/I C S HEALTH

HEALTH/IMMUNIZATION
COVER SHEET
Gina Green (Main Campus) [email protected] 602-589-2810 (Fax)
Cassie Reynolds (AT Stills Campus) [email protected] 602-343-3751 (Fax)
Tiffany Houser (SHC Campus) [email protected] 480-270-3919 (Fax)
From: _________________________________________ Date: __________________
Nursing Student, Grand Canyon University
Phone: _________________________________________ # Pages (including cover): ________
Email: _________________________________________
The following documentation is included:
□Tuberculosis (TB)
o Option A
TB test 1: ____________ & TB test 2: ____________
o Option B
TB test 1: ____________ & TB test 2b: ____________
o Option C
Chest X-Ray: ____________ & TB form: ____________
□Tetanus (Td)
□MMR
Shot completed: ____________ (expires 10 years from date completed).
Lab result date: ____________ (results must show immunity)
□Varicella (Chicken Pox)
Lab result date: ____________ (results must show immunity)
□CPR/BLS for Healthcare Providers. Expires____________ [OR]
CPR/BLS for Professional Rescuer. Expires____________
□Hepatitis B form
o Option A
Vaccines &/or Titer
o Option B
Waiver
□Proof of Health Insurance Coverage
□Health History form (pages 1 and 2)
□Healthcare Provider’s Report form
□DPS Fingerprint Clearance card. Expires: ____________
□Influenza form
o Vaccine: ____________ (from within the past year)
□Other item: _______________________________________________________________.
Comments: ________________________________________________________________
College of Nursing - Health, Safety and Immunization Information
The required documentation is listed on the following pages. Carefully read the description of what is required and what must be
submitted. Turn in the entire packet at once and use the enclosed cover sheet to indicate what is being submitted.
The items listed below must be turned in by April 8, 2013
Attend the orientation. There will be a one hour orientation held to go over the health and immunization requirements and
answer any questions you may have.
Make an appointment. Contact your Admissions Counselor to make an appointment with Gina Green, Office of Field Experience
or Cassie Reynolds if you are with AT STILL Campus. The meeting will last approximately 15 minutes.
• Bring a copy of all the health/immunization documentation you have.
• Gina/Cassie will input your information and will print out a tracking sheet showing if you are cleared to register or if
additional items are needed.
• If any additional items are needed, fax or email scanned copies of your additional documents to June. Allow one week for
processing.
• Do not include any documentation that is not related to your health/immunization information. (For example, do not
include scholarship forms or the Essential Functions for Nursing Students form. Those go to your Admissions Counselor.)
• Students must keep their CON file current by submitting updated documentation. The tuberculosis (TB) requirement is due
annually from the date of the most recent result. Tetanus is required every 10 years from the date of the vaccine. CPR
renewal is due prior to the expiration. Influenza is required and due annually from the date of the last vaccine.
Once your health/immunization documentation is determined to be complete, June will notify you.
*Obtaining the fingerprint clearance card, scheduling the CPR certification card and the physician’s report generally take the
greatest amount of time. It is recommended to complete those items first.
Page 1 of 15
Required Health/Immunization Items:
ITEM
DESCRIPTION
CPR card*
CPR certification for the Professional Rescuer or Healthcare Provider is
required. Information as to the availability of courses may be obtained by
calling either the American Heart Association or American Red Cross, or
checking online. (Classes are sometimes called “BLS/AED for
Professional Rescuer” or “BLS/AED for Healthcare Provider” or
“Healthcare Pro”)
DPS
Fingerprint
Clearance
Card*
Health care
Provider’s
Report &
Physical
Exam*
Other CPR courses will NOT fulfill this requirement. Online-only courses
are not acceptable.
Arizona: The FP Clearance card must be submitted prior to beginning the
program for all new students. This is not a copy of your actual
fingerprints. See the Department of Public Safety for forms &/or
questions: http://www.azdps.gov/Services/Fingerprint/
When requesting a fingerprint clearance card, please ask for a "Healthcare
Student" card (which encompasses criminal and sex offender checks
performed at the federal and state levels). In other words, per the
Fingerprint Clearance Card application, students are to indicate that they
are Health Sciences Students and Clinical Assistants (ARS 15-1881).
When completing the Fingerprint Clearance Card application, please list
Grand Canyon University (and its address) as the sponsoring agency.
