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Dear Student,
Pursuant to the Abraham S. Fischler College of Education (FCE) Student Grievance
Procedure, the Grievance Form is for use in filing a grievance when a satisfactory
resolution is not achieved through a formal appeal. Please note that this form and any
supporting documentation must be properly completed, received, and on file in the
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correspondence disclosing the appeal committee's decision, otherwise, the grievance
will no longer be eligible for review. Students are encouraged to submit the Grievance
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Cardinal Station Newburg Center for Primary Care
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UofL Department of Family & Geriatric Medicine
Dear New Patient,
Welcome to your University of Louisville Physicians Family practice! We
are offering patient-centered medical care and are enthusiastic about our
relationships with our patients. In order to better serve your needs, we are
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The first sheet will help us learn more about you; please completely fill out this
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completely fill that out for our doctors to treat you to the best of their ability; it
gives us permission to review your medical records from your previous primary
medical facilities.
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you have received and understand our Privacy Policies. Finally, the last form is the
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your name at the bottom of the letter.
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your office visit. Please bring in any and all medication you take, in their
original bottles, to your appointment.
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adult and will need to bring a copy of their current immunization certificate.
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We look forward to seeing you!
University of Louisville Physicians
UofL Family and Geriatric Medicine

CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 1 PROGRAM AND HEALTH REQUIREMENTS FOR BSN STUDENTS Advancing Excellence in Nursing Professionals Cleveland State University CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 2 Dear Nursing Student, Congratulations on your acceptance into Cleveland State University's School of Nursing. You have worked hard to prepare for this rigorous program and you should be proud of what you have accomplished—we certainly are. In my opinion, which may not be totally objective, nursing is the most challenging, exciting, and rewarding profession. We are so glad that you have decided to make it your career path and will help and support your efforts as you work to achieve your goal. Cleveland State is committed to Engaged Learning, and the School of Nursing excels at just that. Our program includes experiences in the classroom, the lab, and in a great variety of clinical sites. You will have the opportunity to learn and provide patient car e in many excellent hospitals and community health agencies in the Greater Cleveland area. These experiences are vital to your learning the art and science of being a professional nurse. With this opportunity comes a personal responsibility to adhere to the requirements expected in the health care setting. This packet summarizes the data that all nursing students must provide before being allowed to participate in clinical experiences. The many agencies with which the School of Nursing partners to provide an outstanding learning environment for you have set these requirements for your protection as well as for the patients you will encounter. Please be aware of deadlines for all, not just now as you are beginning, but throughout the program. CSU cannot allow you into an agency if your data is not on file or is outdated/expired. Inability to complete clinical experiences can result in your not progressing through the program. Please notify us if you have any questions or conc erns about this packet. We look forward to providing you with an outstanding educational experience. If you put forth the effort required, you will learn to become an excellent professional nurse. I will you all the best in your journey. Sincerely, Vida B. Lock, Ph.D., RN Dean Mailing Address: 2121 Euclid Avenue, JH 238 Cleveland, Ohio 44115-2214 Campus Location: Julka Hall, Room 238 2485 Euclid Avenue (216)687-3598 CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 3 PROGRAM AND HEALTH REQUIREMENTS FOR STUDENTS This packet contains information and forms which must be completed. Please adhere to the appropriate deadlines for submission of the forms to the School of Nursing: o Basic BSN Program (Early Decision) – Before May 15th o Basic BSN Program – Before June 15th o Accelerated BSN Program – Before October 30th o RN to BSN Fall Program – Before September 30th o RN to BSN Spring Program – Before January 30th • Student Handbook:  Go to the School of Nursing Home page at www.csuohio.edu/nursing  Download the Undergraduate Student Handbook and read completely Print and sign the following sheets:  Memorandum of Understanding  Informed Consent • Program and Health Documentation Required: Ability to Perform Nursing Tasks Health Examination Medical Forms Varicella (Chicken Pox) Titer Tuberculin Mantoux Skin Test or Chest X-Ray Verification Hepatitis B Titer Vision Screening Dental Exam Form (optional but recommended) • Other Information Required: Health Insurance Verification Automobile Information Fingerprinting and Background Check Information CPR Certification Information Agency Confidentiality and related forms Uniform – Dress Code Requirements 1. Before you submit the documents indicated above- make a copy for your records. 