PRE-CLINICAL HEALTH REQUIREMENTS (PCHR)-Freshman,Transfer, 2nd Degree Nursing

PCHR Guidelines and General Information

Academic Programs with PCHR: Duquesne University School of Pharmacy Duquesne School of Nursing

Undergraduate

Graduate

Second degree Rangos School of Health Science

Athletic Training

Health Management Systems

Occupational Therapy

Physician Assistant

Physical Therapy

Speech, Language Pathology

All PCHR forms are available on Duquesne University Health Service Web Site:http://www.duq.edu/life-at-duquesne/student-services/health-service/pre-clinical-health-requirements

The Pre-Clinical Requirements Coordinator is located in Duquesne University Health Service (DUHS) Phone 412-396-1650 Fax: 412-396-5655 Email: pchr@duq.edu Address: Duquesne University Health Service (attn. Carol Dougher, RN)

2nd Floor Union600 Forbes AvenuePittsburgh PA, 15282-1920

Schedule an appointment only for questions or concerns regarding requirements

Appointments can be made by calling 412-396-1650 after 8:00 AM Monday-Friday

What to bring (if you have already downloaded the form and collected required documents)

Proof of Immunization (see individual school forms) –obtain a copy of records from your MDoffice(Make additional copies for your records)

Proof of Immune Blood tests if required by your school (see individual school forms)– obtain a copy of your lab results (Make additional copies for your records)

The Duquesne University Health Service is able to provide:

Physical Examination $50.00

PPD (two-Step) $30.00

PPD (Annually) $15.00

Quantiferon Gold (Q-Gold) blood test –alternative to PPD- $60.00

Immunizations can be obtained through the Duquesne University Center for Pharmacy Care

Appointments for immunizations can be scheduled by calling the center at 412-396-2155.

*Fees – Payable by cash, check or credit card* *Fees are subject to change

Blood Testing for Immunity (titers) - If required by your school can be obtained from:

Personal Physician

Allegheny County Health Department

4th floor Hartley Rose Building425 First Avenue Pittsburgh, PA 15219 (between Cherry Way & 1st Ave. Next to Art Institute)412-578-8304 (No appointment needed) M-T-Th-F 9:00 am-4:00 pm W 1:00 pm-8:00 pm

All PCHR documents must be submitted electronically to Health Services through the HEALTH

SERVICE STUDENT PORTAL -gain access by: (Log into DORI>select "student" from the drop down options under "Go To">select “HEALTH SERVICE STUDENT PORTAL >Follow instructions in portal)

Entering Nursing Student Pre-Clinical Health Requirements & Instructions

The following health requirements are mandatory for all newly entering nursing students.

1. Immunization Compliance Record (see Clinical Compliance Forms)

MMR - 2 doses

Tdap (Tetanus/Diphtheria-Acellular/Pertussis) - within past 10 years Meningitis (one MCV4 dose administered on or after the 16th birthday) Hepatitis B - series of 3 injections

Varicella Vaccine (Varivax) /Chickenpox - 2 doses of vaccine

OR if history of chickenpox disease, an immune blood test is required in place of the vaccine

Influenza Vaccine - completed by December 1st

2. REQUIRED Blood Tests

MMR titers (Measles [Rubeola] IgG / Mumps IgG / Rubella IgG)

Hepatitis B Surface Antibody

Varicella Titer IgG (OR proof of 2 doses of Varivax [chickenpox] vaccine)

Please be advised that additional immunizations may be required for blood results which may indicate non-immunity. PLEASE READ each separate form for specific information.

3. TUBERCULOSIS skin testing (2-step PPD [Mantoux] or IGRA (T-Spot or Quantiferon Gold)

4. Physical Exam by a licensed practitioner

Duquesne University Health Service can provide Physical Exams, TB testing. Fees apply.

