NASSAU COMMUNITY COLLEGE
NASSAU COMMUNITY COLLEGE
NASSAU COMMUNITY COLLEGE
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Students must retain a photocopy of this form for their personal records.<br />
Student Health Services<br />
One Education Drive<br />
Garden City New York 11530-6793<br />
(516) 572-7123•FAX: (516) 572-9637<br />
<strong>NASSAU</strong> <strong>COMMUNITY</strong> <strong>COLLEGE</strong><br />
All Nursing/Allied students must complete this form prior to participating in clinical experiences. Students must comply with the requirements<br />
of the agency where their clinical experience will be. Physical examination and mantoux should begin 90 days prior to the first day of class.<br />
STRICT CRITERIA MUST BE MET. COMPLETED PHYSICAL MUST BE ON ORIGINAL NCC FORM WHEN SUBMITTED.<br />
20 _____ Allied Health (Please complete) 20_____ Nursing (Please complete)<br />
______ 1st Year _________________________ ______ 1st Year 101______ 105 ______<br />
(area of study)<br />
_______<br />
______ 2nd Year _________________________ ______ 2nd Year 203 ______ 204<br />
(area of study)<br />
A. NAME _____________________________________________________ ________________________ _____________<br />
(Print) Last First M.I. Birth Date Sex<br />
ADDRESS_________________________________________________________ _____________________________________<br />
Number and Street Banner I.D. #<br />
________________________________________________________________ (_______)_____________________________<br />
City State Zip Phone<br />
B. PERSONAL HISTORY -- (To be filled out by student)<br />
Yes No Yes No Yes No<br />
Rheumatic Fever ____ ____ Hernia ____ ____ High Blood Pressure ____ ____<br />
Heart Disease ____ ____ Asthma ____ ____ Convulsive Disorder ____ ____<br />
Tuberculosis ____ ____ Kidney Disease ____ ____ Speech Disorder ____ ____<br />
⊕TB Skin Test ____ ____ Hepatitis ____ ____ Allergies ____ ____<br />
Orthopedic Problem ____ ____ Sickle Cell Disease/Trait ____ ____ Latex Allergy ____ ____<br />
Diabetes ____ ____ Fainting ____ ____ Vision Problems ____ ____<br />
Medications ____________________________________________________________ Other ____________________________<br />
________________________________________________________________________________________________________<br />
Signature: ____________________________________________________<br />
C. CLINICAL EVALUATION - (To be completed by physician) - Required of all students.<br />
Height ____________ Weight __________ Blood Pressure ____________ Pulse __________________<br />
Head<br />
_________________ Chest-Lungs _________________ Menses<br />
_________________<br />
Skin<br />
_________________ Heart<br />
_________________ Cardiovascular _________________<br />
Eyes<br />
_________________ Breast<br />
_________________ Endocrine System _________________<br />
Nose<br />
_________________ Abdomen _________________ Lymphatic System _________________<br />
Throat<br />
_________________ Hernia<br />
_________________ Neurological _________________<br />
Teeth<br />
_________________ Genitalia (Male) _________________ Spine-Musculoskeletal _________________<br />
Ears<br />
_________________ Pelvic (Optional) _________________ Upper Extremities _________________<br />
Neck-Thyroid _________________ Ano-Rectal _________________ Lower Extremities _________________<br />
LAB Values - ABNORMAL RESULTS MUST BE ADDRESSED<br />
Urinalysis ____________________________ Hemoglobin ______________________ OR Hematocrit ____________<br />
Repeat Urinalysis _______________________________________________________<br />
Required Annually: (at the time of physical)<br />
Tuberculin Test (PPD intrademal only)<br />
Date Given: ____________________________ Date Read (48-72 HRS) ___________________ Result: in mm: ________________<br />
Hx ⊕ PPD (MANTOUX) Test: Date _________________________<br />
POSITIVE reactors to TB Test must submit written results of Chest X-ray report (PA & lateral) within two years. (Attach copy of CXR report)<br />
Date: ________________________________ Result: __________________________________________________________________
NAME ____________________________________________________________<br />
Banner I.D. #________________________<br />
Required on Initial Physical Only: TITRES NEED TO BE DONE ONE TIME ONLY FOR INITIAL PHYSICAL<br />
*Attach Lab Reports to this Form (FOUR (4) TITRES MUST BE SUBMITTED) EQUIVOCAL TITRES ARE NOT ACCEPTABLE.<br />
NEGATIVE TITRES REQUIRE IMMUNIZATION. REPEAT TITRE WILL BE REQUIRED IN 30 DAYS.<br />
*Rubeola Titre (Value) __________ Date __________ Result: __________<br />
If negative, Vaccine administered:<br />
__________________<br />
(1) Date<br />
*Mumps Titre (Value) __________ Date __________ Result: __________ __________________<br />
(1) Date<br />
*Rubella Titre (Value) __________ Date __________ Result: __________ __________________<br />
(1) Date<br />
*Varicella Titre (Value) __________ Date __________ Result: __________ __________________ ______________<br />
(1) Date (2) Date<br />
*All dates must be filled in on this form each time you hand in the form.<br />
Polio Salk-Sabin (any history) Date: ___________________________________________<br />
Diphtheria/Tetanus Booster within ten years, Date: ________________________________<br />
Hepatitis B Vaccine: 1) Date _____________ 2) Date _______________ 3) Date __________________ Titre: ___________<br />
ALLIED HEALTH AND NURSING STUDENTS ARE ADVISED TO BE IMMUNIZED WITH HEPATITIS B VACCINE PRIOR TO THE<br />
BEGINNING OF CLINICAL PRACTICE OR MUST SIGN A DECLINATION STATEMENT.<br />
DECLINATION STATEMENT<br />
I understand that during my participation in my clinical internship, I may be exposed to blood or other potentially infectious<br />
materials and I may be at risk of acquiring Hepatitis B Virus (HBV) infection. I have been informed of the need<br />
to be vaccinated with Hepatitis B vaccine. However, I decline Hepatitis B vaccination at this time. I understand that by<br />
declining this vaccination, I continue to be at risk of acquiring Hepatitis B, a serious disease. I understand that Nassau<br />
Community College cannot mandate that I take this vaccination in order to continue my education in my chosen health<br />
science program. My failure to be immunized could jeopardize the successful fulfillment of the requirements of my program<br />
at Nassau Community College, which may preclude me from graduating. I further understand and agree that I<br />
cannot hold Nassau Community College responsible for any injury or illness arising from my activity and/or exposure<br />
to blood or other blood-borne pathogens in my program and clinical laboratories.<br />
Name (Print) ________________________________________________________<br />
Date: ____________________________________<br />
Student Signature ___________________________________________________<br />
PHYSICIAN'S CERTIFICATION -<br />
Above named patient is deemed to be free from any addictive substances (by visual inspection only).<br />
Is this the first time you have seen this patient Yes No<br />
Cleared<br />
Not Cleared<br />
________________________________________________________________________________________________________<br />
________________________________________________________________________________________________________<br />
________________________________________________________________________________________________________<br />
Physician's Signature __________________________________________<br />
Date ____________________________<br />
Physician's Name __________________________________________ License No. __________________________________<br />
(Please Print)<br />
Physician's Stamp ______________________________________________ Phone ( ) _____________________<br />
(Area Code) (Number)<br />
Address ________________________________________________________________________________________________<br />
SPS-4 (Rev. 09/08)<br />
(ALL INFORMATION IS CONFIDENTIAL)