Clinical Requirements Verification Notebook Checklist Date administered Date Date administered Date Date administered Date expired expired expired L L L E E TDaP (past 10 years) ____________ ______ ______ ____________ _________ E ____________ V V Hep B Complete: Y N Hep B Complete: Y N Hep B series Hep B Complete: Y N V MMR complete: Y N MMR complete: Y N MMR (2 doses) E E MMR complete: Y N E Varicella Varicella: Y N Varicella: Y N Varicella: Y N L L L TB skin test (annual) Hepatitis B titer Immune: Y N 2 3 I (Circle One) Measles Titer Immune: Y N Mumps Titer Immune: Y N Rubella Titer Immune: Y N Varicella titer Immune: Y N (Circle One) CPR (AHA) Drug Screen (annual) Background Check ordered Liability insurance & Kaplan Fees Personal Health Insurance Flu Vaccine Student Health Exam form CAPP Clinical Orientation/ (TCPS) (For instructor use): Confirmed by: ______________________fall ______________________fall ______________________fall ______________________spring ______________________spring ______________________spring
Clinical Requirements Verification Notebook Checklist L E V E L I Date administered Date expired L E V E L 2 Date administered Date expired L E V E L 3 Date administered Date expired TDaP (past 10 years) Hep B series MMR (2 doses) Varicella ____________ Hep B Complete: Y N MMR complete: Y N Varicella: Y N ______ ____________ Hep B Complete: Y N MMR complete: Y N Varicella: Y N ______ ____________ Hep B Complete: Y N MMR complete: Y N Varicella: Y N _________ TB skin test (annual) Hepatitis B titer Immune: Y N (Circle One) Measles Titer Mumps Titer Rubella Titer Immune: Y N Immune: Y N Immune: Y N Varicella titer Immune: Y N (Circle One) CPR (AHA) Drug Screen (annual) Background Check ordered Liability insurance & Kaplan Fees Personal Health Insurance Flu Vaccine Student Health Exam form CAPP Clinical Orientation/ (TCPS) (For instructor use): Confirmed by: ______________________fall ______________________fall ______________________fall ______________________spring ______________________spring ______________________spring
Clinical%20Requirements%20Checklist.docx