Public Health – Health Requirements Checklist
Instructions: Complete all of the items listed below by the deadline. All forms can be
downloaded from the CHS Clinical Requirements webpage or Castle Branch.
Student Account Set-up
 Set up student account with Castle Branch (https://portal.castlebranch.com/HF84)
Health Requirements
 MMR Vaccinations (2 MMR’s are required)
 Tdap (Tetanus/Diphtheria/acellular Pertussis)
 Physical Examination form
 American Heart Association BLS for Healthcare Provider certification (we will NOT accept
any other certification)
 TB/PPD Clearance – ONE of the following is required
o Copy of a current 2-step TB
o Copy of two annual TB tests; one of which needs to be current
o If you’ve had a positive TB test, please provide the following: date of positive TB
with reading in mm, a current negative chest x-ray (1 year or less), and TB
Monitoring Questionnaire.
 Seasonal Influenza on CHS form
 HIPAA & Bloodborne Pathogens Certification
 Health Insurance
Once you have complete the requirements listed above, you must scan and upload a copy of
the documentation into your Castle Branch health tracker prior to the deadline given.
Questions: If you have technical questions about Castle Branch, please contact: (888) 7234263. If you have questions about the health requirements, please contact: Risa Tanaka at
(808) 236-5816 or [email protected].
Updated on 2/28/14
Physical Examination Form (3 pages)
to be completed within 1 year of entry or upon request of the Dean
Name: ___________________________________ HPU ID Number: __________________
Immunization Record and Health Report to be signed or stamped by health care provider.
Information written on this report is NOT proof of immunization or labs.
Immunizations/Screens
1. Mumps:
 Immunization is required.
2.
Rubeola (Measles):
 Immunization is required.
3.
Rubella:
 Immunization is required.
4.
Tdap (Tetanus/Diphtheria/acellular Pertussis) – NOTE: effective Fall 2014 Tdap is
required for ALL students:
 Immunization within the last 10 years is required
 For adults: Those who did not get the Tdap should get one dose as a booster. Most
pregnant women not previously vaccinated with Tdap should get a dose before leaving
the hospital. (Source: U.S. Centers for Disease Control and Prevention)
Tuberculosis (TB/Mantoux/PPD):
Last two annual TB tests OR two-step TB test required
 2 annual TB tests: Tests must be less than 1 year apart and must be less than a year old.
 Two-step TB tests: Two TB tests within a two-week time period, the second one
administered a week after the first one is read.
 Positive TB test: Positive TB test and results AND x-ray report/card with clear or
negative findings. X-ray must be less than 1 year old.
5.
Student Signature: __________________________________ Date: ___________________
Student’s Signature is acknowledgement that they understand the requirements of immunizations.
Health Care Provider Signature: ___________________________ Date: ______________
Health Questionnaire: To be completed by Student prior to Physical Examination
_____ Yes _____ No
Do you have any physical limitations that would affect your ability to
lift, turn, or transfer patients?
_____ Yes _____ No
Do you have any limitations in use of your senses, such as in sight,
hearing, which would limit your ability to practice a health profession?
_____ Yes _____ No
Do you have any other condition that might interfere with your ability
to practice in the health care profession?
If you answered “yes” to any of the above, please explain your limitations in detail, including any medications
you take on a regular basis in the past year (attach a separate sheet of paper if necessary):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
History: Include any significant information regarding previous medical/surgical or psychiatric conditions
and use of alcohol or drugs:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Student Signature: ___________________________________________ Date: ____________________________
Health Care Provider’s Certification of Fitness:
PHYSICAL EXAMINATION FORM

Students will be examined for evidence of being able to meet the physical requirements necessary for a
nursing student:
o Ability to stand, sit, kneel, bend, push, pull, carry, walk, reach, and twist
o Manual dexterity to perform fine motor tasks needed for essential nursing tasks and use of
equipment.
o Ability to see, hear, and feel.
o Ability to lift at least 50 pounds (essential to assist clients with ambulation, transfers, positon
changes, transport).
Any comments r/t history provided: ______________________________________________________________
_____________________________________________________________________________________________
Gender: __________ Age: __________ Height: __________ Weight: _________
Blood pressure: _________________________ Pulse: ____________
Build: Slender _________ Medium _________ Heavy _________ Obese _________
Color vision: _______ Vision: OD 20/______ OS 20/________ Corr-to 20/________
Normal
Abnormal
Details of Abnormality
Head, neck, face, & scalp
Eyes, ears, nose
Mouth, teeth, gingiva, & throat
Thyroid
Lungs
Heart & vascular
Abdomen & viscera
Hernia
Neck, back, & spine
Upper extremities
Lower extremities
Other musculoskeletal
Skin and lymphatics
Neurologic
Psychiatric (specify deviations noted)
Lab Data (if indicated): Hgb: __________ WBC: __________ Urinalysis (dipstick): __________
I have examined ___________________________________ and have found her/him to be free from any
impairments or restrictions that may impede functioning in a health care role.
