☐ 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;
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Password-protected access; Restricted access permissions; Role-based access, when available; Secure electronic storage; and
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• 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.
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