HealthRecordForm.pdf - MIAMI DADE COLLEGE MEDICAL CAMPUS...

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MIAMI DADE COLLEGEMEDICAL CAMPUSStudent Health Record FormName:_______________________________________________MDID:__________________LastFirstMiddle InitialI understand that student health information is protected and confidential under State of Florida and federal laws.I voluntarily provide, andconsent to my medical provider or physician providing, the medical information contained in this document to the Miami Dade College andhealth care facilities that I am assigned to as part of Miami Dade College’s medical program requirements.I also understand that all requestedStudent Health Record information is a prerequisite to enrollment in the clinical training of any Medical Campus program.Failure to completethis record will prevent my participation in the clinical training. The student and Health Care Examiner (MD, DO, PA, ARNP) must sign in theappropriate spaces provided on the form.This form and documentation of all titers, vaccines, drug screening, TB testing, and x-raysrequested on this form must be uploaded to Complio by American Data Bank at.SECTION 1: PERSONAL INFORMATIONAll areas of this section must be completed.This information will be kept on file and used in the event that the student must be contacted oran emergency contact is required.SECTION 2: REQUIRED INFLUENZA INJECTION (FLU SHOT)Students participating in a clinical rotation must receive the influenza injection as soon as it is available and show proof to the school and thehealth care facility.Students that cannot participate in the influenza injection process as a result of a medical condition or refuse to participatein the influenza injection may be required to participate in additional measures established by a clinical site. Additionally, it may jeopardize thestudent’s ability to participate in the clinical portion of a Medical Campus program. It is highly recommended that all students receive theinfluenza injection.SECTION 3: REQUIRED TITERS/TESTSA.Varicella(Chicken Pox):A Varicella Titer must be drawn andthe resultsmust be uploaded to Complio by American Data Bank at.Arecord of the Varicella Vaccine will not be accepted as documentation of the requiredtiter.The date of the titer and results must be indicated in the appropriate area.(INDICATING THE DISEASE PROCESS OR IMMUNIZATIONDATES IS NOT ACCEPTABLE FOR DOCUMENTATION IN THIS AREA).Mumps,Rubeola (Measles), and Rubella(German Measles):A Mumps, Rubeola, and Rubella Titer must be drawn andthe results must beuploaded to Complio by American Data Bank at.Arecord of the MMR (Mumps, Measles,Rubella) Vaccine will not be accepted as documentation of the required titer.The dates of the titers and the results must be indicated inthe appropriate area.(INDICATING THE DISEASE PROCESS OR IMMUNIZATION DATES IS NOT ACCEPTABLE FOR DOCUMENTATION INTHIS AREA).

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Term
Spring
Professor
de
Tags
Nursing, Health care provider, American Data Bank

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