Fresno, California
Section 1(Personal Information) / Section 2(Orientation)
NAME / Gender
☐Male ☐Female / Initial Orientation Date
SSN / DOB / School / Program
Email / School Coordinator / Phone
Cell # / Home
Professional License Type (e.g., RN) / Number / Exp / This form and all information in Section A, A-1, and B must be complete and provided to Clinical Education.
Immunity requirements are specific and must be in compliance with the guidelines shown on page 2 of this document. This document is also form driven and intended to be downloaded, typed, and forwarded to Clinical Education via email to: .
Security / Vehicle License Plate #
Emergency Contact / Name / Relation
Cell / Home
Section 3(Immunity Information – Completed by individual and validated by Clinical Education)
Mark appropriate checkboxes [☐]below for titer, dose or type and input date(s) where indicated. [See page 2 for immunity requirements]
MMR☐+ Titer or
☐2 doses / Varicella
☐+ Titer
☐2 doses / Tdap
Vaccine
(as an adult) / Influenza
☐Vaccine
☐Decline / Hepatitis B
☐Titer ☐Series ☐Declination / Tuberculosis
☐2-Step (neg) w/ mmor
☐Neg CXR / Questionnaire* / ACLS/BLS
AHA
(expiration)
mm / ☐ACLS
☐ BLS
If declining complete & attach appropriate form(s) / *Symptom Document showing negative for TB
Above faculty information verified by:
Clinical Education, Practice & Informatics Department / Signature or enter name
Section 4(Clinical Education Use Only)
REQUIREMENTS / Initials / Date / Live Orientation / Initials / Date
☐ / Immunizations turned in / PCSO Day 4 Orientation
☐ / Contract Verified / ☐ / Safe Patient Handling
☐ / Criminal Background Check / ☐ / POCT access (granted by lab)
☐ / ID Badge ☐Initial ☐Renewal / ☐ / Emergency Medication Math
☐ / PYXIS access form (for new faculty) / ☐ / EKG (For Telemetry/monitored patient rotations)
SJVNEC Website Orientation Documents
☐ / Certification/Licensing Verified (trio)
☐BLS
☐ACLS
☐RN ☐LVN License / ☐Attestation
☐Confidentiality/HIPAA
☐Elder Abuse / ☐Child Abuse
☐Universal Precautions
☐Hand Hygiene / ☐Student Mandatory Training Quiz
HealthConnect Requests
☐ / NUID / Date / ☐ / CPM (RN) / Date / ☐ / KPHC Requested / Date / NUID# / Password
Template for RN Inpatient Charge Nurse
November1, 2016
Health Screening Requirements for Faculty and Students
Kaiser Permanente requires health screening and immunization for healthcare workers or persons who perform work at Kaiser Permanente Medical Center, Medical Office Buildings or having contact with patients.
You will need to provide proof of adequate vaccination or current immunity by documentation which will be reviewed prior to beginning your clinical instruction at Kaiser Permanente.
The following list is provided for you to meet the health screening and immunizations that are required and need to be complete prior to your start date.
TB Screening:
2-Step PPD on entry to clinical portion of nursing program with date of placement, date read with results documented in millimeters, and if negative or positive, signed off by a medical provider. PPD then required annually.
If a history of a positive TB Skin Test, require a negative chest x-ray to rule out active disease, followed by completion of symptom review questionnaire annually.
Immunization Screening:
Rubella2 MMR vaccines, or serological testing to demonstrate immunity.
Rubeola2 MMR vaccines, or serological testing to demonstrate immunity.
Mumps2 MMR vaccines, or serological testing to demonstrate immunity.
Varicella Zoster (Chickenpox)2 varicella vaccines, or serological testing to demonstrate immunity.
Tetanus,diphtheria,pertussisDocumentation of 1 T-dap vaccine as an adult.
Influenza Flu vaccine current seasonor signed declination for the current season.
All students and faculty that decline vaccination are required to wear a mask when on nursing units.
Hepatitis B Documentation of 3 Hepatitis B vaccines, serological testing to demonstrate immunity, or sign a declination. If requesting vaccine, noted as “in progress” of receiving series of vaccine.
Employee Health Service
Kaiser Permanente Fresno Medical Center
Criminal Background Checks
Kaiser Permanente - Fresno
Students with background check indicating any of the following felony and/or misdemeanor convictions within the last 7 years are not eligible for clinical placement:
- Violent crimes such as murder, rape, sexual assault and robbery, kidnapping, attempted murder, assault with deadly weapons
- Crimes involving theft, embezzlement, burglary, forgery, fraud, arson, identity theft
- Sex crimes includingsexual molestation and sex crimes against children, or any conviction for which a candidate is required to register as a sex offender with a state or federal government agency
- Drug related crimes such as drug theft, sales, distribution, manufacturing and possession of controlled substances
- Multiple convictions (more than one conviction for same or different crime)
- Posted name on any government sanctioned or debarred list
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