☐ 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
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Required Tuberculosis Screening
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Required Health Screening ☐
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Required Infection Prevention Documentation Clinical-Site-Specific Immunization Requirements Clinical-Site-Specific Screening Requirements
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Other Required Documentation
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Additional Requirements or Notes
Student Verification and Acknowledgment
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