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
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