University of Arkansas Health Forms

University of Arkansas
Eleanor Mann School of Nursing (EMSON)
Health and Immunization Requirements
Students will not be permitted in clinical practicum courses until compliance requirements are met.
Students are responsible for maintaining their compliance throughout the program. Students who are
unable to achieve compliance by the designated due date will be withdrawn from the program. Students
unable to meet compliance requirements may petition to be re-enrolled in the program in the subsequent
semester only after compliance is confirmed by the EMSON; however, students will not be guaranteed
placement and will be placed according to space available and our priority ranking policy (Academic
Progression Policy). Failure to meet compliance requirements for clinical courses may delay graduation.
Note: It is the student’s responsibility to complete clinical compliance.
These records must always be current.
Return forms to Sentry MD by emailing your forms to [email protected] OR to
[email protected] OR fax to 1-214-619-1830 OR 1-817-251-9593.
The deadline to submit these forms is November 15, 2014.
Part I-Student Profile:
Name: (Please Print)
University of Arkansas Email Address
Last, First MI
Date of Birth: ____/_____/_____
Secondary Email Address
phone: (____) ______-_______
Street Address
City, State, Zip
Additional Certification and Licensure to submit to Sentry MD:
1. CPR Certification: Basic Life Support and Automated Emergency Defibrillation CPR for
Healthcare Providers (American Heart Association). Please submit a copy of your CPR card.
Due December 15, 2014.
2. Licensure: LPN’s must maintain a current, unencumbered licensed practical nurse license in
order to participate in clinical practicum experiences. Student is expected to provide to EMSON
proof of a current license upon renewal.
3. Health Insurance: Copy of your current health insurance cards, update annually. Health
Insurance cards must have student name listed and a current date.
The University of Arkansas (EMSON) works with Sentry MD, a confidential health information service.
Sentry MD maintains and processes all student immunization records and monitors compliance with state
and program law requirements.
Students must email required immunization forms, certifications and licensure documents directly
to [email protected] OR [email protected] OR Fax to 1-817-251-9593
OR 1-214-619-1830
Page 1
University of Arkansas
Eleanor Mann School of Nursing (EMSON)
Health and Immunization Requirements
Print student name:_______________________________ Date of Birth:_________________
Part II- Immunizations: to be completed by your health care provider.
In order to promote and maintain a safe environment while in the University of Arkansas EMSON
Program and clinical affiliate sites, the following information is required prior to enrollment. Please have
the information in Part II completed by your health care provider. Submit the forms by email to
[email protected] OR [email protected] OR fax to 1-214-619-1830
OR 1-817-251-9593.
KEEP A COPY FOR YOUR OWN RECORDS. Forms Due by November 15, 2014.
Measles, Mumps and
Rubella (MMR):
A two injection series;
Serologic evidence of
immunity, or vaccination
dates.
Date of Serologic Evidence
of Immunity (Titers):
Vaccination Dates:
MMR 1:
___/____/____
Measles(Rubeola)
___/____/___
MMR 2:___/____/___
Mumps:____/_____/_____
Rubella:_____/_____/____
Tetanus Diphtheria
(Td)
Within last ten years. If a
Tdap has never been
received, it must be
administered. If a Tdap
has been received, a Td
booster every 10 years
is required.
Varicella: A two
Injection series; Reliable
history of varicella
disease, a positive titer,
evidence of immunity, or
vaccination dates.
Hepatitis B: with dates
of each injection or
declination completed.
Three (3) HBV injections
are needed. At least the
first two of three
injections must be
completed and received
before the student may
practice in the practicum
setting. The third HBV
vaccine must be
received and
documented by the end
of the first clinical
semester or a positive
Hep B surface antibody
titer
Results of MMR Titers:
Measles Titer Result:
Pos_____
Neg_____
Mumps Titer Result:
Pos_____
Neg_____
Rubella Titer Result:
Pos_____
Neg_____
Tdap Vaccine Date:
____/____/_____
TD Date:
____/____/_____
Date of Disease:
Month and Year are
Required.
Date of Titer:
Vaccine 1:
______/______/_____
_____/_____/_____
Pos_____
Dose 1:
_____/_____/____
Dose 2:
____/_____/_____
Dose 3:
____/_____/_____
Hep B Surface Antibody
Date: ____/____/______
______/______/_______
Pos_____
Booster:
____/_____/_____
Page 2
Neg_____
Neg_____
Varicella 2:
_____/______/_____
University of Arkansas
Eleanor Mann School of Nursing (EMSON)
Health and Immunization Requirements
Last TB skin test
(PPD/Mantoux): with
date and results. Or TSpot TB test
results. (May never be
more than one year old
during matriculation).
TB Skin Test Date:
T-Spot Skin Test Date:
X-Ray Date:
_____/_____/_____
_____/_____/________
_____/______/______
TB Skin Read Date:
Pos_____
Pos_____
If a TB skin test is
positive it may be
verified with a T-Spot.
Result:________mm
Neg_____
Neg_____
_____/______/_____
If T-spot is positive or if
only a positive skin test
is submitted, a chest xray must be completed
and updated yearly.
If a skin test is positive
and the T-spot is
negative, a T-Spot must
be updated yearly.
If PPD is positive, chest
x-ray is required. After
submitting a normal
chest x-ray at entry, an
annual note from your
health care provider that
you are symptom free or
a repeated normal chest
x-ray will satisfy the
yearly test required.
2014 Influenza Vaccine
*If you require a declination form, please contact Sentry MD to obtain the form
Due 11/15/14
Date of vaccine: _____/_____/_____
*Any other immunization that may be required by clinical agencies.
Print student name:_______________________________ Date of Birth:_________________
Primary Care Provider Signature AND Provider’s stamp is required for immunizations on this form
to be accepted.
____________________________________________ PLACE PROVIDER’S STAMP HERE
Provider’s Signature
Provider Name (printed): _______________________
Phone Number: (____) _______________________
Page 3
University of Arkansas
Eleanor Mann School of Nursing (EMSON)
Health and Immunization Requirements
Students: Be sure to sign the immunization release statement below
I have reviewed this immunization history for completeness and agree to release the information
provided on the University of Arkansas EMSON Documents to authorized members of University
of Arkansas EMSON staff and authorizes staff of cooperating agencies, as may be required.
Print student name:_______________________________ Date of Birth:_________________
Student Signature:________________________________ Date:________________________
University of Arkansas works with Sentry MD, a confidential health information service. Student Sentry
MD maintains and processes all student immunization records and monitors compliance with state law
requirements. The information may be provided to authorize members of University of Arkansas and
authorized staff of cooperating agencies as may be required.
Page 4
University of Arkansas
Eleanor Mann School of Nursing (EMSON)
Health and Immunization Requirements
Student Checklist
1. Student information is complete in Part I.
2. Submit a copy of the following documentation:
 CPR Certification, and
 Licensure, only applicable to LPNs
 Copy of current Health Insurance, update annually.
3. Immunizations in Part II are complete with dates of titers/vaccines and results are signed by your
Health Care Provider. You have the option to submit additional documentation of your vaccines.
The above requirements are to be submitted to Sentry MD by November 15, 2014.
Submit documents to Sentry MD by email to [email protected] OR
[email protected]
OR
Fax to1-817-251-9593 OR 1-214-619-1830
Any questions please email Sentry MD at [email protected] or call 1-800-633-4345 or
visit our website at www.sentrymd.com.
Page 5