NCE’s 2023-2024 fiscal year, illustrating how the College is following through with our commitment to the betterment of education on both a local and national level.
PHYSICIAN ASSISTANT PROGRAM
HEALTH SCREENING AND IMMUNIZATION COMPLIANCE VERIFICATION FORM
ARC-PA Standard A3.18
Record Classification: Confidential Student Educational/Compliance Record Purpose: Verification of required immunization and health-screening compliance for participation in the NLU PA Program and Supervised Clinical Practice Experiences (SCPEs). Confidentiality Notice: This form is intended to document compliance with required immunization and health-screening requirements. It is not intended to serve as a comprehensive student medical record. Access to this information is limited to authorized NLU PA Program and University personnel with a legitimate responsibility to verify compliance with applicable Program and clinical education requirements.
SECTION I. STUDENT IDENTIFICATION
Student Name: ___________________________________________
NLU Student ID Number: ___________________________________
Cohort/Graduation Year: __________________________________
Date of Matriculation: _____________________________________
SECTION II. MATRICULATION IMMUNIZATION VERIFICATION
CHECK ONE:
☐ The NLU PA student, ________________________________________, Student ID Number ________________________, has matriculated with all NLU PA Program required
immunizations up to date. An immunization record document has been signed by the student's medical provider and uploaded into the NLU PA Program student file.
☐ The NLU PA student, ________________________________________, Student ID Number ________________________, has a medical contraindication or other approved exception to one or more required immunizations, as documented through the appropriate NLU and PA Program process.
Unless Contraindicated or Exception Applies — Explanation
Applicable Immunization(s):
Reason for Contraindication or Approved Exception:
Documentation of contraindication or exception has been maintained through the appropriate confidential process:
☐ Yes ☐ No ☐ Not Applicable
Date Compliance Status Verified: ____________________________
Student Verification and Acknowledgment
I acknowledge that I have reviewed the NLU PA Program immunization requirements and have provided the required documentation or completed the appropriate process for any applicable contraindication or approved exception.
Student Name: ___________________________________________
Student Signature: ________________________________________
Date Signed: _____________________________________________
NLU PA Director of Didactic Education Verification
I verify that the student's immunization compliance status has been reviewed and documented for the purpose of determining compliance with applicable NLU PA Program requirements.
Name: ___________________________________________________
Signature: _______________________________________________
Date Signed: _____________________________________________
NLU PA Director of Clinical Education Verification
I verify that the student's immunization compliance status has been reviewed and documented for the purpose of determining compliance with applicable NLU PA Program and clinical education requirements.
Name: ___________________________________________________
Signature: _______________________________________________
Date Signed: _____________________________________________
SECTION III. CLINICAL PHASE/SCPE IMMUNIZATION AND SCREENING VERIFICATION
CHECK ONE:
☐ The following required immunizations and health-screening requirements were checked prior to the student's placement in the clinical phase of the NLU PA Program Supervised Clinical Practice Experiences (SCPEs) and are in compliance with all applicable affiliated clinical site requirements.
☐ The student requires additional documentation, verification, site-specific requirements, or approved exception review before placement in one or more Supervised Clinical Practice Experiences (SCPEs).
Verification Date:
Date Requirements Were Checked: ____________________________
Immunization and Screening Compliance Checklist
Not Applicable/Approved Exception
Additional Action Required
Requirement
Verified/Compliant
Required Program Immunizations
☐
☐
☐
Required Tuberculosis Screening
☐
☐
☐
Required Health Screening ☐
☐
☐
Required Infection Prevention Documentation Clinical-Site-Specific Immunization Requirements Clinical-Site-Specific Screening Requirements
☐
☐
☐
☐
☐
☐
☐
☐
☐
Other Required Documentation
☐
☐
☐
Additional Requirements or Notes
Student Verification and Acknowledgment
I acknowledge that the NLU PA Program has reviewed my immunization and health-screening compliance status for the purpose of determining my eligibility for participation in the clinical phase of the curriculum and Supervised Clinical Practice Experiences.
