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Student Name:
College:
Northwest University, Buntain School of Nursing
Program:
BSN
Date of Entry:
8/30/2010
Point of Contact:
Carl Christensen, RN, PhD, Dean
Form verified by:
Ramona L Nakashima, Office Coordinator
Name
RLN
Date
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Name Click to enter text. Date
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Name Click to enter text. Date
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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.
SUBMITTED ONCE
SUBMITTED EVERY YEAR
Circle the applicable letter in each box.
Circle the applicable letter in each box.
TUBERCULIN STATUS
TUBERCULIN STATUS
A. Two-step
TSTL:
A. Annual TST:
mm
1) Skin Test #1 Date
Dates
Neg
Pos
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OR
mm
B. Annual QuantiFERON (QFT):
2) Skin Test #2 Date
Neg
Pos
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OR
Dates
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OR
B. Quantiferon (QFT)
Result
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C.
If
New
Positive/Exam/Chest
X-ray:
Date
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OR
Exam Dates
X-ray Date
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OR
OR
C. If New Positive/Exam/X-ray
Date click date
North Puget Sound Student
Clinical Passport
Requirements
OR
D. Positive TB/Negative X-ray
Known Positive/Possible Treatment/ Annual
Symptom Check from Health Care Provider:
Date click date
Background Check (including Disclosure Statement)
A. National Criminal Background Check
Hepatitis B (3 primary series shots: (at 0,1,6 mo) + titer confirmation)
A. Vaccination Dates:
1)
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2)
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3)
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Dates
B.
Immunity confirmed by titer
OR
A. Immunity by titer (anti-HBs)
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OR
B. Signed waiver
C. Had the disease
D. antiHBc
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OR
OR
Result
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C.
MMR (Measles, Mumps, Rubella)
A. Vaccination Dates
Dates
1)
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B. Immunity by titers
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Varicella (Chicken Pox)
A. Vaccination Dates
Dates 1)
2)
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B. Immunity by titers
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Tetanus/Diphtheria (primary series of three)
OR
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OR
A. Booster within the last 10 years
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B. If booster after 2004, was this a Tdap (please find out)
If no, Tdap required once
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Date Complete click date
Yes
AND
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AND
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Influenza
A. Proof of annual vaccination
Dates
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Signed waiver
OR
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OR
Not Applicable
Insurance
Professional Liability Policy
Date: 10/4/2011
OPTIONAL REQUIREMENTS (if applicable)
A.
Vehicle Insurance
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B.
Personal Health Insurance
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C.
Drug Screen
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D. Hepatitis A Vaccine Two doses
1)
2)
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E. Current First Aid Card
Ex. Date
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F. Proof of U.S. Citizenship
Yes
No
G. Confidentiality Statement
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H. Code of Conduct
I.
Color Vision Test
Choose one
B.
No
CPR Health Care Provider Level (adult, infant, child, AED)
Expiration Date
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License (RNs, LPNs, CAN)
A.
WA State
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B.
2)
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Excluded Provider Search on OIG and GSA
Dates
Click
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Washington State Patrol Check
Dates
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4)
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REQUIRED EDUCATION
EACH HEALTHCARE INSTITUTION WILL COMMUNICATE TO INSTRUCTORS
REQUIRED EDUCATIONAL CONTENT TO BE COMPLETED BY STUDENTS
PRIOR TO PARTICIPATING IN PATIENT CARE.
This is not a comprehensive list; there may be more items.
2011-12-14
North Puget Sound
Student Clinical Passport
Requirements
Student Name:
«Last», «First»
College: Northwest University, Buntain School of Nursing
Program: BSN
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.
SUBMITTED ONCE
SUBMITTED EVERY YEAR
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 + TB → F/U by healthcare provider (chest X-ray,
symptoms check and possible treatment) may need to
complete health questionnaire
 If History + 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 clinical during repeat series and considered a
non-responder to vaccination after 2 complete vaccine
series and negative titer OR
 If + titer and no 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)
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, Diphtheria, Pertussis (Tdap)
 Routine series of Td-containing vaccine
 Routine booster every 10 years
 Tdap required once
CPR

Healthcare provider level (adult, infant, child, AED)
TUBERCULIN STATUS
 New one-step TST OR
 QuantiFERON TB Gold test OR
 If New + TB Test results→ F/U with healthcare
provider, chest X-ray, & symptom check OR
 Known + TB skin results and prior negative chest X-ray
results: submit annual symptom check from healthcare
provider
Background Checks
(Upon admission and every year)
 Washington State Patrol Background check per
RCW 43.43.830 through RCW 43.43.842 AND
 National Criminal Background Check covering WA State
AND
 Excluded provider search on OIG
http://exclusions.oig.hhs.gov/search.aspx AND
GSA https://www.epls.gov/epls/search.do?ssn=true
Influenza
 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
Washington State)

Current

Unencumbered
Insurance
 Professional Liability $1,000,000/3,000,000 policy
REQUIRED EDUCATION
EACH HEALTHCARE INSTITUTION WILL COMMUNICATE TO
INSTRUCTORS REQUIRED EDUCATIONAL CONTENT TO BE
COMPLETED BY STUDENTS PRIOR TO PARTICIPATING IN
PATIENT CARE.
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.
2011-12-14