February 24 7

Friday April 21, 2017

as directed Y y

Acceptable documentation includes:

• Copy of immunization record • Copy of lab report • Must have at least two identifiers such as

name and DOB

Submit ONCE 1. Academic Regulations Form (pg. 1) 2. Acknowledgement of Influenza Vaccination

Education (pg.2) 3. SRHS Confidentiality Agreement/Waiver and

Release (pgs. 3-5) 4. MBSON Confidentiality Agreement/ Consent to

Release Information/Honor Pledge (pgs. 6-7) 5. SR&I Authorization (pg. 8) 6. DHEC Confidentiality Agreement (pg. 9-10) 7. Consent/Waiver for Hepatitis B Vaccine (pg. 11) 8. Authorization to Release Health Information

(pg. 12) 9. Health History Form: The enclosed forms must

be filled out and signed. A print out from the doctor’s office will not replace these forms. (pgs. 13-15)

10. Tdap (Tetanus/Diphtheria/Pertussis) a. Submit Documentation of immunization

in the last 10 years. b. DTaP is not the same thing

11. MMR (Measles, Mumps, Rubella) a. Series of 2 doses on or after first

birthday. b. Submit documentation of

immunizations or titer that includes results.

12. Varicella (Chicken Pox) a. Series of 2 doses b. Submit documentation of

immunizations or titer that includes results

c. Report of having had the disease is NOT proof of immunity

Please return health requirements to:

Terri Whitaker, Director, Nursing Student Services AND Health Services Department

Submit NOW and ANNUALLY 1. PPD (TST or Tuberculosis Screening)

a. Student must complete initial two-step series – two tests administered 7-21 days apart.

b. Thereafter, students will submit documentation of a single step PPD annually.

c. If you have had a positive PPD, please go to Health Services for further testing.

2. Flu Vaccine 3. Health Insurance (pg. 16)

a. Must be current at all times b. Photocopy of insurance card (front and

back) is required with the packet. c. Proof of insurance must be supplied

annually

WAIT for Instructions to Submit 1. CPR Certification

a. Each student must have a CPR card that is current through an entire semester. This may require that you re-certify early if the card will expire in the middle of a term.

b. American Heart Association BLS for Healthcare Providers ONLY. “Community CPR” or “Heartsaver CPR” is not acceptable.

c. Course must include: 1 person/2 person, infant, child, choking and AED.

d. No online CPR courses will be accepted withoug personal skills certification by a licensed instructor.

2. CareLearning: SPARTANBURG students only 3. HealthStream/EPIC Training: GREENVILLE

students only

Health Requirements Student Checklist

Section 1

Signature Forms

Instructions:

1. Please sign all papers in BLUE ink.2. Make a copy of Section I of the packet for yourself. Many instructors will require to see these

documents later in the program. MBSON will NOT make a copy of the documents for you atthat time since you have been advised to make a copy yourself.

3. Scan in color and email papers back to Terri Whitaker, twhitaker@uscupstate.edu. Photos takenby a phone are not acceptable for this requirement.

4. Bring originals to an Information Session or directly to Terri’s office in Spartanburg, HEC 3095.Originals may also be mailed to:

USC Upstate Mary Black School of Nursing

800 University Way Spartanburg, SC 29303

Attn: Terri Whitaker HEC 3095

Academic Regulations Form

“The University assumes that students, through the act of registration, accept all published academic regulations appearing in this catalog, online course schedule, the University Web site, or in any other

official announcement.” (From The USC Upstate Academic Catalog)

o I acknowledge that I have read the entire Mary Black School of Nursing Student Handbook.o I understand that I am responsible for the policies and procedures stipulated in The School of

NursingHandbook, the University Student Handbook, and the University Academic Catalog aswell as any other official publication or announcement.

o I understand that only one Nursing course may be repeated to make a C or better. Any coursewith an earned grade of less than a C is considered a course failure. If I have had a previousNursing course failure from USC Upstate or any other school, it will count as the one allowablefailure within the Mary Black School of Nursing program.

o I will regularly check my USC Upstate email address and Blackboard for announcementsregarding the Mary Black School of Nursing baccalaureate program including, but not limitedto, changes to the School of Nursing Handbook or the University Student Handbook andAcademic Catalog.

o If I have questions, I will contact the appropriate School of Nursing representative.

