Rev Date: 1/2019 Page 1 www.cpcc.edu

Student Health Record for Health Career Programs

Welcome! We are glad that you have chosen to enter one of CPCC’s outstanding health programs and look forward to working with you as you prepare for your career in healthcare.

A crucial step in this process is the completion of your Student Health Record, which is required for all students to participate in clinical training. Below are detailed instructions and information on how to complete this requirement.

Submission of Student Health Record Documentation

CPCC has partnered with CastleBranch to maintain and track the student health records, facilitate drug screens, and conduct criminal background checks.

Students must set up an account with CastleBranch. To do so:

Go to http://portal.castlebranch.com/CP18 and select “Place Order”

Select the appropriate health program from the list of programs and complete all information

Pay the $97 fee for the package which includes a criminal background check, drug screen, and immunization record tracker

Use the email address and password selected during the account set-up process to complete additional steps

Once the account is set up, students can submit required documents to CastleBranch one of three ways:

Scan and Upload via CastleBranch Secure Website

Utilizing the myCB iPhone App

Fax Documents as Instructed on Cover Sheet (cover sheets obtained through CastleBranch secure website)

For questions regarding: Uploading Documentation: Required Health Documentation:

CastleBranch Service Desk 888-914-7279

For CYT, DA, DH, HIT, MA, MLT, OMA, OTA, PHM, or PTA: Charlene James Central Campus, Belk 1105B 704-330-2722 ext 3029 charlene.james@cpcc.edu

For CVT, NA, Nursing, RCP, or SUR:

Patrice Williams Central Campus, Belk 1105C 704-330-6163 patrice.williams@cpcc.edu

Rev Date: 1/2019 Page 2 www.cpcc.edu

Criminal Background Check Requirements

Please note that all students must complete a criminal background check as a requirement from our clinical agencies.

Once students set up an account with CastleBranch, follow instructions for completing the criminal background check as part of the CastleBranch package.

For any questions about this requirement, please contact the designated Medical Records Specialist per the contact information on Page 1.

Drug Screen Requirements

CPCC adheres to the policies and procedures of all clinical facilities with which the health programs are affiliated for student clinical learning experiences. These policies and procedures address the requirement for a drug screen and circumstances when policies are not followed.

Once students set up an account with CastleBranch, please follow the following steps:

Follow the instructions in CastleBranch to locate the specified Lab Corp locations for completing the

drug test. Please note:

The Lab Corp location listed is based on your zip code.

Not all Lab Corp locations are participating with CastleBranch.

Schedule an appointment.

Print out the registration form provided.

On the day scheduled for the drug screen, take the registration form and a picture ID with you to the

testing site.

The charge for the drug screen is included in the package fee for the Immunization Tracker.

The 12 Panel Drug Screen includes: Amphetamines

Barbiturates

Benzodiazepine

Cannabinoid

Cocaine

Ecstasy (MDMA)

Methadone

Methamphetamines

Opiates

Oxycodone

Phencyclidine (PCP)

Propoxyphene

Positive drug screen due to prescribed medications

A positive drug screen due to prescribed medications must be substantiated by documentation from the physician ordering the medications.

Positive drug screen due to non-prescribed drugs

A positive drug screen due to non-prescribed drugs will result in the student being ineligible to participate in a clinical experience. The student will be withdrawn from the program.

Rev Date: 1/2019 Page 3 www.cpcc.edu

Physical Examination

Examination by Healthcare Provider

Only a physician, physician assistant, or nurse practitioner shall perform the physical examination.

Students must print out page 9 and bring to the exam for healthcare provider to complete.

Upload completed form to CastleBranch.

Hearing and Color Vision Tests Hearing and vision tests must be included as part of the physical examination. The vision test must include a color vision test due to clinical skills where visualization of color is necessary to patient care.

Signatures/Facility Stamp The Physical Examination and Immunization Record forms must include the healthcare provider’s signature and the address/phone number or facility stamp.

Health Insurance Requirement

Required Coverage All students must submit proof of health insurance coverage. There is no minimum coverage amount required. The coverage must:

Be in effect by the first day of class.

Be maintained throughout enrollment in the program of study.

Be updated by the student in CastleBranch when the coverage changes and/or expires and is renewed.

