KENTUCKY STATE UNIVERSITY
School of Nursing
400 EAST MAIN STREET FRANKFORT, KENTUCKY 40601
STUDENT HEALTH SCREENING FORM
STUDENT HEALTH SCREENING FORM
DEMOGRAPHIC INFORMATION | Completed by student. Please print.
Last Name First MI Age Date of Birth
First
Age
Last Name
MI
DEMOGRAPHIC INFORMATION | Completed by student. Please print.
KySU ID
Phone Number
City
State
Zip Code
KySU ID Phone Number City State Zip Code
Date of Entry
Programs (circle one): AAS BSN DNP 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
Office Stamp/Address & Phone Number