Health Examination Form For Admission To The Nurse Aide Training Program

Health Examination Form for Admission

to the Nurse Aide Training Program

TOP PORTION TO BE COMPLETED AND REVIEWED BY THE STUDENT (please print):

Name: ___________________________________________Date of Birth: ________________________________

Address: ____________________________________________________________________________________

City/State/Zip: _______________________________________________ Phone Number: ___________________

All students are required to have the annual influenza vaccine if attending a Nurse Aide Training class between the

months of October through March. Date administered: __________________

Please bring the receipt or documentation from your health care provider to the first day of class.

Student Eligibility Requirements for Nurse Aide Training

Note to Healthcare Professional performing physical assessment:

•

The student must pass a physical examination, and must be free of communicable diseases.

•

Student must have completed the 2-step PPD test prior to the first day of class or bring the IGRA blood test results.

•

Training in transferring, positioning, and the turning of residents/clients is an important part of the training program;

therefore, each student must have the physical ability to succeed in such training.

•

The student must be able to lift 40 pounds to waist level without restrictions.

please print

TO BE COMPLETED AT PHYSICIANS OFFICE/MEDICAL CLINIC (

2-step Tuberculin test, PPD or Mantoux type

(This is required. Form is not complete until the results are read and reported.)

Step 1

Date administered: _________ R.arm/L.arm (circle one) by whom- signature and title: _____________________

Date read: _______________ By whom- signature and title: _________________________________________

Results: ___________mm

7-21 days after the first PPD is read Step 2 must be administered

Step 2

Date administered: _________ R.arm/L.arm (circle one) By whom- signature and title: _____________________

Date read: _______________ By whom- signature and title: _________________________________________

Results: ___________mm

If PPD results are positive, please describe the treatment given and the date completed: __________________________

(

(QFT–

If PPD’s are not given please bring lab results from the IGRA blood test

QuantiFERON® – TB Gold In-Tube test

GIT)

or SPOT® TB test (T–Spot). This test with negative results will be accepted if PPD’s are not completed.

TO BE COMPLETED BY MD, DO, CRNP or PA:

Yes____ No____ I certify that the student/employee is free from communicable diseases in the communicable state.

Yes____ No____ I certify that the student/employee has no medical conditions/restrictions, which will prevent the

student/employee from performing the essential function of the job. (If the student/employee has restrictions that require

accommodation, please note them in the comments section below.)

Yes ____ No____ Is applicant able to lift 40 lbs. to waist level?

Comments: If applicant has any limitations, please explain: _____________________________________________________

____________________________________________________________________________

Date of Examination: ________________

Examiner’s Name and Title: ______________________________________________________________________________

Examiner’s Signature: ___________________________________________________________________________________

Address: ______________________________________________________________________________________________

City/State/Zip: ________________________________________________________ Phone: __________________________

PLEASE NOTE: All students must undergo a physical examination as well as a 2-step Tuberculin test (PPD) or IGRA blood

test. Documentation is only acceptable if performed within one year prior to the start of class and must be submitted on the

first day of class. A PPD expiring during the course of the class will require an annual PPD (one step) in addition to proof of

the 2-step PPD.

Direct any questions to: Nurse Aide Training at: 1-800-222-4222 ext. 1352 or (717)221-1352

3/09 Rev. 12/11 Rev. 7/12, 10/12, 1/14, 6/14

Health Examination Form For Admission To The Nurse Aide Training Program - Hacc

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