NLU PA Program — Didactic Year Handbook
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 requirements. ( ☐ ) The student requires additional documentation, verification, site-specific requirements, or approved exception review before placement in one or more SCPEs. Compliance checklist (Verified/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
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