Requirements Form





ID Number: ___________________________ Name: ____________________________________________

Allergies: ___Yes   ___ No – If yes, please specify: _______________________________________________________________

Latex-Reaction: __________; Medication – Name & Reaction: __________________________ Other: _____________________

CPR Certification: (expiration date) ___/___/___  Attach copy of card


TB Status: Result of PPD (Intermediate Strength): ___ Negative     ___ Positive     Date: ___/___/___ Attach proof of test & reading.  PPD must be renewed annually.


Date of PPD MUST be within the past 12 months.  If you have a Positive reaction, or if you have a history of BCG or previous positive PPD, DO NOT REPEAT THE PPD, attach health care provider statement verifying chest x-ray and safe status for nursing practice.  An annual assessment must be performed by a health care provider and documentation for continued safe status for nursing practice provided.

Varicella               Date of vaccination ___/___/___

OR   ___N/A because had Chicken Pox: ____________________ (specify year)

OR  Date of Titer ___/___/___  Results

Tetanus                 Date of vaccination ___/___/___ Must be within the last 10 years (must include Pertussis)


Hepatitis B            Date of vaccination             #1 ___/___/___

#2 ___/___/___

#3 ___/___/___

AND Date of Titer ___/___/___     Results __________________

Measles, Mumps, Rubella


                                Date of MMR #1 ___/___/___

Date of MMR #2 ___/___/___

OR          Dates of Titers:                     Rubeola ___/___/___         Results ____________________

Mumps ___/___/___          Results ____________________

Rubella ___/___/___          Results ____________________

WV Licensure:    Expiration Date ___/___/___            License Number: ________________________


I verify that the above data is accurately and honestly reported.  I have attached photo-copies to document for CPR certification, PPD, Immunizations,  or Titers, stated above.  I realize I am accountable for this information.  I am aware that the most current data is required to be on file in the Nursing Office prior to the beginning of any clinical nursing practice.  I know it is my responsibility to update this record by submitting a photo-copy of new data when it becomes available annually.

Signature: ______________________________________  Date: ___________________


tjf: 8/13