requirements. ( ☐ ) The student requires additional documentation, verification, site - specific requirements, or approved exception review before placement in one or more SCPEs. Compliance checklist (Verifi ed/Compliant, Not Applicable/Approved Exception, or Additional Action Required): 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. Verification Date / Date Requirements Were Checked: _______________________________________________________ Student Signature / Date: _______________________________________________________ NLU PA Director of Didactic Education Signature / Date: _______________________________________________________ NLU PA Director of Clinical Education Signature / Date: _______________________________________________________ Section IV. Authorization for Release of Immunization and Screening Information The student may authorize release of specified immunization/screening compliance information (e.g., Immunization Compliance Verification, TB Screening, Health Screening, Clinical-Site- Specific Compliance) to a named clinical affiliate or authorized recipient, for a stated purpose (e.g., verification of eligibility for clinical placement or of clinical -site health and safety requirements), with an effective date and, if applicable, an expiration date. Student Name / NLU Student ID Number: _______________________________________________________ Authorized Recipient (Clinical Affiliate/Organization, Contact/Department): _______________________________________________________ Authorization Effective Date / Expiration Date, if applicable: _______________________________________________________ Student Signature / Date: _______________________________________________________ Section V. Electronic Student File Documentation
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