PBT 101 Student Check List

PBT 101 STUDENT CLINIC CHECK SHEET

Name ___________________________  Date of Birth ______________________

1. CPR certification ___________
2. Background Check _____________
3. Urine Drug Screen _____________
4. Medical Form (physical) ___________
5. Uniform __________
6. Immunizations
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:  ________________________