Application Checklist

Application Checklist

Student Name:

Acknowledgement of Completion:

 Program application form

 Community service form

 Admission advisement certificate of attendance

 Job shadow form

 Criminal background check disclosure/consent form

 Review and self-assessment of performance standards

American Heart Association BLS/AED for Healthcare Providers certification achievement card to be completed after admission

 Health certification requirements:

  • Immunizations:
    • MMR immunizations 1 and 2 or rubella titer
    • Rubeola immunization or titer
    • Chicken pox – proof of having chicken pox or chicken pox immunization per authorized medical signature or varicella titer
    • Influenza immunization
    • Meningitis immunization
  • TB skin test – to be completed after admission to the program
  • Hepatitis B vaccination (series of 3) Signed verification of Hepatitis B status or declination
  • DTAP – Diphtheria, tetanus and pertussis immunization within the last 10 years
  • Influenza immunization - to be completed in season no later than November 1.

    All requirements are subject to change based on clinical affiliate requirements.