2. Faxed documents cannot be accepted. 3. NOTE: The original documentation should be submitted to the School of Nursing The CSU Health & Wellness Services Department provides medical services and i mmunizations inexpensively and most health insurance is accepted. For an appointment, please call 216/687-3649. The Department is located at 2112 Euclid Avenue, Room 205 CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 4 Ability to Perform Nursing Tasks Please consider carefully any physical limitations you might have. If you have a diagnosed disability that may prevent you from carrying out any of these physical expectations, please discuss your situation with the School of Nursing Undergraduate Program Director/Advisor. Students who enter the program do so with the understanding that they will be expected to meet course requirements, with or without any reasonable accommodations. Students who have a disability will be referred to the Office of Disability Services for determination of the reasonable accommodation that can be made.* Inability to carry out any of these activities while in the program may prevent completion of the program. Students – Please place a checkmark next to the items that you are unable to perform. _____1. Work for hours in a standing position and do frequent walking and stair climbing. _____2. Independently lift and transfer an adult patient up to 6 inches from a stooped position; then, push or pull the adult up to 3 feet. _____3. Independently lift and transfer an adult patient while you move from a stooped to an upright position to accomplish bed-tochair and chair-to-bed transfers. _____4. Physically apply up to 10 pounds of pressure to bleeding sites or in performing CPR. _____5. Immediately respond and react to auditory instructions/requests, monitor equipment and perform auditory auscultation without auditory impediment. _____6. Perform a clinical/laboratory experience for up to 12-hour duration, including standing for up to 4 hours straight at a time. _____7. Perform close and distant visual activities involving objects, persons, and paperwork, as well as discriminate depth and color perception (If need accommod ation, i.e. glasses or contacts, check line). _____8. Discriminate between rough/smooth and hot/cold when using hands. _____ 9. Manipulate small objects in precise movements; for example, prepare and administer injectable medications. _____10. Communicate intelligibly, both orally and in writing. _____11. Use products containing natural rubber latex due to allergy. STUDENT STATEMENT – PLEASE SIGN ONE OF THE FOLLOWING STATEMENTS: 1. I am able to perform the unchecked tasks without accommodation. Student Signature _____________________________________________ Date _________________ 2. I am able to perform the checked tasks only with accommodation. Student Signature _____________________________________________ Date _________________ If you have a disability that requires accommodation, please have your physician/nurse practitioner verify the disability. PHYSICIAN STATEMENT I have examined the above student and hereby verify that she or he has a physical disability (# ______ above) that will require accommodations in order to carry out activities. Physician/Nurse Practitioner Signature ____________________________________________________ Physician/Nurse Practitioner Name ________________________________ Date _______________ (Please print name) This information must be legible and include professional credentials. * The University Office of Disability Services will determine if an accommodation is reasonable in accordance with applicable law. To be completed by a physician/nurse practitioner. Please return to: School of Nursing 2121 Euclid Avenue, JH 238 Cleveland, OH 44115-2214 CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 5 Health Examination Medical Form A physical examination is required for all students upon admission to the Nursing Program. The student may have a physical examination performed by his/her private physician/nurse practitioner or at CSU Health & Wellness Services Department. Complete this page and give to your physician/nur se practitioner when the physical examination is done. This information will be treated confidentially. Last First M. I. CSU I.D. Number Street Address: (City) (State) (Zip) ( ) ( ) _____/ _____ /_____ (Home Phone with Area Code) (Cell Phone with Area Code)( (Date of Birth) HEALTH HISTORY (COMPLETE BEFORE VISIT WITH PHYSICIAN/NURSE PRACTITIONER) Have you had, or do you now have, any of the following: (Please check all YES answers.) Allergies High Blood Pressure Scarlet Fever Anemia Joint Pains Seizures Asthma Kidney Pain Shortness of Breath on Exertion Cancer Liver Disease Sickle Cell Disease/Trait Cold Sores (frequent) Migraine Headaches Strep Throat Cough (persistent) Mononucleosis Stroke Diabetes Psychological/Psychiatric Problems Heart Trouble Rheumatic Fever Do you use tobacco in any form? If yes, specify type: _________________________ Amount: ________________ Do you have any physical impairment that limits your activity? No Yes (If yes, please explain) _______________ _________________________________________________________________________ Do you have any other health or medical problems not listed? No Yes (If yes, please explain) ________________________________________________________________________________________ Are you presently taking any kind of medication(s) No Yes (If yes, name drug(s) and how often taken) ________________________________________________________________________________________ Do you have any allergies (food, medicine, environmental)? No Yes (If yes, please list) I hereby certify that I have read and understand all of the above questions, and have responded to them to the best of my knowledge. I also consent to the release of medical information to the Program and clinical site. _____________________________________________________ ________________________ Student's Signat CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 6 Student Name: _________________________________________ CSU I.D. Number: _____________ _____________ Date: ____________________ PHYSICAL EXAMINATION *ABNORMAL HEIGHT WEIGHT PULSE B/P General Appearance PHYSICIAN'S NOTE ON PHYSICAL & SUMMARY OF SIGNIFICANT FINDINGS*Abnormal finds must have documentation. Skin Eyes, include Fundus Ears /Hearing Nose/Sinuses Mouth, Throat Neck, include Thyroid Chest, include Breasts Heart Vascular System Lymphatic System Abdomen, Include Inguinal Genitourinary System Nervous System Extremities Spine, Other Musculoskeletal Anus, Rectum DISTANT VISION URINE HEARING Right 20/___ Corrected to 20/___ Left 20/___ Corrected to 20/___ Both 20/___ Corrected to 20/___ Glucose Protein Right: Passed Left: Passed Failed Failed IMMUNIZATIONS/INFECTIOUS DISEASE EVALUATION – REQUIRED Polio Date: ___ / ___ / ___ and Type of Original Full Series: _____________________________________________ Polio Booster Date:: ___ / ___ / ___ Tetanus/Diphtheria – Boosters required every 10 years. (Original Series may be DPT or Td) Date of Original Series _ ____________________________ Date of Last Boster _________________________ Tuberculin (TB) Skin Test . . . . . . . . Complete Form on Page 9 *TB (Mantoux Only..... 2 Step Process) NOTE: Chest x-ray required if Mantoux positive (CHEST X-RAY: Date & Results) Hepatitis B . . . . . . . . . . . . . . . . . . . . Complete Form on Page 10 MMR (Measles, Mumps, Rubella) . . . . . . Complete Form on Page 10 Varicella . . . . . . . . . . . . . . . . . . . . . . Complete Form on Page 8 Seasonal Flu – Required . . . . . . . . By October 15th, Complete Form on Page 10 ____________________________________________________________________________________________________________________________ Physician/Nurse Practitioner's Name (Please Print) Office Address City, State Zip Code This information must be legible and include professional credentials. _________________________________________________________________________________________________________________________________ Examining P hysician or Nurse Practitioner Signature Date Phone # including area code Place Physician's Office Stamp in the Box on the Right for Validation*: *An Official Letter from the Physician/Nurse Practitioner detailing the above may be substituted for a validation stamp. CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 7 IMMUNIZATION STATUS – Students must provide documentation of satisfactory immunization status for the following: a. Polio Vaccine – If the student received a polio vaccine either on a sugar cube or in a paper cup on the National Sabin Sundays, and received three doses of vaccine, the student has been immunized (the year was 1962 and the type was "Sabin Oral"). Documentation of either the original vaccine or a booster is required to show immunity. The booster is also available through the County Board of Health. b. Tetanus-Diphtheria Toxoid - Most students will have completed their original DPT (Diphtheria, Pertussis or "Whooping Cough" and Tetanus) series d uring their childhood. If the student was older than six years, the primary immunization series required three injections of TD. The date of completion of either series and the date of a TD (Tetanus-Diphtheria) booster within the past ten years must be recorded on the Health Examination Form Please indicate number of immunizations received in the series and dates of the boosters. If the student is due for a TD booster at this time, he/she should have it administered at least two month prior to classes, with the scheduled date of the immunization noted on the form. c. MMR (Measles, Mumps, Rubella) –Students must show proof of a positive titer. If titer is negative, student must be re-immunized and retested with blood titer results showing immunity recorded on the Measles, Mumps, Rubella Form. Rubella also known as German Measles Rubeola also known as English Measles d. Varicella - Students are required to submit proof from a physician or health institution of having a posit ive titer. If titer is negative, student must be re-immunized and retested with result recorded