Student /Faculty Clinical Passport

STUDENT/FACULTY INFORMATION
NAME:

SCHOOL: _______________________________________
LAST

DATE OF BIRTH:

FIRST

STUDENT TARGET GRADUATION DATE:

_____/______/__________

_____________

CRIMINAL BACKGROUND CHECK:

FACULTY LICENSURE VERIFICATION:

Date: ___________ Verified by: ______________________

RENEWAL # ______________ EXPIRATION DATE: _____

DRUG SCREEN (if available or required):

CERTIFICATIONS/SPECIALTY:

Date: __________ Verified by: _____________________

HEALTH RECORD
MEASLES, MUMPS, & RUBELLA
Dates of Vaccine: MMR #1:
Date drawn and result of: Measles titer:
Mumps titer:
Rubella titer:

MMR #2:
Result:
Result:
Result:

TUBERCULIN SKIN TEST (PPD) (annual requirement)

Result:
Date:
Result:
Date:
Result:
Date:
Result:
Date:

OR

HEPATITIS B
Dates of Vaccine: HB#1: _______ HB#2:_______
Date of Disease:
Immunity confirmed by blood titer HbsAB: Date:

Chest x-ray if positive PPD

Date:
Medical Screening Report
Date:

Result:
Result:

HB#3: _______

Hepatitis B declination waiver signed: Date: _______

VARICELLA (CHICKEN POX)
Date and result of varicella titer:

DIPTHERIA/TETANUS (Must be within 10 years)

Last booster date:

Dates of vaccination: #1:

#2:
CPR

Students/Faculty must have a current card/roster indicating Healthcare Provider status to participate in clinical!

Expiration Date: _______________ American Heart Association or - American Red Cross

Expiration Date: _______________ American Heart Association or - American Red Cross
Expiration Date: _______________ American Heart Association or - American Red Cross
Expiration Date: _______________ American Heart Association or - American Red Cross
9/2010

SAFETY
Date: ___________
Date: ___________

GENERAL ONLINE HEALTHCARE ORIENTATION

Complete this content once per academic year!
INFECTION CONTROL & BLOODBORNE PATHOGENS
Date: ___________
Date: ___________
Date: ___________
Date: ___________
Date: ___________
Date: ___________

CONFIDENTIALITY & COMPLIANCE

Date: ___________
Date: ___________
Date: ___________
Date: ___________

CARING FOR DIVERSE POPULATIONS

Date: ___________
Date: ___________
Date: ___________
Date: ___________

EMERGENCY PREPAREDNESS
Date: ___________
Date: ___________
Date: ___________
Date: ___________
GENERAL ORIENTATION QUIZ - the Completion Certificate should be kept with the Clinical Passport!
Date: ___________ Score: ___________
Date: ___________ Score: __________
Date: ___________ Score: ___________
Date: ___________ Score: __________
CLINICAL FACILITIES SPECIFIC ORIENTATION
Be sure and include any required facility documentation including Quiz Certificates with your Passport!

Date:
Date:
Date:
Date:
Date:
Date:
Date:
Date:
Date:
Date:
Date:
Date:

Facility: ___________________
Facility: ___________________
Facility: ___________________
Facility: ___________________
Facility: ___________________
Facility: ___________________
Facility: ___________________
Facility: ___________________
Facility: ___________________
Facility: ___________________
Facility: ___________________
Facility: ___________________

Date:
Date:
Date:
Date:
Date:
Date:
Date:
Date:
Date:
Date:
Date:
Date:

Facility: ___________________
Facility: ___________________
Facility: ___________________
Facility: ___________________
Facility: ___________________
Facility: ___________________
Facility: ___________________
Facility: ___________________
Facility: ___________________
Facility: ___________________
Facility: ___________________
Facility: ___________________

VERIFICATION OF ACCURATE DOCUMENTATION (SIGNATURE of INSTRUCTOR & DATE)

1ST YEAR
DATE
DATE
DATE

__________________________________
__________________________________
__________________________________

SIGNATURE: ______________________________
SIGNATURE: ______________________________
SIGNATURE: ______________________________

2ND YEAR
DATE
DATE
DATE

__________________________________
__________________________________
__________________________________

SIGNATURE: ______________________________
SIGNATURE: ______________________________
SIGNATURE: ______________________________

3RD YEAR
DATE
DATE
DATE

__________________________________
__________________________________
__________________________________

SIGNATURE: ______________________________
SIGNATURE: ______________________________
SIGNATURE: ______________________________

4TH YEAR
DATE
DATE
DATE
9/2010

__________________________________
__________________________________
__________________________________

SIGNATURE: ______________________________
SIGNATURE: ______________________________
SIGNATURE: ______________________________