My first document

DEPARTMENT OF CAREER AND TECHNICAL EDUCATION HEALTH SCIENCE PROGRAMS

A health report, including a physical, is essential before the school district will admit any applicant to a Health Science Education program which involves clinical training/patient contact, because it shows evidence that the person can meet the demands of the occupation and adjust to them without hazard to self and to the patient/client.

STUDENT HEALTH RECORD

Student Name: School: Date:

Phone # SSN:

Health Record is to be completed by a Health Care Provider

*Asterisk items must be current within one year of first clinical rotations. Submit original form to Health Science Department Chair. DO NOT LEAVE SECTIONS BLANK – IF NOT APPLICABLE PLEASE PRINT N/A

Requirements Completion

Health Screen Qualifications

*10 Panel Drug Urine Screen

*TB Test if negative history (Mantoux) (Initial test is 2-step TB test) OR

Blood assay for Mycobacterium TB (BAMT – QuantiFERON or T-SPOT )

Chest X-ray if positive TB skin test or positive BAMT

Vaccination Record or Titer

Hepatitis B

copy of lab report

*Flu Vaccine

COVID 19 Vaccination

Free of Communicable Disease Statement

I certify that the above information is correct, and this student has been evaluated by me and found to be:

☐Qualified to begin clinical rotations for which the exam was requested and free of communicable disease.

☐Not qualified to begin clinical rotations for which the exam was requested.

Health Care Provider Name (Print):

Health Care Provider Signature__________________________

Date

Results

(MM/DD/YY)

Fit

☐ YES

☐ NO

for Duty

or

☐Negative ☐ Positive

Attach

☐Negative ☐ Positive ________ mm induration ☐Negative ☐ Positive

☐Negative ☐ Positive

Date

1st IgG

_________________________ Attach copy of lab report 2nd 3rd Measles Immunity 1st IgG Titer result _____________________ Attach copy of lab report 2nd Mumps Immunity 1st IgG Titer result _____________________ Attach

lab

2nd Rubella 1st IgG Titer result _____________________ Attach

2nd Varicella 1st IgG Titer result _____________________ Attach copy

lab

2nd

Titer result

copy of

report

copy of lab report

of

report

1st Provide original

Department chair. 2nd

copy to Health Science

_____________Date___________

Address __________________________________

______________________ License Number

DOB: FM-5899 Rev. (12-22)

Certification of Applicant - To be reviewed and completed by applicant

I hereby certify to the best of my knowledge; I have no mental impairments or physical illness which could interfere with the general performance of functions assigned to me as a health care provider.

I understand that I must submit a medical clearance from an obstetrician if I am pregnant or become pregnant during my training program.

Name of Applicant: _____________________________________________________________________________________

Signature: ____________________________________________________________________________________________

Parent Signature (If applicable): ___________________________________________________________________________

Date: ________________________________________________________________________________________________

FM-5899 Rev. (12-22)

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