Directions For Completing Medical Requirement Forms (Page 2 of 8) in pdf

Directions For Completing Medical Requirement Forms Page 2

Physician/Nurse Practitioner Responsibility

Immunization/Communicable Disease Record (if student resides in a remote area, the CHN will complete

Section A and D. The physician or NP will fill in Sections B and C)

______Venous blood sample for MMR Titer and Hepatitis B seroconversion if no record of either

______ If student has history of TB, then a chest x-ray is required and doctor’s note

______ Certify student is symptom free of any reported communicable disease (bottom of page 4)

Pre-Entrance Health Examination

______ Record your findings

______ Complete physical ability clearance section

______ Include the office stamp with name, address and phone number

______ Sign and date at the bottom of the form

For students who reside in remote areas where the Physician or NP does not administer vaccines:

Student’s Responsibility

______ Fill out top of page 5

Community Health Nurse Responsibility

______ Complete Immunization/Communicable Disease Form – Page 5, Sections A and D.

______ Record and photocopy IZ record

______ Administer all vaccines to bring students up-to-date*

_____ Initial areas where IZ was administered by you

* including MMR 2

dose if born between 1970-1991

Medical Form

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Directions For Completing Medical Requirement Forms Page 2