NASSAU COMMUNITY COLLEGE

Students must retain a photocopy of this form for their personal records.
Student Health Services
One Education Drive
Garden City New York 11530-6793
(516) 572-7123•FAX: (516) 572-9637
NASSAU COMMUNITY COLLEGE
All Nursing/Allied students must complete this form prior to participating in clinical experiences. Students must comply with the requirements
of the agency where their clinical experience will be. Physical examination and mantoux should begin 90 days prior to the first day of class.
STRICT CRITERIA MUST BE MET. COMPLETED PHYSICAL MUST BE ON ORIGINAL NCC FORM WHEN SUBMITTED.
20 _____ Allied Health (Please complete) 20_____ Nursing (Please complete)
______ 1st Year _________________________ ______ 1st Year 101______ 105 ______
(area of study)
_______
______ 2nd Year _________________________ ______ 2nd Year 203 ______ 204
(area of study)
A. NAME _____________________________________________________ ________________________ _____________
(Print) Last First M.I. Birth Date Sex
ADDRESS_________________________________________________________ _____________________________________
Number and Street Banner I.D. #
________________________________________________________________ (_______)_____________________________
City State Zip Phone
B. PERSONAL HISTORY -- (To be filled out by student)
Yes No Yes No Yes No
Rheumatic Fever ____ ____ Hernia ____ ____ High Blood Pressure ____ ____
Heart Disease ____ ____ Asthma ____ ____ Convulsive Disorder ____ ____
Tuberculosis ____ ____ Kidney Disease ____ ____ Speech Disorder ____ ____
⊕TB Skin Test ____ ____ Hepatitis ____ ____ Allergies ____ ____
Orthopedic Problem ____ ____ Sickle Cell Disease/Trait ____ ____ Latex Allergy ____ ____
Diabetes ____ ____ Fainting ____ ____ Vision Problems ____ ____
Medications ____________________________________________________________ Other ____________________________
________________________________________________________________________________________________________
Signature: ____________________________________________________
C. CLINICAL EVALUATION - (To be completed by physician) - Required of all students.
Height ____________ Weight __________ Blood Pressure ____________ Pulse __________________
Head
_________________ Chest-Lungs _________________ Menses
_________________
Skin
_________________ Heart
_________________ Cardiovascular _________________
Eyes
_________________ Breast
_________________ Endocrine System _________________
Nose
_________________ Abdomen _________________ Lymphatic System _________________
Throat
_________________ Hernia
_________________ Neurological _________________
Teeth
_________________ Genitalia (Male) _________________ Spine-Musculoskeletal _________________
Ears
_________________ Pelvic (Optional) _________________ Upper Extremities _________________
Neck-Thyroid _________________ Ano-Rectal _________________ Lower Extremities _________________
LAB Values - ABNORMAL RESULTS MUST BE ADDRESSED
Urinalysis ____________________________ Hemoglobin ______________________ OR Hematocrit ____________
Repeat Urinalysis _______________________________________________________
Required Annually: (at the time of physical)
Tuberculin Test (PPD intrademal only)
Date Given: ____________________________ Date Read (48-72 HRS) ___________________ Result: in mm: ________________
Hx ⊕ PPD (MANTOUX) Test: Date _________________________
POSITIVE reactors to TB Test must submit written results of Chest X-ray report (PA & lateral) within two years. (Attach copy of CXR report)
Date: ________________________________ Result: __________________________________________________________________

NAME ____________________________________________________________
Banner I.D. #________________________
Required on Initial Physical Only: TITRES NEED TO BE DONE ONE TIME ONLY FOR INITIAL PHYSICAL
*Attach Lab Reports to this Form (FOUR (4) TITRES MUST BE SUBMITTED) EQUIVOCAL TITRES ARE NOT ACCEPTABLE.
NEGATIVE TITRES REQUIRE IMMUNIZATION. REPEAT TITRE WILL BE REQUIRED IN 30 DAYS.
*Rubeola Titre (Value) __________ Date __________ Result: __________
If negative, Vaccine administered:
__________________
(1) Date
*Mumps Titre (Value) __________ Date __________ Result: __________ __________________
(1) Date
*Rubella Titre (Value) __________ Date __________ Result: __________ __________________
(1) Date
*Varicella Titre (Value) __________ Date __________ Result: __________ __________________ ______________
(1) Date (2) Date
*All dates must be filled in on this form each time you hand in the form.
Polio Salk-Sabin (any history) Date: ___________________________________________
Diphtheria/Tetanus Booster within ten years, Date: ________________________________
Hepatitis B Vaccine: 1) Date _____________ 2) Date _______________ 3) Date __________________ Titre: ___________
ALLIED HEALTH AND NURSING STUDENTS ARE ADVISED TO BE IMMUNIZED WITH HEPATITIS B VACCINE PRIOR TO THE
BEGINNING OF CLINICAL PRACTICE OR MUST SIGN A DECLINATION STATEMENT.
DECLINATION STATEMENT
I understand that during my participation in my clinical internship, I may be exposed to blood or other potentially infectious
materials and I may be at risk of acquiring Hepatitis B Virus (HBV) infection. I have been informed of the need
to be vaccinated with Hepatitis B vaccine. However, I decline Hepatitis B vaccination at this time. I understand that by
declining this vaccination, I continue to be at risk of acquiring Hepatitis B, a serious disease. I understand that Nassau
Community College cannot mandate that I take this vaccination in order to continue my education in my chosen health
science program. My failure to be immunized could jeopardize the successful fulfillment of the requirements of my program
at Nassau Community College, which may preclude me from graduating. I further understand and agree that I
cannot hold Nassau Community College responsible for any injury or illness arising from my activity and/or exposure
to blood or other blood-borne pathogens in my program and clinical laboratories.
Name (Print) ________________________________________________________
Date: ____________________________________
Student Signature ___________________________________________________
PHYSICIAN'S CERTIFICATION -
Above named patient is deemed to be free from any addictive substances (by visual inspection only).
Is this the first time you have seen this patient Yes No
Cleared
Not Cleared
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Physician's Signature __________________________________________
Date ____________________________
Physician's Name __________________________________________ License No. __________________________________
(Please Print)
Physician's Stamp ______________________________________________ Phone ( ) _____________________
(Area Code) (Number)
Address ________________________________________________________________________________________________
SPS-4 (Rev. 09/08)
(ALL INFORMATION IS CONFIDENTIAL)