Acceptable Sources Acceptable sources of health insurance include (but are not limited to):

Medicaid

Affordable Care (healthcare.gov)

Military Insurance (Tri-Care)

Blue Cross Blue Shield

Aetna

Cigna

United Healthcare

Sliding scale programs and family planning plans are not accepted as insurance.

Program Essential Functions/Competencies

The program’s Essential Functions form provides a list of competencies which students must be able to perform. This form must be signed and uploaded to your CastleBranch account.

Rev Date: 1/2019 Page 4 www.cpcc.edu

Vaccination and Titer Requirements

The following vaccinations and titers (blood test to prove immunity) are required. All records/reports must be verified with a healthcare provider’s signature or stamp in the same manner as the physical examination (page 3). Please note when uploading these documents:

The documentation must be uploaded under each of the titled requirements.

When a series of vaccinations is needed, the first vaccination document should be uploaded then, upon the next vaccination being completed, the current vaccination documentation should be uploaded with the previous vaccination document.

Required Vaccination/Titer Requirements

Tdap (Tetanus, Diphtheria, Pertussis)

Documentation of Tdap vaccination within the past 10 years, or

Tetanus/diphtheria vaccination and Pertussis titer

(Note: A Negative titer will require a Tdap vaccination)

MMR (Measles, Mumps, Rubella)

Documentation of 2 MMR vaccinations, or

Measles/mumps/rubella titers

(Note: A Negative titer will require 1 MMR vaccination)

Hepatitis B (HepB) Documentation of 3 HepB vaccinations and HepB antibody titer

(Note: A Negative titer will require the HepB vaccination series)

If you have not received the HepB vaccination, begin the vaccination series now.

Special Note: Positive HIV and Hepatitis B Infected North Carolina State Law Section 15A NCAC 19A.0207 (Positive HIV and Hepatitis B Infected)

This law addresses HIV and Hepatitis B infected Health Care Workers (THIS INCLUDES STUDENTS IN HEALTH PROGRAMS.)

Excerpt: “(b) All health care workers who perform surgical or obstetrical procedures or dental procedures and who know themselves to be infected with HIV or Hepatitis B shall notify the State Health Director.....The notification shall be made in writing to the Chief, Communicable Disease Control Section, 1902 Mail Service Center, Raleigh, NC 27699-1902.”Where applicable: CPCC students are required to comply with this notification to the Chief, Communicable Disease Control Branch

Varicella (Chicken Pox) Varicella titer (Note: A Negative titer will require a series of two vaccinations one month apart)

Tuberculin Skin Test (PPD) Two-Step PPD completed 2-4 weeks apart, or

Documentation of 2 PPDs completed within the last 12 months, or

QuantiFeron Gold blood test, or

Documentation of chest x-ray within last 5 years with current TB health screening if previously received BCG vaccination (Request form from Medical Record Specialist)

(Note: A Positive PPD result will require a chest x-ray)

Annual PPD (or TB screening if applicable) will be due within 12 months

Seasonal Influenza Influenza vaccination is mandatory (Religious/medical exemption forms are available) and are available beginning in September of each year.

Students will be denied clinical rotation if documentation is not provided prior to clinicals.

Rev Date: 1/2019 Page 5 www.cpcc.edu

STUDENT HEALTH RECORD FOR HEALTH CAREER PROGRAMS

PART I: AUTHORIZATIONS

SECTION A: AUTHORIZATION FOR DISCLOSURE: CPCC INTERNAL RELEASE

All medical records, physical examination results, reasonable accommodation request forms, or other medical information must be collected on separate forms, maintained in separate medical files kept apart from a student's general educational records, and treated as confidential in accordance with the Rehabilitation Act of 1973 and the Americans with Disabilities Act.

As indicated by my signature below, I consent to disclosure of the medical, criminal background check and, if applicable, FBI information to administrators, Division Directors, Program Chairs, and other college officials involved in a request for reasonable accommodation or evaluation of qualifications for or performance in a course, program, service, activity or for purposes of implementing and enforcing necessary restrictions and accommodations; and for First Aid and safety personnel if a known disability may require emergency treatment.

By signing below, I authorize Central Piedmont Community College and the Division to release and disclose any and/or all pertinent medical information as indicated in the above provision.

