Nursing Clinical Placement District #1
Student Clinical Passport
Requirements
Student Name:
College:
Program:
These requirements are in place for the health and safety of Washington State
health care students and their patients.
By contract with your academic institution, all students participating in patient care in this healthcare institution must meet the following health and safety
requirements. Academic institution is responsible for ensuring requirements have been met prior to participation in patient care/clinical experience. Records will be
kept at the academic institution and random review by the healthcare institutions will occur on a regular basis. All documentation must meet requirements at all times
during clinical course. Required immunizations must include mm/dd/yyyy if available
SUBMITTED ONCE
TUBERCULIN STATUS
 If no history or more than 12 months since last TST → 2 step TST OR
 If negative TB Test within 12 months → one step TST OR
 If New positive TB → F/U by healthcare provider (chest X-ray,
symptoms check and possible treatment) may need to complete health
questionnaire

SUBMITTED EVERY YEAR
TUBERCULIN STATUS
 New one-step TST OR
 QuantiFERON TB Gold test OR
 If New positive TB Test results→ F/U with healthcare provider,
chest X-ray, & symptom check OR

If history of positive TB → provide proof of chest X-ray and negative
symptom check OR
If history of BCG vaccine → QFT. If negative → OK; If positive → do Chest X-Ray
HEPATITIS B
 Proof of immunity by vaccination and titer OR IF
 Negative titer → must repeat vaccine series. Student will be allowed in
BACKGROUND CHECKS
 National Criminal Background Check upon admission and
reentry/ readmission to nursing program to include all counties
of residence, all Washington State counties per RCW 43.43.830
(WATCH), and OIG and GSA screens. Excluded provider search
on OIG http://exclusions.oig.hhs.gov/search.aspx
clinical during repeat series and considered a non-responder to
vaccination after 2 complete vaccine series and negative titer OR

Proof of vaccine series(without titer):
Known positive TB skin results and prior negative chest X-ray
results: submit annual symptom check from healthcare
provider
GSA https://www.epls.gov/epls/search.do?ssn=true

Washington State Patrol Background check per
o
If series is < 5yrs old, draw titer only. If positive titer, ok. If neg.
titer, repeat vaccine series and redraw titer.
o
If series is > 5yrs old, one dose of Hep B and titer 1-2 months later. If
positive titer, ok. If neg titer, complete vaccine series
INFLUENZA
(2 additional doses) and redraw titer. Neg. titer=nonresponder

If positive titer and no history of vaccine, must obtain antiHBc test, the
marker for past infection.

Signed waiver for students who decline vaccination Specific healthcare
institutions may require vaccination without exception (i.e., no waiver)
RCW 43.43.830 through RCW 43.43.842 annually thereafter


Proof of annual vaccination(s) OR
Signed waiver for students who decline vaccination
Specific healthcare institutions may require vaccination without
exception (i.e., no waiver)
LICENSE (if student licensed or certified as RN, LPN, or CNA in
MMR (Measles, Mumps, Rubella)

Proof of vaccination (2 doses) OR

Proof of immunity by titer
VARICELLA (Chicken Pox)
 Proof of vaccination (2 doses) OR
 Proof of immunity by titer.
TETANUS,DIPTHERIA, PERTUSSIS (Tdap)
 Routine series of Td-containing vaccine
 Routine booster every 10 years
 Tdap required once
CPR

Healthcare provider level (adult, infant, child, AED)
REQUIRED EDUCATION
 HIPAA & Privacy Training (Student Training Module)
 Fire Safety Training (Student Training Module)
 Blood borne Pathogen Training (Student Training Module)
Washington State)


Current
Unencumbered
INSURANCE
 Professional Liability $1,000,000/3,000,000 policy
OPTIONAL REQUIREMENTS (if applicable)
Some healthcare settings may have additional requirements, such as the
following:







Vehicle Insurance (for access to VA & Military Facilities)
Personal Health Insurance
Drug Screen
Hepatitis A Vaccine
Current First Aid Card
Proof of U.S. Citizenship
Color Vision Test
Instructors will inform students prior to clinical experience if optional or
additional requirements need to be met.
2012-7-12
Copyright 2012 Nursing Clinical Placement District #1
Nursing Clinical Placement District #1
Student Clinical Passport
Requirements
Student Name:
College:
Program:
Date of Entry:
Point of Contact:
Form verified by:
Name
Name
Name
Date
Date
Date
By contract with your academic institution, all students participating in patient care in this healthcare institution must meet the following health and safety requirements. The
academic institution is responsible for ensuring requirements have been met prior to participation in patient care/clinical experience. Records will be kept at the academic
institution and random review by the healthcare institutions will occur on a regular basis. All documentation must meet requirements at all times during clinical course.
Required immunizations must include mm/dd/yyyy if available.
SUBMITTED ONCE
Circle the applicable letter in each box.
TUBERCULIN STATUS
A. Two-step TST 1) Skin Test #1 Date_____Result: Neg____Pos____mm___
2) Skin Test #2 Date_____Result: Neg____Pos____mm___
OR
B. QuantiFERON (QFT)
Date_______ Result:_________
OR
C. If New Positive/Exam/X-ray
Date_________
OR
D. Positive TB/Negative X-ray
Date_________
HEPATITIS B (3 primary series shots: (at 0,1,6 mo) plus titer confirmation
(1-2 months later)
A. Vaccination Dates
1) ______________
2) ______________
3) ______________
4) Immunity confirmed by titer Date _______ OR
B. Vaccine Series > 5yrs old (without titer confirmation)
Hep B booster Date_________
then immunity confirmed by titer Date _________
C. Immunity by titer (anti-HBs) Date_________ OR
D. Signed waiver Date __________
E. Had the disease Date__________
F.
B.
A. Annual TST
Date_________ Result: Neg____Pos____mm______
Date_________ Result: Neg____Pos____mm______
Date_________ Result: Neg____Pos____mm______
OR
B. Annual QuantiFERON (QFT)
Dates__________,__________,_________OR
C. If New Positive/Exam/Chest X-ray
Exam Date________ X-ray Date_______ OR
D. Known Positive/Possible Treatment/ Annual
Symptom Check from Health Care Provider Date_________
BACKGROUND CHECK (including Disclosure
Statement)
A.
B.
National Criminal Background Check upon admission
Date_____________
Washington State Patrol Check (upon admission and
annually)
Dates_________,________,_________,_________AND
C.
Excluded Provider Search on OIG and GSA
Dates ________, ________, _________,__________
Influenza
Vaccination Dates
1) ___________ 2) _____________
Immunity by titers Date___________
A.
OR
Varicella (Chicken Pox)
A. Vaccination Dates
B.
TUBERCULIN STATUS
antiHBc Date_______ Result______
MMR (Measles, Mumps, Rubella)
A.
SUBMITTED ONCE
Circle the applicable letter in each box.
1) _________ 2)_________ OR
Immunity by titer Date___________
B.
Proof of annual vaccination
Date 1._______2._________ 3. ________ OR
Signed waiver
Date___________
License (RNs, LPNs, CNAs)
A. WA State
Date___________ OR
B. Not Applicable
Insurance
A. Professional Liability Policy Date: _______
Tetanus/Diptheria (primary series of three) Date Completed _______
A.
B
Booster within the last 10 years. Date _________ If booster
after 2004, was this a Tdap (please find out) Yes_____
No______
If no, Tdap required once
Date ________
CPR Health Care Provider Level (adult, infant, child, AED)
Expiration Date __________
Fire Safety Module
Date Completed ____________
HIPAA Privacy Training
Date Completed ___________
Bloodborne Pathogens Training
OPTIONAL REQUIREMENTS (if applicable)
A.
B.
C.
D.
Vehicle Insurance
Date___________
Personal Health Insurance Date___________
Drug Screen
Date___________
Hepatitis A Vaccine Two doses
Dates: 1.___________2). ___________
E. Current First Aid Card
Date___________
F. Proof of U.S. Citizenship
G. Confidentiality Statement Date______
H. Code of Conduct
I. Color Vision Test
Date _______
This is not a comprehensive list; there may be more items.
Date Completed ____________
2012-7-12
Copyright 2012 Nursing Clinical Placement District #1