on the Verification of Having Varicella (Chicken Pox) Illness, Immunization, and Blood Titer Test Form. e. TB Mantoux Test - The two-step TB Mantoux Test report is required for all students admitted to the Nursing Program and a one-step is required for every subsequent year in the program. A physician will determine the appropriate follow-up for positive results. The results of the TB Mantox Test or Chest X-Ray should be indicated on the TB Mantoux Skin Test or Chest X-Ray Form. The PPD and/or Chest X-Ray can be administered by your private physician or at the County Tuberculosis Clinic located on the ground floor of the Bell Greve Building at Cleveland MetroHealth Medical Center. The telephone number is (216) 778 - 8305. An appointment is required. The PPD is also available at the CSU Health & Wellness Services Department. f. Hepatitis B – The School of Nursing requires that al l nursing students receive the Hepatitis B Vaccine. This is to be administered as a series of three. The date of each dose is to be recorded on the Verification of Completed Hepatitis B Immunization Form and submitted after each injection. Documentation of a positive titer is required to show immunity. The vaccine is also available at the CSU Health & Wellness Services Department. g. Seasonal Influenza (Flu Shot) Vaccination - The Centers for Disease Control established the requirement that anyone working in any health care setting must receive a Flu Shot every year. Documentation must be recorded on the Seasonal Influenza (Flu Shot) Vaccination Form and submitted by October 15th ANNUALLY to be qualified to continue or begin clinical. CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 8 To be completed by physician or nurse. Please return to: School of Nursing 2121 Euclid Avenue, JH 238 Cleveland, OH 44115-2214 HEPATITIS B IMMUNIZATION Student Name: CSU ID Number: Have you com pleted a series of Hepatitis B immunization? 1. If so, have a titer drawn and complete the following: Titer Result: Positive Negative Physician/Nurse Practitioner Name & Credentials (Please Print): (Date of Titer) (Physician/Nurse Practitioner Signature) Place Physician's Stamp in the Above Box for Validation* If your results are positive, you are done! 2. If not, one full series of re-immunization is required followed by a second titer to confirm immunization. Place Physician's Stamp in this Box for Validation* 1st Vaccination Date Physician/Nurse Practitioner Signature Place Physician's Stamp in this Box For Validation* 2nd Vaccination Date Physician/Nurse Practitioner Signature Place Physician's Stamp in this Box For Validation* 3rd Vaccination Date Physician/Nurse Practitioner Signature 3. Upon completion of the full series, a second titer to confirm immunization is required. Titer Result: Positive Negative Physician/Nurse Practitioner Name & Credentials (Please Print): (Date of Titer) (Physician/Nurse Practitioner Signature) Place Physician's Stamp in the Above Box for Validation* 4. Please note, if the titer remains negative, the physician/nurse practitioner will need to determine follow up as appropriate and provide the School of Nursing with the plan. * * * EVIDENCE OF EACH DOSE/TITER RESULT MUST BEAR A VALIDATION STAMP AND BE SUBMITTED TO THE SCHOOL OF NURSING ONCE IT IS ADMINISTERED. *An Official Letter from the Physician/Nurse Practitioner detailing the above may be substituted for a validation stamp. CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 9 To be completed by physician or nurse. Please return to: School of Nursing 2121 Euclid Avenue, JH 238 Cleveland, OH 44115-2214 MEASLES MUMPS RUBELLA (MMR) IMMUNIZATION Student Name: CSU ID Number: Have you received your MMR immunization? 1. If so, have a titer drawn and complete the following: If your results are positive, you are done! 2. If any of the results are negative, r e-immunization is required followed by a second titer to confirm immunization: Measles Mumps Rubella (MMR) Booster Place Physician's Stamp in this Box for Validation* Physician/Nurse Practitioner Name & Credentials (Please Print): (Date of MMR Booster) (Physician/Nurse Practitioner Signature) 3. Upon completion of re-immunization, a second titer to confirm immunization is required: 4. Please note, if the titer remains negative, the physician/nurse practitioner will need to determine follow up as appropriate and provide the School of Nursing with the plan. * * * * EVIDENCE OF EACH DOSE/TITER RESULT MUST BEAR A VALIDATION STAMP AND BE SUBMITTED TO THE SCHOOL OF NURSING ONCE IT IS ADMINISTERED. *An Official Letter from the Physician/Nurse Practitioner detailing the above may be substituted for a validation stamp. Measles (Rubeola) Mumps Rubella (Measles) Titer Result: Positive Negative Titer Result: Positive Negative Titer Result: Positive Negative Physician/Nurse Practitione r Name & Credentials (Please Print): (Date of Titer) (Physician/Nurse Practitioner Signature) Place Physician's Stamp in the Above Box for Validation* Measles (Rubeola) Mumps Rubella (Measles) Titer Result: Positive Negative Titer Result: Positive Negative Titer Result: Positive Negative Physician/Nurse Practitioner Name & Credentials (Please Print): (Date of Titer) (Physician/Nurse Practitioner Signature) Place Physician's Stamp in the Above Box for Validation* CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 