New Mexico: The FP Clearance card must be submitted prior to beginning
the program for all new students. In New Mexico GCU has partnered with
Hospital Services Corporation (HSC). To obtain more information
regarding costs and the Authorization for Release of Information form
please contact your admissions representative or Kristin Kelley-Gomez
(505) 823-8631.
A physician or other health care provider completes this form following a
physical exam of the student. If the physical performed within the last six
months, the form may be completed based of that exam. (Form enclosed.)
WHAT MUST BE SUBMITTED
• Copy of the student’s CPR card that shows the date of the
class and expiration.
• The card must have Professional Rescuer or Healthcare
Provider in the title.
• Copy of the students current, unexpired DPS fingerprint
clearance card. (Arizona example shown.)
• The form enclosed below, completed and signed by the
student’s health care provider.
Page 2 of 15
Required Health/Immunization Items:
ITEM
DESCRIPTION
Tuberculosis
Initially, two-step testing will be required for all incoming students. Two- Option A “Two Step”:
step testing is useful for the initial skin testing of adults who are going to
• TB Test 1 (Negative result must be dated within the past year)
be retested periodically, such as health care workers or nursing home
• TB test 2 (Negative result must be dated one to three weeks
residents. This two-step approach can reduce the likelihood that a boosted
after TB test 1 negative result date.)
reaction to a subsequent TST will be misinterpreted as a recent infection.
Two-step testing is a strategy used in TB screening programs to
Option B “History”:
distinguish a boosted reaction (caused by TB infection that occurred many
• TB Test 1 (Negative result must be dated within the past year)
years before the skin test) from a reaction caused by recent infection. If a
• TB test 2b (Negative result must be dated from within the past
person has a negative reaction to an initial skin test, a second test is
three years)
given 1 to 3 weeks later; a positive reaction to the second test probably
represents a boosted reaction, not recent infection.
Option C “Chest X-Ray”:
• Chest X-Ray (Results must be dated from within the past two
• An exemption from two-step testing may be granted by the CON if
years)
the student submits documentation showing a history of annual TB
• TB Screening Questionnaire (Must be dated from within the
testing
past three months. Obtain form from CON.)
• For positive skin tests, a health department clearance is required.
(Contact health department.) Recent (within past 2 years) clear chest
X-ray, along with a completed TB screening form from within the
past year. Evaluation will be made on an individual basis.
Documentation of Tetanus or Tetanus-Diphtheria vaccination administered Documentation may include:
within the past 10 years. (Tdap vaccines are accepted.)
• Copy of immunization record with tetanus shot date listed.
• Your health care provider may write the date vaccine
received on the “Health care Provider’s Report” form
(enclosed.)
Influenza vaccine is required annually. Declination for religious and
Option A “Vaccine”
medical reasons will have to be reviewed. If declination is approved, a
• Student must have received the standard influenza vaccine
mask must be worn at all times upon entering the building (except while
within the past year. Complete the top half of the Influenza
eating in cafeteria or employee lounge). Please contact your site clinical
form (enclosed) and list the vaccine date.
coordinator to obtain the declination forms. The Flu season is considered
Option B “Waiver”
to be from December through March. Students are responsible for
• See your Site Clinical Coordinator for the Declination form.
updating their influenza record annually.
(TB)
TetanusDiphtheria
(TD)
Influenza
(Flu)
WHAT MUST BE SUBMITTED
Page 3 of 15
Required Health/Immunization Items:
ITEM
DESCRIPTION
WHAT MUST BE SUBMITTED
Hepatitis B
Hepatitis B vaccine (3 doses) is strongly recommended. A waiver is
required if vaccine not administered. (Form enclosed.)
MMR:
Students must show
• Proof of immunity (Lab evidence indicating positive MMR titers)
(Because of recent changes in policies, documentation of two or more
MMR vaccines is not sufficient.)
Option A “Vaccines”
• Student must have completed the Hep B vaccine series (of
three doses). Complete the top half of the Hep B form
(enclosed) and include 3 vaccine dates. Student may also
include any booster shots and/or titer date and result as
applicable.
Option B “Waiver”
• Complete only the bottom half of the Hep B form if you have
not completed all three vaccines or if your blood test
indicates you are not immune to Hepatitis B.
