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STUDENT HEALTH SCREENING FORM

DEMOGRAPHIC INFORMATION | Completed by student. Please print.

Last Name First MI Age Date of Birth

First

Age

Last Name

DEMOGRAPHIC INFORMATION | Completed by student. Please print.

KySU ID

Phone Number

City

State

Zip Code

Date of Entry

Programs (circle one): AAS

PHYSICAL | Completed by provider

I examined the above-named student on ____/____/____. The student is found to be in good physical and mental health, is free of communicable diseases, and is able to undertake all aspects of the nursing education program (including essential functions [p. 2] without limitations.

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The student

___

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Signature with Credentials Date

Signature with Credentials

Office Stamp/Address & Phone Number

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School of Nursing

Nursing Students - Essential Functions*

FOCUS	STANDARD	REQUIRED ACTIVITIES (Select Examples)
Critical Thinking	Critical thinking ability sufficient for clinical judgment	- Identify cause-effect relationships in clinical situations - Use of the scientific method in the development of patient care plans - Evaluation of the effectiveness of nursing interventions
Inter- and Intra-professional Relationships	Interpersonal skills sufficient for professional interactions with individuals, families and groups from diverse social, emotional, cultural and intellectual backgrounds	- Establish rapport with patients/clients and colleagues - Capacity to engage in successful conflict resolution - Peer accountability
Communication	Abilities are sufficient to interact with others both verbally and written	- Explain treatments & procedures - Initiate teaching - Documentation & interpretation of nursing interventions & patient responses
Mobility	Physical abilities sufficient for movement from room-to-room and in small spaces	- Navigate client's room, workspace, & treatment areas - Perform rescue procedures
Motor skills	Gross and fine motor abilities are sufficient to provide safe, effective nursing care	- Therapeutic positions of patients - Calibration & use of equipment
Hearing	Auditory ability sufficient for monitoring and assessing health needs	- Hear monitor alarms & emergency signals - Discern auscultatory sounds & cries for help
Visual	Visual ability sufficient for observation and assessment necessary in nursing care	- Observation of patient condition & response to treatment
Tactile	Tactile ability sufficient for physical assessment	- Ability to perform palpation - Perform therapeutic interventions (e.g. catheter insertion)

FOCUS

STANDARD

Critical Thinking

Critical thinking ability sufficient for clinical judgment

Inter-and Intra-professional Relationships

Communication

Abilities are sufficient to interact with others both verbally and written

Mobility

Physical abilities sufficient for movement from room-to-room and in small spaces

Motor skills

-Therapeutic positions of patients -Calibration & use of equipment

Hearing

Auditory ability sufficient for monitoring and assessing health needs

Visual

Tactile

Tactile ability sufficient for physical assessment

Adopted from the SREB Council on Collegiate Education for Nursing Core Performance Standards

*If you believe that you cannot meet one or more of these standards without accommodations or modifications, it is your responsibility to request appropriate assistance and guidance from the faculty.