WEST LIBERTY UNIVERSITY
RN – BSN PROGRAM
REQUIREMENT 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