Contact Pre-Clinical Requirements Coordinator (PCHR)to schedule: 412-396-1650 pchr@duq.edu

LEVEL REQUIREMENTS

Entering Basic BSN Student August 1st

All Entering Students Requirements above November 15th

Influenza Vaccine Entering Second Degree BSN Student

August 1st All Entering Students Requirements above

November 15th

Influenza Vaccine

Sophomore July 1st Annual TB Test Tdap (if needed)

November 15th

Influenza Vaccine

Junior

July 1st Physical Exam Annual TB Test Tdap (if needed)

November 15th

Influenza Vaccine

Senior July 1st Annual TB Test Tdap (if needed)

November 15th

Influenza Vaccine

READ AND SUBMIT INFORMATION AS PER INSTRUCTIONS ON EACH COMPLIANCE FORM

Entering Nursing Student Demographic Information Form

LAST NAME: ___________________________ FIRST NAME: _____________________ MIDDLE INITIAL: ___

DATE OF BIRTH: ________________________

PROGRAM: BSN SECOND DEGREE GRADUATE YEAR OF GRADUATION: ______________

PERMANENT STREET ADDRESS: _______________________________________________________________

CITY: _____________________________________________ STATE: ______ ZIP CODE: _________________

IF INTERNATIONAL: COUNTRY: _______________________ POSTAL CODE: __________________________

PERSONAL EMAIL ADDRESS: ___________________________ PERSONAL CELL PHONE: __________________

SCHOOL EMAIL ADDRESS: ____________________________________________________________________

INSTRUCTIONS FOR SUBMITTING COMPLETED REQUIREMENTS

ALL PRE-CLINICAL HEALTH REQUIREMENTS MUST BE UPLOADED TO THE HEALTH SERVICE STUDENT PORTAL.

Log into DORI> Select "Student" from the drop down options under "Go To"> Select "Health Service Student Portal"> Follow instructions in portal.

ALL PRE-CLINICAL HEALTH REQUIRMENTS MUST BE UPLOADED TO: HEALTH SERVICE STUDENT PORTAL

Please note that all douments must be uploaded to the "Entering Nursing Student Pre-Clinical Health Requirement" tab.

QUESTIONS: Contact Duquesne University Health Service

600 Forbes Avenue, Pittsburgh PA 15282

Phone: 412-396-1650 Fax: 412-396-5655 Email: pchr@duq.edu

Entering Student Clinical Compliance #1

MMR (Measles, Mumps, Rubella)

Last name: _____________________ First name: ____________________ Middle initial: _____

Program: Basic BSN Second Degree BSN RN-BSN

MSN DNP PhD

MMR (Measles, Mumps, Rubella) Vaccination #1 Date:

Vaccination #2 Date:

REQUIRED BLOOD TESTS Please complete the following titers. Attach results of laboratory tests.

Rubeola ( Measles) titer results: Date:

Mumps titer results: Date:

Rubella (German Measles) titer results: Date:

Negative or Equivocal results on any of the above REQUIRE an MMR Booster MMR Booster Dose/Date:

I hereby attest to the validity of the above dates and testing results and certify them to be true and accurate:

Examiner’s Name (Print): Phone:

Signature: Date:

Entering Student Clinical Compliance #2

Tetanus, Diptheria, Pertussis Booster (Tdap)

and

Meningitis Vaccination

Last name: _____________________ First name: ____________________ Middle initial: _____

Program: Basic BSN Second Degree BSN RN-BSN

MSN DNP PhD

Tdap – Booster required within last 10 yearsTetanus, Diptheria, Pertussis (Tdap): Date of vaccination:

Meningococcal Vaccine(MCV4) must be on or after 16th birthday

Meningococcal conjugate (MCV4) Date of vaccination:

I hereby attest to the validity of the above dates and testing results and certify them to be true and accurate:

Examiner’s Name (Print): Phone:

Signature: Date:

Entering Student Clinical Compliance #3

Hepatitis B Series

Last name: _____________________ First name: ____________________ Middle initial: _____

Program: Basic BSN Second Degree BSN RN-BSN

MSN DNP PhD

Hepatitis B Vaccine - Required Vaccination #1 Date:

Vaccination #2 Date:

Vaccination #3 Date:

A positive Hepatitis B surface antibody titer is required following 3 dose series. (Either HepBsAb or antiHepB)

Titer Results: Attach results of laboratory tests. Date:

If titer is negative, must complete HEPATITIS B dose # 1 then REPEAT Titer. If REPEAT titer is Negative, Doses # 2 and #3 are required with a final REPEAT titer Vaccination provided following NEGATIVE titer 1st Dose Date:

Repeat titer date and results: (If negative, Doses #2 and 3 required)

2nd Dose Date: 3rd Dose Date:

Repeat Titer date and results:

I hereby attest to the validity of the above dates and testing results and certify them to be true and accurate:

Examiner’s Name (Print): Phone:

Signature: Date:

Entering Student Clinical Compliance #4

Varicella Vaccine

Last name: _____________________ First name: ____________________ Middle initial: _____

Program: Basic BSN Second Degree BSN RN-BSN

MSN DNP PhD

Varicella Vaccine (Chicken Pox) Vaccination #1 Date:

Vaccination #2 Date:

OR If history of disease, Varicella IgG titer required. Attach results of laboratory tests. If positive titer, no vaccination is required as immunity has been verified.

