Texas State University - St. David’s School of Nursing

2014 Health Certificate

As a student conditionally admitted to the School of Nursing, you are to complete this Health Certificate and an Immunizations and Tests Form. Make an appointment with your healthcare provider to document:

·  All immunizations are completed including date of booster.

Note: See Immunizations and Tests Form - Clinical affiliations may require additional immunizations and/or tests.

·  You in good physical and mental health and free from diseases listed on the Immunizations and Tests Form.

Completed Health Certificate and Immunizations and Tests Form must be received by the School of Nursing by 5:00PM on Friday, July 11, 2014.

School of Nursing Student:
Last / First / MI
Address:
Street / City / State / Zip
Telephone: / ( ) / Date of Birth: / / /
I have examined:
(School of Nursing Student)
and find this student to be in good physical and mental health. I also find the above named student is free from the diseases listed on the Immunizations and Tests Form.
Restrictions or Limitations (i.e. latex allergy*) / ¨ No / ¨ Yes, Explain:
Date: / Telephone: / ( )
Healthcare Provider Signature:
Printed Name:
Healthcare Provider’s Address:
Street / City / State / Zip

*If you indicated you have a latex allergy, we ask you to take responsibility for your health and complete the following:

·  Contact the Office of Disability Services in the Avery Building to initiate the process for the accommodation of using latex free gloves. Your contact person is Autumn Gruel ().

·  After the accommodation process is complete, give your documentation to Lynn Heimerl, the SON Admission and Retention Coordinator. This documentation will be placed in your file.

·  Prior to the first week of classes, alert your faculty of record for each clinical course and Dr. Tiffany Holmes, Simulation Laboratories Coordinator of your latex allergy immediately. Contact Lynn Heimerl () for their email addresses.

·  Throughout your nursing education at St. David’s School of Nursing your accommodation will be negotiated to reasonable extent. Latex free gloves will be provided along with sterile latex free gloves.

·  You must take responsibility for your protection. There is no way to totally eliminate latex from the simulation labs.

·  You are to bring latex free gloves to your clinical sites if they are not provided.

Please return this completed Heath Certificate and the Immunizations and Tests Form to:

St. David’s School of Nursing: Admission

Texas State University - Round Rock Campus

1555 University Boulevard

Round Rock, Texas 78665-8017

Completed 2014 Health Certificate and Immunizations and Tests Form must be received by the School of Nursing by 5PM on Friday, July 11, 2014.

5/9/2014