Paperwork showing immunity (Positive) to Measles (Rubeola),
Mumps, and Rubella. Documentation to include one of the
following:
• Copy of lab report showing results
• Healthcare provider’s report form showing this information.
• Copy of other official medical record (such as Employee
Health Records or military records) indicating immunity.
• Doctor’s note indicating date of titer results and if positive or
negative.
Paperwork showing immunity (Positive) to Varicella (chicken
pox) Documentation to include one of the following:
• Copy of lab report showing result
• Healthcare provider’s report form showing this information.
• Copy of other official medical record (such as Employee
Health Records or military records) indicating immunity.
• Doctor’s note indicating date of titer result and if positive or
negative.
Measles
(Rubeola),
Mumps,
Rubella
Varicella
(Chicken Pox)
If not immune (negative titer results), then student must be vaccinated and
be re-tested at least 30 days after receiving the vaccination. If, after the
second blood test, the student is still showing “negative” or “non-reactive”
for immunity, no further vaccines/titer requests will be required.
Students must show
• Proof of immunity (Lab evidence indicating positive varicella titers)
(Because of recent changes in policies, documentation of history of
chicken pox or varicella vaccinations are not sufficient.)
If not immune (negative titer results), then student must be vaccinated and
be re-tested at least 30 days after receiving the vaccination. If, after the
second blood test, the student is still showing “negative” or “non-reactive”
for immunity, no further vaccines/titer requests will be required.
Health History Student completes this form (enclosed).
Student to fill out both pages one and two of the form.
form
Page 4 of 15
Required Health/Immunization Items:
ITEM
DESCRIPTION
WHAT MUST BE SUBMITTED
Health
Insurance
Verification of the student’s current health insurance coverage. (e.g.,
Copy of insurance card.) This information will be required at the start of
each semester you are enrolled.
Please note that this is ONLY for your nursing file,
and is not shared with other GCU departments .
Please note that this is only for your nursing file, and is
Documentation may include one of the following:
NOT shared with other departments. Contact your
• Copy of current health insurance card
• Letter from insurance company indicating coverage
Enrollment and/or Finance Counselor (FC) to learn about
GCU insurance policies and costs, if you already have
Additionally, for military or Native American students the
alternate health insurance coverage or if you are enrolling
following documentation is accepted:
in GCU’s student coverage. Failure to contact your FC may • Copy of current, valid military ID
result in automatic enrollment in GCU’s student insurance
• Letter or other verification from Indian Health Services
coverage and charges to your account.
Background
check
Must be completed prior to acceptance to the program.
This item should be completed prior to acceptance.
Other requirements: The items listed below are completed after the first day of class.
ITEM
DESCRIPTION
WHAT MUST BE SUBMITTED
Drug Screen
A negative drug screen is required prior to beginning first clinical
experience.
This will be scheduled by the College of Nursing during the first eight
weeks of the semester.
The student pays the cost of the drug screen (approximately $50).
This will be distributed by Level I instructor, to be completed prior to
beginning clinical experience.
Nothing is turned in prior to the start of the program.
Students are to budget for this requirement so funds are
available any time during the first eight weeks of class, as the
drug screen will be randomly scheduled by the CON.
HIPAA form
Nothing is turned in prior to the start of the program. This form
will be completed in class. If the instructor does not turn in the
HIPAA form to the Admin. Assistant, then the AA will require
the student to sign a second HIPAA form for the student’s CON
file.
Page 5 of 15
HEALTH/IMMUNIZATION COVER SHEET
To: Gina Green (Main Campus) [email protected]
602-761-3317 (Fax)
Samantha Chacon (Main Campus) [email protected] 602-589-2810 (Fax)
Cassie Reynolds (AT STILL) [email protected] 602-343-3751 (Fax)
From: _________________________________________
Nursing Student, Grand Canyon University
Date: __________________
Phone: _________________________________________ # Pages (including cover): ________
Email: _________________________________________
The following documentation is included:
Tuberculosis (TB)
o Option A TB test 1: ____________ & TB test 2: ____________
o Option B TB test 1: ____________ & TB test 2b: ____________
o Option C Chest X-Ray: ____________ & TB form: ____________
Tetanus (Td) Shot completed: ____________ (expires 10 years from date completed).