The School of Nursing Student HandbookThe University Student Handbook

The USC Upstate Academic Catalog located

Student Name (print): _____________________________________________

Student Signature: ________________________________________________

Date: ___________________________________________________________

- TW 1

Acknowledgement of Influenza Vaccination Education

Spartanburg Regional Healthcare System has recommended that I receive influenza vaccination to protect the patients I serve. I acknowledge that I am aware of the following facts.

• Influenza is a serious respiratory disease that kills an average of 36,000 persons and hospitalizesmore than 200,000 persons in the U. S. each year.

• Vaccination is recommended for all healthcare workers to protect patients from influenzadisease, its complications, and death.

• If I contract influenza, I will shed the virus for 24-48 hours before symptoms appear. Myshedding the virus can spread influenza disease to patients in my facility.

• If I become infected with influenza, even when my symptoms are mild or non-existent, I canspread severe illness to others.

• The strains of virus that cause influenza infection change almost every year, which Is why adifferent influenza vaccine is recommended each year

• I cannot get influenza from the influenza vaccine.• The consequences of my refusing to be vaccinated could have life-threatening consequences to

my health and the health of those with whom I have contact, including my patients, mycoworkers, my family and my community.

______ Based on these facts, I can choose to be vaccinated against influenza. I will provide my school with appropriate documentation.

______ Despite these facts, I am choosing to decline influenza vaccination right now for the following reasons:

� I have an allergy to eggs (or other vaccine components) � I have a history of Guillan Barre or other neurologic disorder � Vaccines are against my religious beliefs. � Other (Please provide a detailed response in writing in order for your concerns to be addressed

about influenza vaccine)

If I decline: I agree to wear a mask anytime I am within 6 feet of patients in a medical or treatment area.

I understand that I can change my mind at any time and be vaccinated, if vaccine is available. I have read and fully understand the information presented in this session, and if I have questions, I understand that I may speak with SRHS Employee Health, SRHS Infection Prevention or my healthcare provider.

Print Name: _____________________________________________________________________

Signature: ______________________________________________________________________

Date: __________________________________________________________________________

2

CONFIDENTIALITY AGREEMENTSPARTANBURG REGIONAL HEALTHCARE SYSTEM

NAME: _______________________________________SCHOOL: ______________________________

PATIENT INFORMATION

Patients have a right to privacy. They have a right to expect that details of their condition, treatment, and medical history. Personal and financial affairs will be kept confidential by all hospital employees and agents. It is not for an employee or agent to decide what information a patient would not object to having disclosed, for what one person considers another may consider being unimportant highly sensitive or embarrassing.

I understand that all information (written, verbal, electronic, or printed) concerning a patient’s medical condition or relating to or referring to a patient’s medical records, regardless of how such information is obtained, is confidential medical information. I agree not to disclose or discuss such information with anyone other than those individuals directly involved in the care of the patient or others with a legitimate business reason to know the information.

CONFIDENTIAL BUSINESS INFORMATION

I acknowledge that certain business information of SRHS is considered confidential information. Such confidential information includes patient or vendor lists, public relations and marketing information, patient account information, training and operations material, memoranda and manuals, personnel records and manuals, cost information, and financial information concerning or relating to the business, accounts, patients, employees, agents and affairs of SRHS. I acknowledge and agree that such information is the property of, and confidential to, SRHS, and further, that I will not publish or disclose, either directly or indirectly, any confidential information of SRHS.

ELECTRONIC/COMPUTER SYSTEMS

Electronic and computer systems include all computer-generated or stored data, voice mail, facsimile, and electronic mail services. The information transmitted by; received from, or stored in these systems is the property of Spartanburg Regional HealthCare System (“SRHS”). I hereby consent to SRHS monitoring my use of its electronic and computer systems at any time. I understand that such monitoring may include the printing and reading of all electronic mail entering, leaving, or stored in these systems.

