___had Syndrome ___disorder that compromises my immune system ___pregnant ___currently ill and have a high I understand that by not receiving the flu vaccination I am obligated to follow the infection control guidelines of the clinical agency in which I am assigned for clinical. Signature of Student:___________________________ Date:_____________ I it is not appropriate for the student to receive the flu vaccination at this time. Signature of Health Care Provider:_____________________________ Date:_________________________ SOUTHEASTERN LOUISIANA UNIVERSITY School of Nursing Admission Health Examination Record PART I--TO BE COMPLETED BY APPLICANT PRINTED NAME: ________ W # DATE OF BIRTH: SEX: I. APPLICANT: Have you had or do you currently have any of the following? a. Visual defects Yes No j. Diabetes Yes No b. Hearing defects Yes No k. Kidney or bladder disease Yes No c. Speech defects Yes No l. Cancer Yes No d. Cardiac disease or disorders Yes No m. Back injuries/surgery Yes No e. High blood pressure Yes No n. Joint injuries or problems Yes No
___had Syndrome ___disorder that compromises my immune system ___pregnant ___currently ill and have a high I understand that by not receiving the flu vaccination I am obligated to follow the infection control guidelines of the clinical agency in which I am assigned for clinical. Signature of Student:___________________________ Date:_____________ I it is not appropriate for the student to receive the flu vaccination at this time. Signature of Health Care Provider:_____________________________ Date:_________________________ SOUTHEASTERN LOUISIANA UNIVERSITY School of Nursing Admission Health Examination Record PART I--TO BE COMPLETED BY APPLICANT PRINTED NAME: ________ W # DATE OF BIRTH: SEX: I. APPLICANT: Have you had or do you currently have any of the following? a. Visual defects Yes No j. Diabetes Yes No b. Hearing defects Yes No k. Kidney or bladder disease Yes No c. Speech defects Yes No l. Cancer Yes No d. Cardiac disease or disorders Yes No m. Back injuries/surgery Yes No e. High blood pressure Yes No n. Joint injuries or problems Yes No
UG_stud_hb_9_30_14.docx