Shepherd


Student Information

  1. Read and complete the Student Information Packet
  2. Complete Notice Regarding Background Investigation (1 page)
    1. Complete entire form
  3. Complete Volunteers & Students/Interns Health History and Screening (3 pages)
    1. Complete top portion
    2. Complete Immunization History
      1. Tetanus Toxoid: Tetanus/Diphtheria/Pertussis (Tdap) from physical
      2. Measles/Mumps/Rubella: 1st MMR date from your physical or titer date
      3. Hepatitis B: 1st Hepatitis date form your physical or titer date
      4. Influenza: Influenza date for current year
    3. Have you had the disease: check yes or no and sign your name
    4. System Review: Check yes or no and explain all of “yes” answers and sign your name
  4. Complete Medication Form (1 Page)
    1. List all Medication, if you have none to be listed write N/A on the first line.  Sign and Date
  5. Forms to take to your Employee Health appointment: Authorization or Refusal for Recombivax-HB Vaccine, Tuberculosis Screening, TST signature page
  6. Students MUST:
    1. Contact Glenn Prescott three weeks prior to clinical start date @ 404-350-7340 to Establish your security Access log-in
    2. Contact Dot Jones three weeks prior to clinical start date @ 404-350-7630 to schedule
      • Physical
      • Drug Screening
      • Background Check - Bring Current Driver’s License & Social Security Card to appointment

AT NO CHARGE TO THE STUDENT!

 

You will not be allowed to start clinical until you are cleared by Employee Health at Shepherd’s

 

 

 

Medical Documents that must be submitted with your clinical paperwork

  1. Front and back copy of your current cpr card

    IMMUNIZATIONS

  2. PPD:
    • Negative PPD: Negative ppd within 90days   
      • If your PPD is older than 90 days you must have another PPD done and submitted with your clinical paperwork
      • Contact your health care provider or KSU clinic @ 770-423-6644 the cost is $5.00

      OR

    • Positive PPD: Chest X-ray or radiology report within the last 12 months

      OR

    • Quantiferon: Must be negative result

  3. Proof of tetanus immunization
  4. Proof of Varicella or titer value report
  5. Proof of two MMR immunization or titer value report
  6. Proof of three Hepatitis B immunization or titer value report
  7. Proof of Flu Immunization for current year 

 

Document Checklist

Notice Regarding Background Investigation (1 Page)

Volunteers & Students/Interns Health History and Screening (3 Pages)

Medication Form (1 Page)

Medical documents (listed above)

Front and back copy of your current CPR Card