PBT Admission Checklist

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) ________________

  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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