I also authorize the release and disclosure of pertinent medical information by Central Piedmont Community College to the Division officials and/or Faculty who need to be aware of medical conditions that may require special needs. I understand that if I refuse to release my medical information to CPCC officials/faculty, I may lose my eligibility to continue as a student in CPCC's Health Programs.

Student Signature Date

Student’s Printed Name Student ID Program

SECTION B: MEDICAL RECORDS RELEASE OF INFORMATION TO OFF-CAMPUS CLINICAL FACILITIES Off-campus clinical facilities may require medical information on students in programs with clinical assignments. Central Piedmont Community College is responsible for providing the clinical facility with medical data abstracted from the student’s medical record. This data may include vaccinations received, medical test results and drug screen results. The facility may also require that the student provide a copy of their medical packet.

By signing below, I authorize Central Piedmont Community College and the Division to release and disclose any and/or all pertinent medical information as indicated in the above provision, to an affiliating clinical facility which may require this information as a condition of my assignment to the facility. I understand that if I refuse to release my medical information to CPCC officials/clinical facilities, I may lose my eligibility to continue as a student in CPCC's Health Programs. I further understand that failure to release the records may result in the facility denying my clinical assignment. I also understand that I may not be able to fulfill the Program's graduation requirements.

Student Signature Date

Student’s Printed Name Student ID Program

Rev Date: 1/2019 Page 6 www.cpcc.edu

SECTION C: HEPATITIS B VACCINATION ACCEPTANCE

If you have previously completed the HepB series of vaccinations:

1. I completed the HepB vaccination series on (date), and will provide

documentation to validate this.

I can provide evidence of a positive HepB Surface Antibody titer dated .

(Submit titer lab report.)

2. I completed the HepB series previously. I am unable to provide documentation of the

dates of the vaccinations or evidence of a positive antibody titer.

I will now complete the HepB Surface Antibody titer test and submit a copy of the lab

report.

Student Signature Date Program

If you have not previously completed the HepB series of vaccinations or have a negative titer:

1. I, understand that due to my status as a student in a

health program there is a high risk of occupational exposure to blood and/or other potentially

infectious materials. I further understand that I am also at a greater risk of acquiring Hepatitis B virus

(HBV) infection as the result of my exposure to blood and/or other potentially infectious materials. I

have been informed about Hepatitis B and the Hepatitis B vaccine that is available.

2. I, agree to receive the Hepatitis B Vaccination series.

I understand that this vaccination is a series of three (3) doses administered in the following sequence:

initial dose; second dose one month later; and the third dose administered six months from the first

dose (or five months from the second dose). I understand that official documentation must be

submitted immediately following the administration of each Hep. B vaccination. I also understand that

if I decide, at any time, to discontinue the vaccination series I must sign a declination form

immediately. Furthermore, I understand that if the Hepatitis B vaccination becomes medically

contraindicated (e.g. pregnant or have reaction to the vaccine) a Hepatitis B vaccination declination

form must be signed. The declination form will be kept in the student’s health records.

Student Signature Date Program

Rev Date: 1/2019 Page 7 www.cpcc.edu

PART II: REPORT OF FAMILY AND PERSONAL MEDICAL HISTORY

To be completed by student – Please type or print in black ink

Last Name First Name Middle Name Student ID

Address City State ZIP Home Phone Number

Cell Phone Number Email Address Date of Birth Gender

Have you previously been enrolled in a Health Careers program?

If so, please list dates/program:

Semester Entering (choose one):

Insurance: Please upload copy of insurance card with this section

Hospital/Health Insurance (Name and Address of Company) Phone Number of Insurance Company

Name of Policy Holder Employer

Is this an HMO/PPO/Managed Care Plan?

Policy or Certificate Number Group Number

Name of Person to Contact in Case of an Emergency Relationship

Address Phone Number

Family and Personal Health History The following health history is confidential, does not affect your admission status and, except in an emergency situation or by court order, will not be released without your written permission. Please attach additional sheets for any items that require a more detailed explanation.