Titer results: Date:

Negative titer results REQUIRE two doses of vaccine

I hereby attest to the validity of the above dates and testing results and certify them to be true and accurate:

Examiner’s Name (Print): Phone:

Signature: Date:

Entering Student Clinical Compliance #5

Tuberculosis Testing – 2-Step

Last name: _____________________ First name: ____________________ Middle initial: _____

Program: Basic BSN Second Degree BSN RN-BSN

MSN DNP PhD

MANDATORY 2-STEP TUBERCULOSIS SKIN TEST “PPD”

PPD (2nd step within 10-21 days of first)

Date given: Date read: (48-72 hours after placement)

Results: (>10mm induration = positive) Induration in mm

NEGATIVE Result

POSITIVE Result**

STEP #1

STEP #2

OR either of following blood tests may replace the 2-step PPD

Select One: Interferon Gamma Release Assay (IGRA) T-Spot/Quantiferon Gold

Date obtained: Negative Positive**

** POSITIVE RESULTS

(PPD > 10 mm OR Positive IGRA or T-Spot Test)

Chest Xray REQUIRED Copy of x-ray must be attached

Date: Result:

INH Treatment: Date Started Date Completed

I hereby attest to the validity of the above dates and testing results and certify them to be true and accurate:

Examiner’s Name (Print): Phone:

Signature: Date:

Entering Student Clinical Compliance #6

Physical Examination and Student Statement

Last name: _____________________ First name: ____________________ Middle initial: _____

Program: Basic BSN Second Degree BSN RN-BSN

MSN DNP PhD

TO BE COMPLETED BY HEALTH CARE EXAMINER

Physical exam completed on (date) ___________ the above individual

I have obtained and reviewed a health history for this individual, and have reviewed immunization status and laboratory results. I certify that this student has no physical limitations and is able to fully participate in nursing class and clinical practica. Note: ANY LIMITATIONS OR EXCLUSIONS MUST BE DESCRIBED IN AN ATTACHMENT

Examiner’s Name (Print):

License #: Phone:

Signature: Date:

STUDENT STATEMENT (TO BE COMPLETED BY STUDENT)

The information provided on the above forms (total – 6 pages) is correct. Attached are copies of all required information and results. I understand that failure to complete this information may jeopardize my progression in the nursing program. I give permission for information contained in this form to be shared with faculty/staff of the school of nursing. I auhorize release of this informaion, upon request, to any organization sponsoring an experiential rotation in which I participate. I forever release & discharge Duquesne University, their respective employees and agents from any claims, damages losses, liabilities, and expenses arising out of gathering & reporting this information. THE FOLLOWING FORMS HAVE BEEN COMPLETED IN THEIR ENTIRETY AND HAVE BEEN/ARE BEING SUBMITTED:

Form #1: MMR Form Form #2: Tdap / Meningitis Vaccine Form

Form #3: Hepatitis B

Form #4: Varicella

Form #5: TB Form

Form #6: Physical Exam Form and Student Statement

Student Signature: Date:

Annual Clinical Compliance

Seasonal Influenza Vaccine

Last name: _____________________ First name: ____________________ Middle initial: _____

Program: Basic BSN Second Degree BSN RN-BSN

MSN DNP PhD

Seasonal Influenza Vaccine (Must be completed by November 15th) Please complete and/or place sticker with information below

Health Care Provider Signature:

Address: City: State: Zip:

Phone number:

THIS FORM AND ALL SUPPORTING DOCUMENTS MUST BE UPLOADED TO DU HEALTH SERVICE STUDENT PORTALINSTRUCTIONS TO UPLOAD TO HEALTH SERVICE STUDENT PORTAL : (Student logs into DORI>selects "Student" from the drop down options under "Go To">selects “Health Service Student Portal” >Follow intructions in portal)

2/2018

Name of Vaccine: ________________Manufacturer:_____________________Lot #______________________________

Expiration Date: ____________________NDC#_____________________________Date given:___________________________