MMR Lab result date: ____________ (results must show immunity)
Varicella (Chicken Pox) Lab result date: ____________ (results must show immunity)
CPR/BLS for Healthcare Providers. Expires____________ [OR]
CPR/BLS for Professional Rescuer. Expires____________
Hepatitis B form
o Option A Vaccines &/or Titer
o Option B Waiver
Proof of Health Insurance Coverage
Health History form (pages 1 and 2)
Healthcare Provider’s Report form
DPS Fingerprint Clearance card. Expires: ____________
Influenza form
o Vaccine: ____________ (from within the past year)
Other item: _______________________________________________________________.
Comments: __________________________________________________________________
Page 6 of 15
Nursing Courses
Below is the list of the nursing courses you will take in each level. A course schedule will be
sent after the days/times are finalized.
•
•
•
•
Please note that you must complete the entire BSN Program of Study (which can be found online).
Non-nursing courses (such as Statistics or University Success or Christian Worldview) may need to be
completed along with your nursing courses. Work with your Academic Counselor to ensure those
classes are completed on time.
The course descriptions are in the GCU Catalog – http://my.gcu.edu/Academics/Pages/Catalog.aspx
You can also find the Academic Calendar (holidays, semester start/end dates, etc.) online –
http://my.gcu.edu/Academics/Pages/Calendar.aspx
Nursing Core
– Level 1 – First 8 weeks
NUR 206A
Intro. to Nursing and Gerontology I
NUR 209
Health Assessment
– Level 1 – Second 8 weeks
NUR 206B
Intro. to Nursing and Gerontology II (Clinical)
NUR 203
Introduction to Pharmacology
3
3
Credits
– Level 2 – First 8 weeks
NUR 311
Adult Health Nursing I (Clinical)
– Level 2 – Second 8 weeks
NUR 312
Adult Health Nursing II (Clinical)
3
3
12
6
Credits
– Level 3 – First 8 weeks
NUR 398*
Research in Nursing (online)
NUR 313**
Care of the Childbearing Family (Clinical)
– Level 3 – Second 8 weeks
NUR 314 **
Family Centered Child Health Nursing (Clinical)
Credits
– Level 4 – First 8 weeks
NUR 411**
Community Health Nursing (Clinical)
NUR 412**
Home Health Care Nursing (Clinical)
– Level 4 – Second 8 weeks
NUR 413**
Community Mental Health Nursing (Clinical)
Credits
– Level 5 – First 8 weeks
NUR 456
Complex Care (Clinical)
NUR 498A
Capstone
– Level 5 – Second 8 weeks
NUR 443
Management and Leadership in Nursing (online)
NUR 498B
Practicum in Nursing (Clinical)
Credits
TOTAL NURSING CORE
6
12
3
6
6
15
5
3
5
13
6
1
2
3
12
64
*Statistics is a pre-requisite to NUR 398 Research in Nursing
**Course Sequencing Note: NUR 313 and NUR 314 offering may be reversed (314 during first 8 weeks, 313
during second 8 weeks) per CON. Additionally, NUR 411/NUR 412 and NUR 413 offering may be reversed
(413 during first 8 weeks, 411 & 412 during second 8 weeks) per CON.
Prerequisite & Co-Requisite Courses:
The contingencies below must be met by the beginning of the semester unless alternate arrangements
have been made.
Make sure all your credits have transferred in correctly.
1. Log in to the Student Portal via www.my.gcu.edu. (Click on “Sign In” at the top of the page.)
• If you do not know your login name and/or password, go to https://accounts.gcu.edu and click on
“Set up your GCU account”. You may also watch a short tutorial video on how to set up your
account by clicking on “Help using Accounts@GCU”.
NOTE: This will also be the login/password to your GCU email address, which is the hotmail
account accessed through the Student Portal.
2. Click on the tutorial to learn about the different features of the Student Portal, including where to find your
Program Evaluation (or Degree Audit). You can use that to determine if all your classes have transferred
over correctly. Contact your Academic Counselor if you have any questions about your courses.
Turn in official transcripts to the Office of Academic Records.
1. Make sure all final grades are posted.
2. Contact your post-secondary institution and provide them with the following information.
Grand Canyon University
Office of Academic Records
P.O. Box 11097
Phoenix, AZ 85061-1097
3. Follow up to make sure the transcripts were sent by the other institution.
4. Allow time for the OAR at GCU to evaluate your transcript(s), and then check your Program Evaluation to
ensure the credits transferred in. If you have any questions, contact your Academic Counselor.