Height: Weight:

Has any person, related by blood, had any of the following:

Yes No Relationship Yes No Relationship Yes No Relationship

High Blood Pressure Diabetes Alcohol/Drug Problems

Stroke Glaucoma Psychiatric Illness

Heart Attack before age 55

Blood or Clotting Disorder

Suicide

Cholesterol or Blood Fat Disorder

Cancer (if yes, please indicate type to the right)

Type of cancer

Have you ever had or have you now: (please select at the right of each item and if yes, indicate year of first occurrence)

Yes No Year Yes No Year Yes No Year Yes No Year

High Blood Pressure Hay Fever Jaundice or Hepatitis Kidney Stone

Rheumatic Fever Allergy Injection Therapy Rectal Disease Protein or Blood in Urine

Heart trouble Arthritis Severe or recurrent abdominal pain

Hearing loss

Pain or pressure in chest Concussion Hernia Sinusitis

Shortness of breath Frequent or severe headache

Easy fatigability Severe menstrual cramps

Asthma Dizziness or fainting spells Anemia or Sickle Cell Anemia

Irregular periods

Pneumonia Severe head injury Eye trouble besides needing glasses

Sexually Transmitted Disease

Chronic cough Paralysis Bone, joint, or other deformity

Blood transfusion

Head or neck radiation treatments

Disabling Depression Knee problems Alcohol use

Malaria Excessive worry or anxiety Recurrent back pain Drug use

Thyroid trouble Ulcer (duodenal or stomach)

Neck injury Anorexia/Bulimia

Diabetes Intestinal trouble Back injury Smoke 1+ pack of cigarettes/week

Serious skin disease Pilonidal cyst Kidney infection Regularly Exercise

Mononucleosis Frequent vomiting Bladder infection Wear Seat Belt

Tumor or Cancer (if yes, specify below)

Gall bladder trouble or gallstones

Broken Bones (if yes, specify below)

Other (if yes, specify below)

Rev Date: 10/2018 Page 8 www.cpcc.edu

Student Name Program

PART II: REPORT OF FAMILY AND PERSONAL MEDICAL HISTORY, cont. Please list any drugs, medicines, birth control pills, vitamins, and minerals (prescription and nonprescription) you use and indicate how often you use them.

Name Use Dosage Name Use Dosage

Name Use Dosage Name Use Dosage

Name Use Dosage Name Use Dosage

Select “Yes” or “No” for each item. Every item answered “Yes” must be fully explained in the space on the right (or on an attached sheet) including an explanation of the type of reaction, your age when the reaction occurred, and if the experience has occurred more than once.

Have you ever experienced adverse reactions (hypersensitivities, allergies, upset stomach, rash, hives, etc.) to any of the following?

Adverse Reactions to: Yes No If Yes, Please Explain As Stated in Instructions Above

Penicillin

Sulfa

Other antibiotics (if yes, specify to the right)

Aspirin

Codeine or other pain relievers

Other drugs, medicines, chemicals, Latex (if yes, specify to the right)

Insect bites

Food allergies (if yes, specify to the right)

For each of the following questions, if you answer “Yes”, please describe fully in the space on the right.

Yes No If Yes, Please Explain As Stated in Instructions Above

Do you have any conditions or disabilities that limit your physical activities?

Have you ever been a patient in any type of hospital? (If yes, please specify when, where, and why to the right)

Has your academic career been interrupted due to physical or emotional problems?

Is there loss or seriously impaired function of any paired organs?

Other than for a routine check-up, have you seen a physician or health-care professional in the past six months?

Have you ever had any serious illness or injuries other than those already noted? (If yes, please specify when and where to the right)

Statement by Student (or Parent/Guardian, if Student is Under Age 18):

(A) I have personally supplied (reviewed) the above information and attest that it is true and complete to the best of my knowledge. I understand that the information is strictly confidential and will not be released to anyone without my written consent, unless otherwise permitted by Court order and/or law.

(B) If I should be ill or injured or otherwise unable to sign the appropriate forms, I hereby give my permission to the institution to release information from my medical record to a physician, hospital, or other medical professional involved in providing me (him/her) with emergency treatment and/or medical care.

