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). 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 is limited to authorized NLU PA Program and University personnel with a legitimate responsibility to verify compliance. Section I. Student Identification Student Name: _______________________________________________________
NLU Student ID Number: _______________________________________________________
Cohort/Graduation Year: _______________________________________________________
Date of Matriculation: _______________________________________________________
Section II. Matriculation Immunization Verification Check one: ( ☐ ) The student has matriculated with all NLU PA Program required immunizations up to date, with a signed provider immunization record uploaded to the student file. ( ☐ ) The student has a medical contraindication or other approved exception to one or more required immunizations, documented through the appropriate NLU and PA Program process (applicable immunization(s), reason, and confidential documentation status to be recorded). Date Compliance Status Verified: _______________________________________________________
Student Signature / Date: _______________________________________________________
NLU PA Director of Didactic Education Signature / Date: _______________________________________________________ NLU PA Director of Clinical Education Signature / Date: _______________________________________________________
Section III. Clinical Phase/SCPE Immunization and Screening Verification Check one: ( ☐ ) Required immunizations and health-screening requirements were checked prior to clinical placement and are in compliance with all applicable affiliated clinical-site
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