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PBT 101 Student Check List

ABTCC PBT PROGRAM ADMISSION CHECK SHEET

Name _________________________________   Date of Birth ___________Student ID#______________

  1. Verify PSY 150 or PSY 118 requirement- □ needs class   or  □ completed ≥ C grade
  2. CPR certification ___________
  3. Background Check _____________
  4. Urine Drug Screen _____________
  5. Medical Form (physical) ___________
  6. Uniform __________
  7. Immunizations
    1. 3 DTP(diphtheria,tetanus,pertussis)_________         _________       _________
      1.  

Tetanus Vaccination _____________

  1. 1 Tetanus=Tdap (Current within last 10 years) ______________
  2. 2 MMR (If born AFTER 1957)  _______________     _______________
    1.   

MMR titer (if born BEFORE 1957)(blood draw –bring lab report with reference ranges for antibody levels of Rubeola IgG=Measles, Mumps IgG and Rubella IgG= German measles) _______________

  1. 2 Varicella (NOT had chicken pox) _____________        ____________
    1.  

Varicella titer (had the chicken pox) (blood draw- bring lab report with reference range for Varicella IgG antibody level) ________________

  1. Hepatitis B (series of 3)  ____________      _____________        _____________
  2. TB skin test (within last 12 months-annual) ________________
  3. Flu shot (seasonal- annual)_________________
  1. Onboarding clearance approved (Mission Education.services@msj.org) ________________

empty check box  Student is now ready to begin clinical rotation

empty check box  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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