If your Degree Program Audit is correct and all pre-requisite classes (and co-requisite classes, for Fast
Track students) have transferred in, you have completed this requirement.
Bachelor of Science in Nursing Programs
Documentation of Hepatitis B Vaccine Status
To be completed if you have previously had Hepatitis B Vaccine
I have received the Hepatitis B vaccine on the dates listed below:
First Dose: ____________________________________________
Second Dose: __________________________________________
Third Dose: ___________________________________________
Boosters, if any: ________________________________________
OR Date of Hepatitis B antibody titer: ________________________
______ Immune ______ Not Immune
Signature_______________________________________________ Date _______________
Student’s Name (printed) ______________________________________________________
Hepatitis B Vaccine Declination
I understand that due to my occupational exposure to blood or other physically infectious materials, I may be at risk
of acquiring hepatitis B (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B
vaccine. However, I decline hepatitis B vaccine at this time. I understand that by declining this vaccine, I continue
to be at risk of acquiring hepatitis B, a serious disease.
Signature _______________________________________________ Date _______________
Student’s Name (printed) _______________________________________________________
Notes
• Vaccine will be available at the Student Health Center at Student’s expense.
• This form will be utilized in clinical courses to document student’s compliance with the vaccine as
required by some clinical placement agreements.
Mail completed report to Grand Canyon University 3300 W. Camelback Rd. Phoenix, Az 85017 or fax to 602-761-3317
Bachelor of Science in Nursing Programs
Documentation of Influenza Vaccine Status
Top portion be completed if you have recently received the Influenza Vaccine:
I have received the Influenza vaccine within the past year on the date listed below:
Date of most recent Influenza vaccine: ________________________
Signature_______________________________________________ Date _______________
Student’s Name (printed) ______________________________________________________
Influenza Vaccine Declination
Declination for religious and medical reasons will have to be reviewed. If declination is approved, a mask
must be worn at all times upon entering the building (except while eating in cafeteria or employee
lounge). Please contact your site clinical coordinator to obtain the declination forms.
The Flu season is considered to be from December through March.
Mail completed report to Grand Canyon University 3300 W. Camelback Rd. Phoenix, Az 85017 or Fax to 602-761-3317
Grand Canyon University
Health care Provider’s Report
We rely heavily on your history and examination of this patient. We appreciate as much information as possible on history and physical
examination. Thank you very much.
Name___________________________________________________ Social Security Number ___________________________
Blood Pressure (1) ________________ (2) ________________ Pulse ________________ Ht. ______________ Wt.____________
Vision (without glasses) Right _____________ Left _____________ (with glasses) Right _____________ Left _______________
Allergies _________________________________________________________________________________________________
Clinical Exam: Check each Item in appropriate column. Elaborate as needed.
Normal Abnormal
______ ________ H.E.E.N.T. _______________________________________________________________________
______ ________ Pupil Size _______________________________________________________________________
______ ________ Skin ____________________________________________________________________________
______ ________ Heart ___________________________________________________________________________
______ ________ Lungs ___________________________________________________________________________
______ ________ Abdomen ________________________________________________________________________
______ ________ Hernia and Genitalia (males) _________________________________________________________
______ ________ Neurological _____________________________________________________________________
______ ________ Spinal Column (scoliosis, etc.) ________________________________________________________
______ ________ Upper Extremeties _________________________________________________________________
______ ________ Lower Extremeties _________________________________________________________________
Present Health Problems:
Comments/Recommendations:
Restrictions:
Required for all Nursing Students: Rubeola Screen _______________________
(May attach records/reports)
Tetanus shot date ______________
Results (+/-) and Date
Rubella Screen _______________________
Results (+/-) and Date
TB PPD (1) ___________________________
Date Read and Result
Yes
Mumps Screen _______________________
Results (+/-) and Date
Varicella Screen _______________________
Results (+/-) and Date
TB PPD (2) ___________________________
Date Read and Result
(OR) CXR _______________________
Result and Date
No: ________________________________ is physically and mentally able to perform duties
Student Name
of nursing student.
Provider’s Address ____________________________ City _________________ State _______ Phone: _________________
Provider’s Signature ________________________________________________________________ Date: _______________
Provider’s Name, printed _________________________________________________________________________________