Comments: ___________________________________________________________________________________
_____________________________________________________________________________________________
___________________________________________
______________________________________________
Signature of Health Care Provider and License Number
Printed name of Stamp of Health Care Provider
Address: ______________________________________________
STUDENT/FACULTY INFLUENZA VACCINE 2016-2017
Flu season runs from August – March. If you are filling out this form outside of the flu season,
please check the “will be receiving box”
PRINT Name:
Date:
Hawai’i Pacific University has mandated that I receive the influenza vaccination due to new
facility requirements.
Provider Information: ________________________
□ Received 2016-2017
inactivated influenza vaccine
Date: _________________
Provider Information: ________________________
□ Received 2016-2017 activated
influenza vaccine
Date: _________________
□ Will be receiving when the flu vaccine is available
Medical Contraindication: _____________________
□ Medical contraindications
(systemic allergic reaction to
ingredients, Guillain-Barre
syndrome, etc.)
Provider Signature: __________________________
** Please inform your clinical instructor that you are
NOT able to take the flu shot, as you will need to adhere
to hospital and unit policies (i.e. wearing a mask
throughout flu season while at clinical)
__________________________________________
_______________
Student Signature
Date
Tuberculosis Monitoring Questionnaire
HPU’s affiliation agreements with the various health care agencies require that we monitor
TB status of nursing students on an annual basis. Individuals with a previous history of a
positive PPD, followed by a negative chest x-ray, are requested to provide ongoing TB
monitoring by filling out this questionnaire to monitor for symptoms of tuberculosis.
Please check “yes” or “no” in the appropriate box. This form will be reviewed by the Health
Records Assistant and you will be contacted if further follow up is required.
Have you experienced any of the following symptoms in the last year?
Cough longer than three weeks
Cough of blood
Shortness of breath
Chest pain
Persistent weight loss without dieting
Night sweats
Chills/fever
Fatigue (more than usual)
Yes
No
















If yes, please explain
___________________
___________________
___________________
___________________
___________________
___________________
___________________
___________________
Print Name: ____________________________________ Student ID: ___________________
Signature: _____________________________________ Date: ________________________
For Office Use Only
Reviewed By: ______________________________
Health Insurance Requirement for Clinical Level Nursing Courses
Students who will be purchasing their health insurance through HPU need to sign and submit the
“Health Insurance Intent to Purchase Agreement” to Castle Branch under the Insurance section by
Sunday, July 10th, 2016. This agreement is binding.
Once you purchase your health insurance, you must submit a copy of the receipt of purchase or a
copy of the insurance card to Castle Branch by:
Monday, August 29th, 2016.
__________________________________________________________________________
Health Insurance Intent to Purchase Agreement
I, (print name) _________________________________________, a level ______ (indicate the
level you will be entering for Fall 2016, 1 – 5)
intend to purchase health insurance through HPU for the coming semester.
I have read the information provided to me and understand the current insurance rates are not yet
published.
Because health insurance is mandatory to work in the clinical facilities, I understand that I must
turn in a copy of my receipt of purchase or a copy of my insurance card. This proof is due no later
than Monday, August 29th, 2016.
I understand that if I do not show proof by this date I will lose my clinical seat.
_________________________________________
Signature
____________________________
Date
HIPAA and Bloodborne Pathogen Training Instructions
HIPAA Training:
1. Go to http://www.hawaiistatecenternrc.org/Student-Center
2. Click on the training module located on the right hand side of the
webpage
3. Read the information and follow the link
4. Complete the Post-Test (link located under the training module on the
webpage listed in #1) and print the last page before closing
5. Sign and upload the page to your Castle Branch tracker
Bloodborne Pathogen Training:
1. Log into a computer in the Library or Computer Lab. Or if you wish to
access the training from your own personal computer, please set up
HPU Cloud to your computer:
a. Set up Cloud – Go to http://www.hpu.edu/vdi and download
the VMware Horizon View Client to your personal computer
or tablet. Be sure to enter the default connection server:
cloud.hpu.edu. If you have questions, please call the ETC at
236-5807.
2. Click on the Windows icon
3. Click on Computer
4. Double Click on Video folder
5. Double Click on Bloodborne Pathogens – 2011 to watch video
6. After watching the video, return to the Video folder and double click
the CNHS Bloodborne Pathogens Training Post Test Survey link
7. Complete Post-Test and print the last page
8. Upload the page to your Castle Branch tracker