TO THE APPLICANT:   Please complete this section before appointment with practitioner:

Name (Miss, Mrs., Mr.) _____________________________________________________________________________________________
				Last 				First			Middle

Address:___________________________________________________________________________________________________________
	   Number & Street          				City		 	State		Zip

Phone Number:_______________________________  Date of Birth:_________/_________/_________
						           Month           Day           Year

TO THE EXAMINING PRACTITIONER

This applicant has been tentatively accepted into the nursing program in the Eastern Community College District.  While enrolled this student will be: required to achieve in a very rigorous academic program; involved in very stressful situations on a one to one basis; called upon to work with groups of people in stressful situations; required to use effectively all sense organs; engaged in activities which require above  average manual dexterity; expected to lift, move, and turn persons who weigh at least as much as he/she does; required to be on his/her feet for four to eight consecutive hours at one time.

IMMUNIZATIONS AND TESTS:

Immunizations and Tests completed: Rubella Titer or Vaccine must be shown for acceptance into the Nursing Program.  
Boosters of Diphtheria and Tetanus must be within the last ten years.  Mantoux test or x-ray to be done at time of examination.

Poliomyelitis	Salk Date:  _________________________		Tetanus Toxoid	     Date:__________________________

		Sabin Date: ________________________		Diphtheria Toxoid    Date:__________________________

Mantoux Test	Date: _____________________________		MMR Vaccine 	     Date:__________________________
								       OR
Reaction_____________________________________________________	Rubella Titer        Date:__________________________

								Reaction_________________________________________
Hepatitis B Dates given:	_______________________________
				_______________________________
				_______________________________
					  OR



Decline To Receive Vaccination

I understand that due to my clinical laboratory exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection.

I have had an opportunity to receive information and to ask questions and understand the benefits and risks of the Hepatitis B Vaccination.  I do not wish to receive this vaccine at this time and request that it not be given to me.

I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease.

______________________________________________________           ____________________________________
Signature of person not to receive vaccine					 Date

If tuberculin test is positive, date and result of the subsequent x-ray must be stated:____________________________________________________

Comments:______________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

I hereby certify that I have examined __________________________________________________ on ____________________________ and that he/she is physically and emotionally able to be enrolled as a nursing student.


___________________________________________________ (M.D., D.O., ARNP)		Date __________________________________
	      Signature of Examiner