Nursing Health Form Information
This file includes information regarding the nursing health forms and requirements for clinical
placements. Completion of these forms is required to progress into Nursing clinical courses.
A clinical information meeting will be held in April yearly for students beginning clinical
experiences in NURS 210 & NURS 211 the following spring semester. Students transferring
after the meeting or progressing directly into fall junior clinical courses (NURS 310 & NURS
311) will receive an email with specific information about the requirements.
All nursing students will be added to the Nursing Canvas site, which is the best source of clinical
information. Also, the clinical coordinator is available to help students meet these requirements.
Please contact me with any questions or concerns after reviewing the information.
Nancy Frank
Clinical Liaison Placement Coordinator
Department of Nursing
Messiah College
[email protected]
(717) 796-1800, ext. 3517
Clinical Health Requirements
Nursing Physical Examination Form:
This form is collected by mid-October for students beginning clinical the following semester
and is valid for the entire student clinical experience unless the clinical agency requires an
update or the student’s enrollment lapses for greater than 1 year. Junior students who are new to
Messiah clinical experiences must complete this physical no later than the first Friday of the fall
semester in order to participate in clinical experiences.
The following information must be included with the Physical Examination form:
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Physical examination (dated after Jan. 1 of year prior to clinical experiences, less
than 1 year old)
PPD (if positive results, must obtain a chest x-ray) required annually
Varicella vaccination X 2 OR Varicella titre (to verify immunity)
Tdap vaccination (within 10 years)
MMR vaccination
Hepatitis B vaccination X 3
Dental Form:
This form is submitted by mid-October for students beginning clinical the following semester
and is valid for the entire student clinical experience unless the clinical agency requires an
update or the student’s enrollment lapses for greater than 1 year. Junior students who are new to
Messiah clinical experiences must complete this exam no later than the first Friday of the fall
semester in order to participate in clinical experiences.
Dental exam must be dated after Jan. 1 of year prior to clinical experiences, less than 1 year old.
Influenza Vaccination:
Submission of the Influenza Vaccination Form required annually. Due mid-October.
Medical Insurance:
Submission of proof of medical insurance due each semester that a student participates in a
clinical course. Due the first Friday of clinical course. Assignment will be available after Jan.
1 & July 1 for each semester.
Messiah College
Department of Nursing
One College Avenue, Suite 3031
Mechanicsburg, PA 17055
(717) 691-6029
Influenza Vaccine Documentation
Student Name:
Student Signature:
I confirm that I have received the influenza vaccine on (date):
I am unable to receive the influenza vaccination due the following reason cited by
the CDC (http://www.cdc.gov/flu/index.htm ). Please circle reason:
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Have had a severe reaction to an influenza vaccination.
Developed Guillain-Barre Syndromé (GBS) within 6 weeks of getting an influenza
vaccine.
Provider Signature:
Provider Name:
Provider Address:
Provider Phone: