===== PAGE 1 ===== ## STUDENT HEALTH SCREENING FORM ### DEMOGRAPHIC INFORMATION | Completed by student. Please print

Last Name	First	MI	Age	Date of Birth
KySU ID	Phone Number	City	State	Zip Code
Programs (circle one): AAS	BSN	DNP	Date of Entry:

## 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. ___ Signature with Credentials Date Office Stamp/Address & Phone Number

===== PAGE 2 ===== # School of Nursing ## Nursing Students - Essential Functions*

FOCUS	STANDARD	REQUIRED ACTIVITIES\n(Select Examples)
Critical Thinking	Critical thinking ability sufficient for clinical judgment	- Identify cause-effect relationships in clinical situations\n- Use of the scientific method in the development of patient care plans\n- 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\n- Capacity to engage in successful conflict resolution\n- Peer accountability
Communication	Abilities are sufficient to interact with others both verbally and written	- Explain treatments & procedures\n- Initiate teaching\n- 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\n- Perform rescue procedures
Motor skills	Gross and fine motor abilities are sufficient to provide safe, effective nursing care	- Therapeutic positions of patients\n- Calibration & use of equipment
Hearing	Auditory ability sufficient for monitoring and assessing health needs	- Hear monitor alarms & emergency signals\n- 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\n- Perform therapeutic interventions (e.g. catheter insertion)

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.