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    Clinical Passport

    Uploaded by

    mintygood
    This document is a student/faculty clinical passport that tracks important health, safety, and orientation information for clinical participation. It includes sections for personal information, health records including vaccinations and tests, certifications like CPR, completion of safety and infection control trainings, and verification of facility-specific orientations. Signatures and dates from instructors are included to validate the accuracy of the documented information for each academic year. The passport aims to provide a single consolidated record of all requirements for clinical eligibility.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Clinical Passport

    Uploaded by

    mintygood
    38 views2 pages
    This document is a student/faculty clinical passport that tracks important health, safety, and orientation information for clinical participation. It includes sections for personal information, health records including vaccinations and tests, certifications like CPR, completion of safety and infection control trainings, and verification of facility-specific orientations. Signatures and dates from instructors are included to validate the accuracy of the documented information for each academic year. The passport aims to provide a single consolidated record of all requirements for clinical eligibility.

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    This document is a student/faculty clinical passport that tracks important health, safety, and orientation information for clinical participation. It includes sections for personal information, health records including vaccinations and tests, certifications like CPR, completion of safety and infection control trainings, and verification of facility-specific orientations. Signatures and dates from instructors are included to validate the accuracy of the documented information for each academic year. The passport aims to provide a single consolidated record of all requirements for clinical eligibility.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    38 views2 pages

    Clinical Passport

    Uploaded by

    mintygood
    This document is a student/faculty clinical passport that tracks important health, safety, and orientation information for clinical participation. It includes sections for personal information, health records including vaccinations and tests, certifications like CPR, completion of safety and infection control trainings, and verification of facility-specific orientations. Signatures and dates from instructors are included to validate the accuracy of the documented information for each academic year. The passport aims to provide a single consolidated record of all requirements for clinical eligibility.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Student /Faculty Clinical Passport

    STUDENT/FACULTY INFORMATION
    NAME:

    SCHOOL: _______________________________________
    LAST

    DATE OF BIRTH:

    FIRST

    STUDENT TARGET GRADUATION DATE:

    _____/______/__________

    _____________

    CRIMINAL BACKGROUND CHECK:

    FACULTY LICENSURE VERIFICATION:

    Date: ___________ Verified by: ______________________

    RENEWAL # ______________ EXPIRATION DATE: _____

    DRUG SCREEN (if available or required):

    CERTIFICATIONS/SPECIALTY:

    Date: __________ Verified by: _____________________


    HEALTH RECORD
    MEASLES, MUMPS, & RUBELLA
    Dates of Vaccine: MMR #1:
    Date drawn and result of: Measles titer:
    Mumps titer:
    Rubella titer:

    MMR #2:
    Result:
    Result:
    Result:

    TUBERCULIN SKIN TEST (PPD) (annual requirement)


    Result:
    Date:
    Result:
    Date:
    Result:
    Date:
    Result:
    Date:

    OR

    HEPATITIS B
    Dates of Vaccine: HB#1: _______ HB#2:_______
    Date of Disease:
    Immunity confirmed by blood titer HbsAB: Date:

    Chest x-ray if positive PPD


    Date:
    Medical Screening Report
    Date:

    Result:
    Result:

    HB#3: _______

    Hepatitis B declination waiver signed: Date: _______


    VARICELLA (CHICKEN POX)
    Date and result of varicella titer:

    DIPTHERIA/TETANUS (Must be within 10 years)


    Last booster date:

    Dates of vaccination: #1:

    #2:
    CPR

    Students/Faculty must have a current card/roster indicating Healthcare Provider status to participate in clinical!

    Expiration Date: _______________ American Heart Association or - American Red Cross


    Expiration Date: _______________ American Heart Association or - American Red Cross
    Expiration Date: _______________ American Heart Association or - American Red Cross
    Expiration Date: _______________ American Heart Association or - American Red Cross
    9/2010

    SAFETY
    Date: ___________
    Date: ___________

    GENERAL ONLINE HEALTHCARE ORIENTATION


    Complete this content once per academic year!
    INFECTION CONTROL & BLOODBORNE PATHOGENS
    Date: ___________
    Date: ___________
    Date: ___________
    Date: ___________
    Date: ___________
    Date: ___________

    CONFIDENTIALITY & COMPLIANCE


    Date: ___________
    Date: ___________
    Date: ___________
    Date: ___________

    CARING FOR DIVERSE POPULATIONS


    Date: ___________
    Date: ___________
    Date: ___________
    Date: ___________

    EMERGENCY PREPAREDNESS
    Date: ___________
    Date: ___________
    Date: ___________
    Date: ___________
    GENERAL ORIENTATION QUIZ - the Completion Certificate should be kept with the Clinical Passport!
    Date: ___________ Score: ___________
    Date: ___________ Score: __________
    Date: ___________ Score: ___________
    Date: ___________ Score: __________
    CLINICAL FACILITIES SPECIFIC ORIENTATION
    Be sure and include any required facility documentation including Quiz Certificates with your Passport!

    Date:
    Date:
    Date:
    Date:
    Date:
    Date:
    Date:
    Date:
    Date:
    Date:
    Date:
    Date:

    Facility: ___________________
    Facility: ___________________
    Facility: ___________________
    Facility: ___________________
    Facility: ___________________
    Facility: ___________________
    Facility: ___________________
    Facility: ___________________
    Facility: ___________________
    Facility: ___________________
    Facility: ___________________
    Facility: ___________________

    Date:
    Date:
    Date:
    Date:
    Date:
    Date:
    Date:
    Date:
    Date:
    Date:
    Date:
    Date:

    Facility: ___________________
    Facility: ___________________
    Facility: ___________________
    Facility: ___________________
    Facility: ___________________
    Facility: ___________________
    Facility: ___________________
    Facility: ___________________
    Facility: ___________________
    Facility: ___________________
    Facility: ___________________
    Facility: ___________________

    VERIFICATION OF ACCURATE DOCUMENTATION (SIGNATURE of INSTRUCTOR & DATE)


    1ST YEAR
    DATE
    DATE
    DATE

    __________________________________
    __________________________________
    __________________________________

    SIGNATURE: ______________________________
    SIGNATURE: ______________________________
    SIGNATURE: ______________________________

    2ND YEAR
    DATE
    DATE
    DATE

    __________________________________
    __________________________________
    __________________________________

    SIGNATURE: ______________________________
    SIGNATURE: ______________________________
    SIGNATURE: ______________________________

    3RD YEAR
    DATE
    DATE
    DATE

    __________________________________
    __________________________________
    __________________________________

    SIGNATURE: ______________________________
    SIGNATURE: ______________________________
    SIGNATURE: ______________________________

    4TH YEAR
    DATE
    DATE
    DATE
    9/2010

    __________________________________
    __________________________________
    __________________________________

    SIGNATURE: ______________________________
    SIGNATURE: ______________________________
    SIGNATURE: ______________________________

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