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Medical Verification - Delaware County Community College - Nursing Assistant Program Form

Delaware County Community College

Nursing Assistant Program

Medical Verification Form

To the Student – Instructions for this Form:

A health care provider must sign this form for program admission and indicate whether the applicant will be able to

function as a nursing student. Health care providers who qualify to sign this declaration include a licensed physician

(M.D., D.O.), a nurse practitioner, or physician’s assistant.

Date of the Examination_______________________________

Student’s Name & Address

Student’s Email and Telephone Number

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Documentation of a Two-Step TB ( Tuberculosis)

Skin Test is Required:

This consists of an initial TB skin test and a boosted TB Skin test 1-3 weeks apart. If you have a

positive skin test, provide documentation of a negative chest X-ray within the last 5 years (Please

attach the chest X-ray documentation to this paper if there is a positive reading).

Two-Step: Must be completed prior to handing in this form.

Step 1: First Visit

Initial Test (#1) Date: _______________________

2 days later Date of Reading: ____________________

Negative OR

Positive

Results/Circle One

Step 2: Second Visit

Boosted Test (#2) Date: ___________________

2 days after (Date of Reading): __________________

Results/ Circle One

Negative

Positive

Health Care Provider Signature:___________________________________________

Licensed Healthcare Provider (M.D., D.O., N.P., P.A.)

Print Name: ________________________________ Telephone Number___________________________________

Address: __________________________________________________

Medical Verification - Delaware County Community College - Nursing Assistant Program Form