Signature of Student Date

Signature of Parent/Guardian, if Student is Under Age 18 Date

Rev Date: 10/2018 Page 9 www.cpcc.edu

PART III: PHYSICAL EXAMINATION To be completed and signed by physician or clinic – Please print in black ink - All sections required except where noted

Last Name First Name Middle Name Student ID

Address City State ZIP Home Phone Number

/ / /

Date of Birth Height Weight TPR BP

Vision: Corrected Right 20 / Left 20 / Urinalysis: (optional)

Uncorrected Right 20 / Left 20 / Sugar: Albumin: Micro:

Color Vision

Hearing: (gross) Right Left

15 ft. Right Left

Are there abnormalities? Normal Abnormal Description of Abnormalities (Please describe fully; attach additional sheets)

1. Head, Ears, Nose, Throat

2. Eyes

3. Respiratory

4. Cardiovascular

5. Gastrointestinal

6. Hernia

7. Genitourinary

8. Musculoskeletal

9. Metabolic/Endocrine

10. Neuropsychiatric

11. Skin

12. Mammary

A. Is there loss or seriously impaired function of any paired organs? Yes No

Explain

B. Is student under treatment for any medical or emotional condition? Yes No

Explain

C. Recommendation for physical activity (physical education, intramurals, etc.) Unlimited Limited

Explain

D. Is student physically and emotionally healthy? Yes No

Explain

Final Health Assessment: Must be completed by the MD, PAC, or FNP doing the physical examination

Based on my assessment of this student’s physical and emotional health on (date), he/she appears able to participate in the activities

of a health professional in a clinical setting. Yes No

If no, please explain:

Signature of Physician/Physician Assistant/Nurse Practitioner (Include Title) Date

Print Name of Physician/Physician Assistant/Nurse Practitioner Phone Number

Required: Office Address or Facility Stamp City State Zip

Rev Date: 10/2018 Page 10 www.cpcc.edu

Student Name Date of Birth

PART IV: IMMUNIZATION RECORD To be completed and signed by physician or clinic – Please print in black ink – A complete immunization record from a physician or clinic should be submitted with this form

Section A: Required Immunizations Mo/Day/Year (#1)

Mo/Day/Year (#2)

Mo/Day/Year (#3)

Mo/Day/Year (#4)

DPT or Td (Must have total of 3)

Tdap

OR Td booster AND Pertussis titer

Measles (2 MMR)(After 1st birthday)

ATTACH TITER LAB REPORTS

Measles(Disease date not Accepted)

Titer Date & Result

Mumps(Disease date not Accepted)

Titer Date & Result

Rubella(Disease date not Accepted)

Titer Date & Result

NOTE: Negative MMR Titer RESULTS Requires 1 MMR vaccination

Section B: Recommended Immunizations (The following immunizations are recommended for all students and may be REQUIRED by certain colleges or departments)

REQUIRED BY CPCC

Hepatitis B Series REQUIRED for all students in Health Programs at CPCC. HepB titer test required upon completion of series.

Date (#1) Date (#2) Date (#3) HepB Surface Antibody titer Date/results ATTACH LAB REPORT

NEGATIVE TITER RESULTS: Require 3 vaccinations

Date (#1) Date (#2) Date (#3) No repeat titer is required

Varicella IgG Titer Test REQUIRED for all students in Health Programs at CPCC. Varicella series of two doses REQUIRED if not immune to chicken pox.

n/a n/a (Disease date not Accepted)

Varicella IG titer ATTACH LAB REPORT

NEGATIVE Titer RESULTS: Require 2 vaccinations

Vacc. #1 Vacc. #2 n/a No repeat titer is required

Second C: Tuberlin Skin Test

2-STEP PPD is required PPD #1 Date PPD #1 Date Read and Results PPD #2 Date PPD #2 Date Read and Results

QuantiFeron Gold Test Date Results Date (Annual) Results (Annual)

Annual PPDs PPD Date PPD Date Read and Results PPD Date PPD Date Read and Results

Chest x-ray required, if positive PPD or History of BCG vaccination

CXR Date CXR Results

TB Screening every 12 months after Chest x-ray

TB Screening Date Results TB Screening Date Results

Section C Other Immunizations Date rec’d

Seasonal Influenza

Signature of Physician/Physician Assistant/Nurse Practitioner (Include Title) Date

Print Name of Physician/Physician Assistant/Nurse Practitioner Phone Number

Required: Office Address or Facility Stamp City State Zip