Nursing Assistant Program Medical Verification Form

To the Student – Instructions for this Form:

A health care provider must sign this form for program admission and indicate whether the applicant will be able to function as a nursing student. Health care providers who qualify to sign this declaration include a licensed physician (M.D., D.O.), a nurse practitioner or physician’s assistant.

Date of Examination

Student's Name and Address

Student's Email

Phone Number

Documentation of a Two-Step TB (Tuberculosis) Skin Test is Required:

This consists of an initial TB skin test and a boosted TB Skin Test 1-3 weeks apart. If you have a positive skin test, provide documentation of a negative chest X-ray within the last 5 years. Please attach the chest X-ray documentation to this paper if there is a positive reading.

Two-Step: Must be completed prior to handing in this form.

Step 1: First Visit

Initial Test (#1) Date

Two days later Date of Reading

Results

Negative

Positive

Step 2: Second Visit

Boosted Test (#2) Date

Two days later Date of Reading

Results

Negative

Positive

To the Health Care Professional: PLEASE READ

I have, this day, given ___________________________________ a thorough physical examination and based on my findings, which include medical history and physical examination; I believe he/she is physically and mentally able to undertake the Nursing Assistant Program at Delaware County Community College. The student is in good health. He/she is free of any communicable disease, can lift 50 pounds, and has no known deficits that would interfere with the ability to participate in a clinical setting.

It is essential that nursing students be able to perform a number of physical activities in the clinical portion of the program. At a minimum, students will be required to lift patients, stand for several hours at a time and perform bending activities. Students who have a chronic illness or condition must be maintained on current treatment and be able to implement direct patient care. The clinical nursing experience also places students under considerable mental and emotional stress as they undertake responsibilities and duties impacting patients’ lives. Students must be able to demonstrate rational and appropriate behavior under stressful conditions. Individuals should give careful consideration to the mental and physical demands of the program prior to making application.

Does the student have any limitations that will interfere with patient safety?

Yes

If yes, please explain

Healthcare Provider OFFICE STAMP

Healthcare Provider Signature

Licensed Healthcare Provider (M.D., D.O., N.P., P.A.)

Date

Name

Phone Number

Address