UNIVERSITY OF HAWAI'I • KAPI'OLANI COMMUNITY COLLEGE
Nursing Department
Surgical Technology Checklist – Proof of Clinical Clearance
Name:______UH ID #: ______
Last name First name & Middle Initial(s)
Preferred Phone No.: ______E-mail Address:
Instructions: Complete and submit all of the items listed below. All forms may be downloaded and printed from
PLEASE RETURN THIS CHECKLIST FORM AND ALL REQUIRED HEALTH FORMS. You may drop off forms in the Health Document mailbox located in the Kōpiko Building, Room 201 OR Mail to KCC Nursing Department, Attention: Kristin Miura, 4303 Diamond Head Road, Honolulu, HI 96816
For Questions: contact Kristin Miura at 808.734.9494 or .
CPR certification:Copy of American Heart AssociationBasic Life Support Provider level (for Healthcare Professionals) – Be sure to copy both sides of your certification card. Be sure the vendor you choose is an American Heart Association Authorized Training Center/Trainer.(Note: On-line course certifications are NOT accepted. Please check the Health Requirements webpage for other restrictions. Adult First Aid/CPR is not acceptable. Must be “BLS Provider Level” by the American Heart Association.)
TUBERCULOSIS (TB) - ONEof the following:
Copies of a current two-step TB/ppd skin test (2 separate injections) with negative results, within current year OR
Copies of a two-step TB/ppd skin test within the last 365 days prior, AND a single negative TB skin test within the current year
If you have had a positiveppd skin test, provide the date with induration size (i.e. 10mm or more) AND a current negative Chest x-ray result (within 12 months from the start of program (August)). You must also completethe (1) KCC TB form, (2)HPH TB Questionnaire Form, (3) Castle Questionnaire Form, and (4) Queens Questionnaire Form.Please contact Ms. Miura as soon as possible via e-mail () to obtain theTB Forms.
(Tdap) TETANUS, DIPHTHERIA and PERTUSSIS or (TD) TETANUS, DIPHTHERIA:
Copy of proof of Tdap vaccination for tetanus, diphtheria and pertussisORTD vaccination for tetanus, diphtheria (within 10 years). Must include information such as “date administered”. Payment receipts are not an acceptable form of documentation.
VARICELLA (Chicken pox):
Copy of a Varicella (chicken pox) titer blood test:After completing the two Varicella immunizations (1 month apart) or a history of disease (If negative/equivocal titer result, you must complete vaccination series) ~ A doctor’s order for the Varicella Antibody blood test is required. Please contact Ms. Miura if your results are negative/equivocal.
RUBELLA:
Copy of a Rubella titer blood test: After completing the two MMR immunizations (1 month apart), ~A doctor’s order for the Rubella Antibody blood test is required. Please contact Ms. Miura if your results are negative/equivocal.
RUBEOLA (Measles):
Copy of a Measles titer blood test: After completing the two MMR immunizations (1 month apart), ~A doctor’s order for the Rubeola Antibody blood test is required. Please contact Ms. Miura if your results are negative/equivocal.
MUMPS:
Copy of a Mumps titer blood test:After completing the two MMR immunizations (1 month apart), ~A doctor’s order for the Mumps Antibody blood test is required. Please contact Ms. Miura if your results are negative/equivocal.
HEPATITIS B Immunity:
Copy of a Hepatitis B Surface Antibody (HbsAb) titer blood test: After completingthree Hepatitis B immunizations, a doctor’s order for the Hepatitis B Antibody blood test is required.Please contact Ms. Miura if your results are negative/equivocal.
INFLUENZA VACCINATION Current Seasonal Documentation:
Copy of proof of vaccination within the current seasonal period.
KCC PHYSICAL EXAMINATION FORM: (Physical examination must be completed within 6 months to start of program)
Original form, completed by your HCPverifying ability to perform program activities.
MEDICAL CONSENT FORM:
Original, signed and dated
UNDERSTANDING AND AGREEMENT FORM:
Original, signed and dated
EXCLUSION OF WORKERS’ COMPENSATION/ CONFIRMATION OF HEALTH INSURANCE COVERAGE FORM:
Original, signed and dated;AND COPY OF VALID INSURANCE CARD (front and back).
DOCUMENT RELEASE FORM:
Original, signed and dated
HEALTH DOCUMENTATION SUBMISSION AGREEMENT:
Original, signed and dated rev.05/2018