PBT 101 Student Check List

PBT 101 STUDENT CLINIC CHECK SHEET

 

Name ___________________________  Date of Birth ______________________ Student ID# ______________________

  1. High School diploma, transcript/GED on file ____________
  2. CPR certification ___________
  3. Background Check _____________
  4. Urine Drug Screen _____________
  5. Medical Form (physical) ___________
  6. Uniform __________
  7. Immunizations
  8. a. 3 DTP  ____________         ________________       _______________

OR

            Tetanus Vaccination_____________

            b.  1 Tetanus (Current within last 10 years) ______________

            c.  2 MMR (If born AFTER 1957)  _______________     _______________

OR  

           MMR titer (if born BEFORE 1957) _______________

           d.  2 Varicella (NOT had chicken pox) _____________        ____________

OR

          Varicella titer ( had the chicken pox) ________________

           e.  Hepatitis B (series of 3)  _________      __________        ___________

           f.  TB skin test (within last 12 months) ________________

           g.  Flu shot (seasonal- annual)_________________

 

 _____ Student is now ready to begin clinical rotation

 _____ Student has been advised what is pending and the deadline to comply before being dropped from the course

Date Completed: ___________________________

Instructor signature:  ________________________

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