________________Date of Birth_________________________ Mailing Address: ____________________________________________________________________________

Street Address

____________________________________________________________________________ City State Zip code

Phone Numbers: Home# __________________________ Cell # ____________________________________ Gaston College Email Address: ________________________________________________________________

Program: (Please check which program you are entering)  Associate Degree Nursing (Traditional)

 Associate Degree Nursing (LPN-RN)  Cosmetology

 Dietetic Technician and/or Dietary Manager  Medical Assisting

 Nursing Assistant  Phlebotomy

 Practical Nursing (LPN)  Therapeutic Massage

 Veterinary Medical Technology

Student Health Record

Emergency Contact Information: (In the event of an emergency)

Name: ________________________________ Relationship:________________________________

Phone Numbers: _________________(Home) __________________(Cell)________________(Work)




(Healthcare Provider to Complete This Form – MD, PA, NP)

Student Name: ______________________________________________________________________________ Date of Birth: (month/day/year) ______/______/______

Height:____________ Weight:____________ Blood Pressure:_________________

Vision: Corrective Lenses  Yes  No Color vision: Is student color blind?  Yes  No Hearing: WNL  Yes  No Hearing Aids Used:  Yes  No

Please indicate below if the prospective Health Sciences Program student has any problems with the following body systems.

Body System Normal Abnormal Describe

Head, Ears, Nose, Throat










A. Is the student currently under treatment for any medical or emotional conditions?  Yes  No

If “yes” explain: ___________________________________________________________________________ ________________________________________________________________________________________ B. Does the student have any life threatening allergies?  Yes  No

If “yes” list allergen: _______________________________________________________________________ C. Does the student require use of Epipen?  Yes  No

D. Does the student require any other prescribed medications for life threatening allergies?  Yes No If "Yes" list medications required: ______________________________________________________________






Gaston College Health Programs

Essential Functions: Core Performance Standards for Admission and Progression (FORM B)

Please read and check yes or no to each function listed!

Function Standard Some Examples of Necessary Activity (Not all inclusive)

Critical Thinking

 Yes  No Critical thinking ability suffi cient for clinical judgment and decision making. Identify cause and effect relationships in clinical situations, carry out care of client/patient correctly. Interpersonal

 Yes  No

Interpersonal abilities suffi cient to interact with individuals, families, and groups from a variety of social, emotional, cultural, and intellectual backgrounds.

Establish rapport with clients, patients, caregivers, and colleagues.


 Yes  No Communication abilities suffi cient for interac-tion with others in verbal and written form. Explain treatment procedures, initiate health teaching as directed, document care, interpret re-sults, and communicate with other caregivers with or without reasonable accommodations. Mobility

 Yes  No

Physical abilities suffi cient to move from room to room, maneuver in small spaces, transport patients and animals in VET tech programas needed for care.

Moves around in patient/animal care rooms, work spaces,and treatment areas. Administer cardio-pulmonary procedures with or without reasonable accommodations.

Motor Skills

 Yes  No

Gross and fi ne motor abilities suffi cient to

pro-vide safe and effective care. Calibrate and use equipment, position client/pa-tient with or without reasonable accommodations. Hearing

 Yes  No

Auditory ability suffi cient to monitor health

needs of patient/client. Hears monitor alarms, emergency signals, aus-cultatory sounds, cries for help, with or without reasonable accommodations.


 Yes  No

Visual ability suffi cient for observation and

as-sessment necessary in patient/client care. Observes patient/client responses to care with or without reasonable accommodations.


 Yes  No

Tactile ability sufficient for physical

assesment. Perform palpation, functions of physical examina-tion and/or those related to therapeutic interven-tion, i.e., insertion of IV’s, catheter with or without reasonable accommodations.

Weight Bearing

 Yes  No

Lifting ability suffi cient for a variety of patient/

client care settings. Performs patient/client care that demonstrates the ability to lift and manipulate at least 50 pounds. *For EMS program, able to lift and manipulate at least 170 lbs.

Temperament & Emotional Control

 Yes  No

Remain calm, patient, and react

professionally to certain situations. High stress clinical areas, working with others in healthcare (TEAM centered).

I have read the program essential functions and based on my assessment of this student’s physical and emotional health on ________________ (date), he/she is able to participate in the activities of this program in a classroom, clinical, and lab setting.


Immunizations Record (FORM C)

Clinical Agency Requirements/Proof of Vaccinations

Student Name: _______________________________________ Student ID #: __________________________ Date of Birth: (Month/day/year) ______/ ______/______

To be completed and signed by physician and


or clinic. A complete immunization record is required and must be met in order to proceed in the program.


IMMUNIZATION MO/DAY/YEAR MO/DAY/YEAR MO/DAY/YEAR MO/DAY/YEAR DPT (Diphtheria, Tetanus, Pertussis) #1 #2 #3 Tetanus Booster (Within 10 years) MMR

(Measles, Mumps, Rubella) #1 #2 OR Titer date & results (attach proof) Hepatitis B

OR Declination Form #1 #2 #3 Titer date & results (attach proof)


(Chicken Pox) series of two doses or titer

#1 #2

OR Titer date & results (attach proof) Tuberculin Skin Test (PPD)

*If PPD is positive a onetime chest x-ray is required (chest x-ray

documentation to include date, results, and recommendations for future testing).

Attach proof with date and results of PPD.

Date of 2 step PPD Results of PPD

#1 #2

SEASONAL VACCINE Date Received Month/Year Flu/Influenza Vaccine

Flu/Influenza Vaccine

RABIES Vaccine for VET Tech Students ONLY


Student Signature Page (Form D)


I, the undersigned student in a health program at Gaston College, understand that participation in a clinical ex-perience is a requirement to complete my program successfully.

(Please initial that you understand each requirement and have had your questions answered regarding these requirements.


Authorization for Disclosure: Off-Campus/Clinical Facility Release of Student Health Information Off-campus clinical facilities may require medical information on students in programs with clinical assignments. Gaston College is responsible for providing the clinical facility with medical data abstracted from the student’s medical record. This data may include vaccinations received, medical test results, criminal background screens and drug screen results. The facility may also require that the student provide a copy of their medical packet if necessary including emergency contact information for first aid and safety purposes if medical treatment is required.

By signing below, I authorize Gaston College and the Health Division to release and disclose any and/or all pertinent medical information as indicated in the above provision, to an affiliating clinical facilities that require this information as a condition of my assignment to the facility. I understand that if I refuse to release my medical information to Gaston College /clinical facilities I may lose my eligibility to continue as a student in Gaston College Health Programs. I further understand that failure to release the records may result in the facility denying my clinical assignment. I also understand that I may not be able to fulfill the Program’s graduation requirements.

Student Signature: ________________________________ Date: ___________________

_________Criminal Background Check and Fingerprinting _________Obligation to Report Criminal Charges

_________Drug Testing

_________Healthcare Provider signed form/Physical and emotional stability for program essential functions _________Obtain and maintain up-to-date CPR Certifi cation





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