I understand that individual clinical affiliates may have additional health, immunization, screening, or safety requirements.
Student Name: ___________________________________________
Student Signature: ________________________________________
Date Signed: _____________________________________________
NLU PA Director of Didactic Education Verification
I verify that the student's applicable NLU PA Program immunization and screening compliance requirements have been reviewed before the student's transition to the clinical phase of the curriculum.
Name: ___________________________________________________
Signature: _______________________________________________
Date Signed: _____________________________________________
NLU PA Director of Clinical Education Verification
I verify that the student's applicable immunization and screening compliance requirements have been reviewed before placement in Supervised Clinical Practice Experiences and that applicable affiliated clinical-site requirements have been addressed.
Name: ___________________________________________________
Signature: _______________________________________________
Date Signed: _____________________________________________
SECTION IV. AUTHORIZATION FOR RELEASE OF IMMUNIZATION AND SCREENING INFORMATION
Student Written Permission
I, ________________________________________, authorize the National Louis University Physician Assistant Program and/or authorized University personnel to release the limited immunization and/or health-screening compliance information identified below to the authorized recipient identified in this section.
NLU Student ID Number: ___________________________________
Information Authorized for Release
☐ Immunization Compliance Verification ☐ Tuberculosis Screening Compliance Verification
☐ Health Screening Compliance Verification ☐ Clinical-Site-Specific Compliance Verification ☐ Other: _________________________________________________
Authorized Recipient
Clinical Affiliate/Organization:
Authorized Contact/Department:
Purpose of Release
☐ Verification of eligibility for clinical placement
☐ Verification of clinical-site health and safety requirements
☐ Other: _________________________________________________
Authorization Effective Date: ______________________________
Authorization Expiration Date, if Applicable: ________________
I understand that this authorization permits release only of the information identified above and that the NLU PA Program will limit the release to information necessary for the stated purpose.
Student Signature: ________________________________________
Date Signed: _____________________________________________
SECTION V. ELECTRONIC STUDENT FILE DOCUMENTATION
Date This Form Was Placed Into the Student Electronic NLU PA Program File:
Electronic File/Record Location:
Uploaded/Entered By: _____________________________________
Title/Role: ______________________________________________
Date Uploaded: ___________________________________________
SECTION VI. PROGRAM RECORD VERIFICATION
☐ Student immunization compliance verification completed.
☐ Required health-screening compliance verification completed.
☐ Clinical-phase/SCPE compliance verification completed.
☐ Applicable clinical-site requirements verified.
☐ Student authorization for release obtained, when required.
☐ Form securely placed in the student's electronic NLU PA Program file.
Verified By: _____________________________________________
Title: ___________________________________________________
Signature: _______________________________________________
Date: ___________________________________________________
RECORD MAINTENANCE AND CONFIDENTIALITY
This form will be maintained in a secure NLU University-approved electronic platform using:
Individual user IDs;
•
Password-protected access; Restricted access permissions; Role-based access, when available; Secure electronic storage; and
•
•
•
•
• Applicable NLU information-security and privacy requirements.
Access to this verification record is limited to authorized individuals with a legitimate responsibility to verify immunization, screening, health-clearance, or clinical-placement compliance.
This form is not intended to provide unrestricted access to the student's confidential medical or health records.
Detailed medical records, diagnoses, treatment information, provider notes, and other confidential health information will not be maintained or reviewed by NLU PA Program faculty or staff except as otherwise specifically authorized by applicable law, institutional policy, or the student's written permission.
FORM CONTROL
Form Title: NLU PA Program Health Screening and Immunization Compliance Verification Form
Form Number: PA-A3.18-001
Related ARC-PA Standard: A3.18
Document Owner: NLU PA Program Director
Effective Date: ___________________________________________
Review Cycle: Annual or sooner if required by changes in ARC-PA Standards, NLU policy, applicable law, or clinical education requirements.
Last Review Date: _________________________________________
Next Scheduled Review Date: _______________________________
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