I understand that electronic and computer systems are to be used solely for SRHS purposes and agree not to copy, modify or otherwise access the software without the appropriate written authorization. I further agree not to circumvent my password or security level. I acknowledge that software is protected by a variety of licensing agreements and laws and that any misuse of the software may subject me to legal liability as well as disciplinary action up to and including termination from hospital learning experiences.

I understand that any violation of this Confidentiality Agreement may result in disciplinary action, up to and including termination from hospital learning experiences. I understand that SRHS may have additional rights and remedies available to them in law or equity in cases of a disclosure of trade secrets or proprietary information.

_________________________________________________ _______________________________Signature Date

3 Revised 05/2014

EXHIBIT AWAIVER AND RELEASE

This Waiver and Release is entered into and signed as of this ____ day of _______________, 20 _, by ______________________________, a student of (“College”), located in

(“Student”), to and in favor of Spartanburg Regional Health ServicesDistrict, Inc., a public hospital corporation and political subdivision of the State of South Carolina (“SRHSD”). In the event that Student is under the age of eighteen (18), then this Waiver and Release is made with the consent and joinder of __________ _______________ as parent or legal guardian of Student (“Parent”).

WHEREAS, Student has been accepted for enrollment in an internship through College to take place on the premises of SRHSD (“Internship”), conditioned upon execution and delivery of this Waiver and Release; and

WHEREAS, Student and/or Parent are willing to execute and deliver this Waiver and Release in order to induce SRHSD to allow Student to participate in the Internship;

NOW, THEREFORE, for and in consideration of the mutual promises contained herein, and for the opportunity to participate in the Internship, Student and/or Parent hereby agree as follows:

1. Medical Condition and Coverage. Student has consulted with a physician as to his personalmedical condition, and represents that he suffers from no health-related issues which preclude orrestrict participation in the Internship. Student is further aware of his medical condition and needs,and has arranged for adequate medical insurance to meet any and all needs for payment of hospitalcosts, and that Student and/or Parent assumes all risk and responsibility therefore. In the event thatStudent’s medical condition or needs change during the course of the Internship in any way thatcould affect his participation in the Internship, then Student and/or Parent agree to notify Collegeand SRHSD of such change.

2. Conduct. Student acknowledges that SRHSD may suspend and immediately remove from thepremises and Internship any Student when their performance is unacceptable in reference to theFacility’s standards of behavior or their conduct is disruptive or detrimental to the Facility or itspatients, within the sole judgment of SRHSD.

3. Assumption of Risk. Knowing the dangers, hazards and risks associated with participation in theInternship, and in consideration of being allowed to participate, Student and/or Parent, on behalf ofStudent, his heirs, assigns, guardians, personal representative and all other persons claiming by orthrough him, voluntarily agrees to assume all risks and responsibility surrounding participation inthe Internship, including transportation, and releases and forever discharges, holds harmless andagrees to defend and indemnify, SRHSD, its board, officers, agents, insurers, affiliates andemployees from and against any and all damages or liabilities arising in any way out of or related tolosses, damages, or injuries, including death, suffered by Student while participating in, or in transitto or from, the Internship, whether based upon tort (including without limitation premises liability),contract, or otherwise.

4. Release of Records. Student understands and acknowledges that, by providing the informationrequested below, he is consenting to College and or SRHSD using such information in order toconduct a criminal records check, drug test health screening, and hereby grants permission for suchchecks, tests and/or screens to be conducted. Student further understands and acknowledges that heis to advise College of any arrests or criminal charges subsequent to completion of this form, and

4 Revised 05/2014

that failure to do so may result in dismissal from the internship program. Student grants permission to College and SRHSD to receive and exchange the criminal records check, drug test results and health screens if shared for the limited purpose of determining Student’s suitability to participate in the internship.

5. Nonemployment. Student acknowledges that the Internship constitutes a clinical learningexperience for which the student will receive no monetary or other compensation from the Facility,and that the Internship does not create an employer/employee relationship as between the studentand the Facility.

