AFFILIATED SCHOOL STUDENT ROSTER SCHOOL ACADEMIC YEAR SEMESTER: RN LVN PT RT MA OTHER COURSE: CCPS# COMPLETE FOR STUDENTS AND INSTRUCTORS - SEE REVERSE FOR DETAILS OF IMMUNITY REQUIREMENTS DATE FORMAT: mm/dd/yy Please indicate after date if a positive titer *For positive TB: List date and then list date for CXR along with results: neg or pos “+” “+” “-“ “+” **Criminal Background Student’s Rubeola Rubella Varicella Hep B QuantiFERON TDap Flu CBC** BLS Legal Name* Gold TB Test + Titer / + Titer / +Titer / + Titer / Titer / Series Vaccine / Vaccine Cannot be (no nicknames) AHA 2 doses 2 2 doses 2 (dates) Declination Test Date Decline Date older than Last, Middle (dates) (dates) (dates) (dates) (date) 18 months Exp Date Initial,
AFFILIATED SCHOOL STUDENT ROSTER SCHOOL ACADEMIC YEAR SEMESTER: RN LVN PT RT MA OTHER COURSE: CCPS# COMPLETE FOR STUDENTS AND INSTRUCTORS - SEE REVERSE FOR DETAILS OF IMMUNITY REQUIREMENTS DATE FORMAT: mm/dd/yy Please indicate “+” after date if a positive titer *For positive TB: List date and “+” then list date for CXR along with results: neg “-“ or pos “+” **Criminal Background Student’s Legal Name* (no nicknames) Last, Middle Initial, Rubeola + Titer / 2 doses (dates) + Titer / 2 (dates) Rubella +Titer / 2 doses (dates) Varicella + Titer / 2 (dates) Hep B Titer / Series Declination (dates) QuantiFERON Gold TB Test Test Date TDap Vaccine / Decline (date) Flu Vaccine Date CBC** Cannot be older than 18 months BLS AHA Exp Date
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