6. Miscellaneous Provisions. In signing this Waiver and Release, Student/Parent acknowledge thatthey are fully aware of the content of this waiver, and are executing and delivery this Waiver andRelease freely and voluntarily, only after having fully read and understood the contents hereof.Student states that he is ___________ years old, and if over the age of eighteen (18), fullycompetent to sign this Waiver and Release. This Waiver and Release shall be construed inaccordance with the internal, substantive, laws of the State of South Carolina, without effect to anychoice of laws provisions that would result in the application of the laws of any other state. TheCourt of Common Pleas for Spartanburg County, South Carolina, shall be the exclusive forum forany suits filed under or incidental to this Waiver and Release or the Internship, and all partieshereby consent to jurisdiction therein. This Waiver and Release shall be severable, such that in theevent that any court of competent jurisdiction holds any term to be illegal or unenforceable, then thevalidity of the remaining portions of such provision and of this Waiver and Release shall not beaffected thereby.

IN WITNESS WHEREOF, the undersigned party (and if under the age of eighteen, parties) has executed this Waiver and Release as of the date first written above.

Witness Student

_________________________ _________________________Student Name:

_________________________ _________________Student Date of Birth

_________________________Student Current Address

__________________________Student Gender

___________________________Student ID

5 Revised 05/2014

UNIVERSITY OF SOUTH CAROLINA UPSTATEMARY BLACK SCHOOL OF NURSING

BACCALAUREATE NURSING PROGRAM

CONFIDENTIALITY AGREEMENT

PATIENT INFORMATION

Patients have a right to privacy. They have a right to expect that details of their condition, treatment, medical history, personal and financial affairs will be kept confidential by all hospital employees and agents. It is not for an employee or agent to decide what information a patient would not object to having disclosed, for what one person considers another may consider being unimportant highly sensitive or embarrassing.

I understand that all information (written, verbal, electronic, or printed) concerning a patient’s medical condition or relating to or referring to a patient’s medical records, regardless of how such information is obtained, is confidential medical information. I agree not to disclose or discuss such information with anyone other than those individuals directly involved in the care of the patient or others with a legitimate business reason to know the information.

CONFIDENTIAL BUSINESS INFORMATION

I acknowledge that certain business information of any health care provider is considered confidential information. Such confidential information includes patient or vendor lists, public relations and marketing information, patient account information, training and operations material, memoranda and manuals, personnel records and manuals, cost information, and financial information concerning or relating to the business, accounts, patients, employees, agents and affairs of any health care provider. I acknowledge and agree that such information is the property of, and confidential to, the provider, and further, that I will not publish or disclose, either directly or indirectly, any confidential information of the health care provider.

ELECTRONIC/COMPUTER SYSTEMS

Electronic and computer systems include all computer-generated or stored data, voice mail, facsimile, and electronic mail services. The information transmitted by; received from, or stored in these systems is the property of the health care provider. I hereby consent to the health care agency monitoring my use of its electronic and computer systems at any time. I understand that such monitoring may include the printing and reading of all electronic mail entering, leaving or stored in these systems.

I understand that electronic and computer systems are to be used solely for the health care agency’s purposes and agree not to copy, modify or otherwise access the software without the appropriate written authorization. I further agree not to circumvent my password or security level. I acknowledge that software is protected by a variety of licensing agreements and laws and that any misuse of the software may subject me to legal liability as well as disciplinary action up to and including termination from hospital learning experiences.

I understand that any violation of this Confidentiality Agreement may result in disciplinary action, up to and including termination from hospital learning experiences. I understand that the health care agency may have additional rights and remedies available to them in law or equity in cases of a disclosure of trade secrets or proprietary information.

__________________________________________Print Name

__________________________________________ ___________________________________Signature Date

6

UNIVERSITY OF SOUTH CAROLINA UPSTATEMARY BLACK SCHOOL OF NURSING

BACCALAUREATE NURSING PROGRAM

CONSENT TO RELEASE INFORMATION

I authorize the University of South Carolina Upstate, Mary Black School of Nursing to release such academic and other

information from my educational record to furnish statements of reference requested by prospective

employers and/or other educational institutions to which I have applied.

HONOR PLEDGE

I do solemnly pledge on my honor as an USC UPSTATE nursing student to faithfully uphold the standards set forth in the

University's Code of Student Conduct. I will abide by all University rules, regulations and policies governing my conduct.

I will refrain from any acts of academic dishonesty both in the classroom and clinical settings, and in my work on/out of

class/clinical assignments.

As a USC UPSTATE student, I am always on my honor not to lie, plagiarize, cheat or steal and to report any student who

violates this pledge.

_______________________________________________________________Print Name

_______________________________________________________________Student Signature

_______________________________________________________________Date

7

8

DHEC Confidentiality Agreement

DHEC 321 Rev 4//2013 Page 1 of 2

I understand that:

(a) the South Carolina Department of Health and Environmental Control (DHEC) has a legal and ethicalresponsibility to protect confidential information given or made available to DHEC in administration ofthe agency’s programs and services;

(b) during the course of my employment, volunteer services, contract performance, or other agencyrelationship with DHEC, I may have access to confidential information in many forms, oral, written, andelectronic;

(c) my compliance with this confidentiality agreement is an essential condition of my employment,volunteer services, or contractual or other agency relationship with DHEC; and

(d) violation of this Agreement may result in termination of my volunteer, contractual, and/or workrelationship with DHEC or my employer and may be grounds for disciplinary action, fines, penalties,imprisonment, or civil suit to be brought against me.

Confidential information is information known or maintained in any form, whether oral, written, or electronic, whether recorded or not, consisting of protected health information, other health information, personal information, personal identifying information, confidential business information, and other information required by law to be treated as confidential, designated as confidential by the Department, or known or believed by me to be claimed as confidential or entitled to confidential treatment. Examples of confidential information include but are not limited to: personal information of job applicants, DHEC employees, DHEC clients, or members of the public, such as an individual's photograph or digitized image, social security number, date of birth, driver's identification number, name, home address, home telephone number, medical or disability information, physical or mental health, health care, payment for health care, education level, financial status, bank account numbers, account or identification numbers issued or used by any federal or state governmental agency or private financial institution, employment history, height, weight, race, other physical details, signature, biometric identifiers, credit records or reports, trade secrets, and confidential business information.

By signing this agreement, I understand and agree that:

(1) I will not disclose confidential information unless the disclosure complies with DHEC policies and isrequired to perform my responsibilities.

(2) I will not disclose confidential information without written authorization from affected persons orparties, except as required by law or, if an employee, as required to perform agency responsibilities.

(3) I will not access or view any confidential information other than what is required to do my job.

(4) If I have any questions about whether I need access to certain information, or whether certaininformation should be disclosed, I will immediately ask my supervisor for clarification.

(5) I will immediately report any unauthorized disclosure of confidential information to the DHECPrivacy Officer and my supervisor or to the DHEC Procurement Officer, if I am an employee of acontractor.

(6) I will immediately report any request I receive for confidential information, including a subpoena,litigation discovery request, court order, or Freedom of Information Act request, to my supervisor, or the

9

DHEC Confidentiality Agreement

DHEC 321 Rev 4//2013 Page 2 of 2

DHEC Procurement Officer, if I am an employee of a contractor, and the DHEC Office of General Counsel.

(7) I will not discuss any confidential information obtained in the course of my relationship with DHECwith any person or in any location outside of my area of responsibility in DHEC, except as otherwiserequired or permitted by law.

(8) I will not make any unauthorized copy or disclosure of confidential information, or remove or transferthis information to any unauthorized location.

(9) My obligations under this Agreement regarding confidential information will continue aftertermination of my employment/volunteer assignment/contract affiliation with DHEC.

THIS CONFIDENTIALITY AGREEMENT DOES NOT CREATE AN EMPLOYMENT CONTRACT BETWEEN ME AND THE DEPARTMENT.

I have read the above Agreement and agree to comply with all its terms.

Print name:

______________________________________________________________________

Signature: _______________________________________ Date: _________________

Witness: ________________________________________ Date: _________________

Work Location: ____ ______________________________

10

UNIVERSITY OF SOUTH CAROLINA UPSTATE

MARY BLACK SCHOOL OF NURSING

BACCALAUREATE NURSING PROGRAM

CONSENT/WAIVER FOR HEPATITIS B VACCINE

Please sign the appropriate area (one section only):

1. I, (Print Name) have been immunized against Hepatitis B.

Dates of Immunizations: 1. TITER Date:

(All three HepB shot dates) 2. OR

3. Titer Results: Immune Not Immune

Print Name:

Signature: Date: ______________________

OR

2. I, ________________________________________ (Print Name), have begun the Hep B vaccine series. I

will complete the series of injections in the time frame required.

Dates of Immunizations: 1. ________________________

2._________________________

3. ________________________

Print Name: _____________________________

Signature: Date: ______________________

OR

WAIVER

3. I, ________________________________________ (Print Name), refuse the Hep B vaccine at this time and

understand the risks of not being immunized.

Print Name:

Signature: Date: ______________________

11

Section 2

Documents required by both MBSON and USC Upstate’s Health Services Dept.

Instructions:

1. Please sign all papers in BLUE ink.2. All immunization documentation should include:

a. Name of facilityb. Two or more identifiers such as Name and Date-of-birth.

3. Scan a copy of the documents. Pictures taken by camera are not appropriate for this requirement.4. Send a copy to Health Services. Contact information is below. Include your name and ID#.5. Prior to sending the originals, send a copy to Terri Whitaker by email twhitaker@uscupstate.edu.

a. If the documents are unacceptable/incomplete you will be contacted for corrections.b. An appointment can be made to discuss in person as needed.

6. Turn in the original documents to Terri in person or by mail. Contact Information below.a. Make a copy of Section 2 of the packet for yourself. Many instructors will require to see these

documents later in the program. MBSON will NOT make a copy of the documents for you at that timesince you have been advised to make a copy yourself.

USC Upstate Mary Black School of Nursing

800 University Way Spartanburg, SC 29303

Attn: Terri Whitaker HEC 3095

USC Upstate Health Services 995 University Way

Spartanburg, SC 29303

Phone: (864) 503-5191 Fax: (864) 503-5099 hs@uscupstate.edu

Authorization to Release Health Information

ALL Students: Please also fax records to Health Services at 864-503-5099

I ____________________________________________________, VIPID# ______________________,

and DOB __________________________, hereby authorize USC Upstate Health Services and the Mary

Black School of Nursing to:

• Release Information to each other• Obtain information from each other• Mail information to each other• Call the other when records are available

These records may include:

• Immunizations• Physicals• Medical records• Health Requirements packet• Other: ______________________________________________________________________

Purpose of this release of information: Nursing School (in case of exposure during clinical)

This authorization may be revoked at any time except when information has already been released. Unless revoked earlier, this consent will remain in effect at all times while the student remains in the nursing program at USC Upstate.

___________________________________________ ______________________________________ Signature of Patient/Student Date

12

____Hearing or vision impairment ____Heart condition ____Diabetes ____Seizure disorder/fainting spells ____Physical limitations ____Latex allergy ____Acute infection ____Any chronic disease ____Emotional problems ____Other: Please specify__________________________________

Please list any drugs (Prescription and Over-the-Counter (OTC) that you use). Name of drug:________________________________________________ Frequency of use:______________________ Name of drug:________________________________________________ Frequency of use:______________________ Name of drug:________________________________________________ Frequency of use:______________________ Name of drug:________________________________________________ Frequency of use:______________________

Part II: TB screening. Original or copy of original documentation AND the following section completed and signed by health care professional.

TB Screening: PPD (TST) – The following is required: 1. Two step PPD: Series of two negative PPD (2nd PPDis to be placed 7-21 days AFTER the first PPD).

**If you have had a positive PPD in the past you willneed to .**

Screening Dates (Step 1 & 2)

Date Given:__________ Date Read:__________Result:__________________________________

Signature:_______________________________

Date Given:__________ Date Read:__________Result:__________________________________

Signature:_______________________________

PERSONAL HEALTH HISTORY This health information will be kept confidential and handled only by appropriate personnel in the School of Nursing.

Part I: To be completed by student. Please print or type.

Name_______________________________________ VIP#_________________________________ Address___________________________________________________________________________Home Phone:_________________________________ E-mail Address:________________________Work Phone:_________________________________Emergency Contact:___________________________ Relationship:__________________________Telephone of Emergency Contact:________________________Address of Emergency Contact:________________________________________________________

General Health InformationDate of last physical examination__________________________ (Proof of physical within the last year must be attachedHave you ever experienced adverse reactions (hyper-sensitivities, allergies, upset stomach, rash, hives, etc.) to any medications?Med:________________ Type reaction:_________________ Med:_________________ Type reaction:______________

Please indicate existing conditions which might impair or affect your functioning in the health care setting or the safety ofpatients/clients.

13

Previous Health HistoryTo be completed by student. Please provide the name of illness, operation, injury and approximate date.

1. Are you receiving health/medical care for any health problems at the present time? Yes NoIf yes, explain (including prescribed medications):

2. List your allergies or sensitivities:

I certify that the above information is true and complete to the best of my knowledge.

Student Signature: Date:

THE FOLLOWING SECTIONS MUST BE COMPLETED BY A PHYSICIAN OR NURSE PRACTITIONER

Health HistoryAll questions must be answered or N/A if not applicable

1. Significant Family History

2. Significant Personal History

3. Does student have any disease, or is any treatment being followed, that should be continued or periodicallyevaluated?

4. Psychiatric or Emotional Factors

5. Other Information

Physical Exam

Blood Pressure ________ Pulse ________Height ________ Weight ________

Normal Abnormal Normal Abnormal Normal AbnormalHead, Face,

Scalp Chest Neurology

Eyes Heart SpineEars, Nose,

Throat Abdomen Extremities

Neck Skin Feet

Teeth Endocrine

Does this person have any condition that might affect normal college attendance and/or performance in the clinical area? Yes No If yes, please explain

Name of Physician or Nurse Practitioner (Print)

Address (Complete)Signature Examination Date

14

Additional Health Requirement Information

Completing your health requirements by the assigned due dates is a professional responsibilityexpected of all students. Failure to meet all health, certification, and documentation requirementsby designated deadlines will prevent the student from beginning or continuing in the nursingprogram. The student may be dropped from all nursing courses. Reinstatement to nursing courseswill depend on space available.

Please make copies of ALL keep in your files

Faxed copies are NOT accepted.

Students are encouraged to report any physical or psychological changes that may impact theirability to progress in the nursing program. Also, if you have previously had psychiatric orpsychological treatment you will need to submit a letter from the examining psychiatrist. Thisinformation will be kept strictly confidential.

Immunizations prevent thousands of deaths each year and prevent countless disabilities. Whenreceiving immunizations, care should be taken to read recommendations, contraindications andrisks for each immunization. If an immunization is contraindicated due to allergy, disease orpregnancy, written verification of the vaccination contraindication must be submitted to theMBSON with signature of health care provider and student.

Health Protection Policy for Faculty and Students

All students and faculty are expected to provide quality care to all clients whatever their diagnosis. Faculty and students must be aware of policies and procedures to reduce the risk of infection to self and others. Students will be taught current information regarding preventing the acquiring and transmitting of infections and will be provided laboratory simulation practice utilizing Standard Precautions. In the event that a nursing student is exposed to an infectious disease or injured at a clinical facility, the student should report immediately to the instructor and nurse manager then proceed to Health Services or the emergency room as directed. Any incident must also be reported to the School of Nursing at 864-503-5444.

Students with special health concerns that may place them at risk during clinical experiences should discuss their situations with their instructor for the clinical course prior to the beginning of the clinical experience. These students may be required to submit medical clearance with specific guidelines for their clinical experiences. Students who are unable to provide clinical care without undue risk may be required to delay taking clinical courses until they are safely able to do so.

15

Name: __________________________________________________________________________

DOB: ____________________________ VIPID: _________________________________________

This serves to verify that I, _________________________________________________, have health Student Name

insurance coverage through _________________________________________________________. Print Name of Insurance Company

My Policy Number is _______________________________________________________________.

The dates of coverage are:

� Ongoing

� Effective Dates: ______________________________________

I give permission for the Mary Black School of Nursing at USC Upstate or their representative to validate my coverage. I understand that I MUST provide proof of coverage every semester and maintain current coverage or I may be withdrawn from the Nursing program.

_______________________________________ __________________________________ Signature Date

**Please submit a copy of your insurance card front/back along with this document.

16