10 To be completed by physician or nurse. Please return to: School of Nursing 2121 Euclid Avenue, JH 238 Cleveland, OH 44115-2214 VARICELLA (CHICKEN POX) IMMUNIZATION Student Name: CSU ID Number: Have you received the Varicella (Chicken Pox) immunization or had chicken pox? 1. If so, have a titer drawn and complete the following: Titer Result: Positive Negative Physician/Nurse Practitioner Name & Credentials (Please Print): (Date of Titer) (Physician/Nurse Practiti oner Signature) Place Physician's Stamp in the Above Box for Validation* If your result is positive, you are done! 2. If the above result is negative, re-immunization is required followed by a second titer to confirm immunization: Varicella (Chicken Pox) Booster Place Physician's Stamp in this Box for Validation* Physician/Nurse Practitioner Name & Credentials (Please Print): (Date of Varicella Booster) (Physician/Nurse Practitioner Signature) 3. Upon completion of the full series, a second titer to confirm immunization is required. Titer Result: Positive Negative Physician/Nurse Practitioner Name & Credentials (Please Print): (Date of Titer) (Physician/Nurse Practitioner Signature) Place Physician's Stamp in the Above Box for Validation* 4. Please note, if the titer remains negative, the physician/nurse practitioner will need to determine follow up as appropriate and provide the School of Nursing with the plan. * * * EVIDENCE OF EACH DOSE/TITER RESULT MUST BEAR A VALI DATION STAMP AND BE SUBMITTED TO THE SCHOOL OF NURSING ONCE IT IS ADMINISTERED. *An Official Letter from the Physician/Nurse Practitioner detailing the above may be substituted for a validation stamp. CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 11 TUBERCULIN MANTOUX SKIN TEST OR CHEST X-RAY Student Name:__________________________________________________________ CSU ID Number: _______________________________________________________ STEP ONE: Date administered: ____________________ Date read: ____________________ Results:  Positive  Negative To be performed 1 – 3 weeks after Step One. STEP TWO: Date administered: ____________________ Date read: ____________________ Results:  Positive  Negative Physician's/Nurse Practitioner's Name (Please Print) Office Address City, State Zip Code This information must be legible and include professional credentials. ______________________________________ ______________________ Physician/Nurse Signature Date The two-step TB Mantoux Test report is required for all students admitted to the Nursing Program and the one-step TB Mantoux Test must be performed ANNUALLY throughout the program. If chest x-ray is needed, you must attach a copy of the results with this form. Documentation must include date X-ray was read and the name and credentials of the individual who read the X-Ray. To be completed by a physician/nurse practitioner after the test has been read. Please return to: School of Nursing 2121 Euclid Avenue, JH 238 Cleveland, OH 44115-2214 Place Physician's Office Stamp in the Box on the Right for Validation*: *An Official Letter from the Physician/Nurse Practitioner detailing the above may be substituted for a validation stamp. CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 12 Student Name: _______________________________________________ CSU ID Number: ____________________________________________ Vision Screening* *Only needs to be done if the Ability to Perform Nursing Tasks (page 4) shows you need accommodation. Optometrist Statement This individual last visited my office on ___________________________. This patient has acceptable vision either by nature or by the use of corrective vision wear. If vision deficits have not all been taken care of, please explain what still needs to be done: Optometrist Name (Please Print) Office Address City, State Zip Code This information must be legible and include professional credentials. _____________________________________ ______________________ Optometrist's Signature Date Vision Right 20/ Corrected to 20/ Left 20/ Corrected to 20/ Both 20/ Corrected to 20/ To be completed by Optometrist. Please return to: School of Nursing 2121 Euclid Avenue, JH 238 Cleveland, OH 44115-2214 Place Physician's Office Stamp in the Box on the Right for Validation*: *An Official Letter from the Physician/Nurse Practitioner detailing the above may be substituted for a validation stamp. CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NUR SING 13 Dental Exam Although this is optional, a dental examination is strongly recommended for all students at the time of admission to the Nursing Program. This information is strictly confidential. Name (Last, First, M.I.) CSU I.D. No. The above named student is a candidate for admission into the Cleveland State University School of Nursing. Dentist's Statement This individual last visited my office on ___________________________. At that time all necessary (Date) dental corrections were made. If they have not all been taken care of, please explain what still needs to be done: Dentist/Nurse Practitioner Name (Please Print) Office Address City, State Zip Code This information must be legible and include professional credentials. _______________________________________ ______________________ Dentist's Signature Date To be completed by Dentist. Please return to: School of Nursing 2121 Euclid Avenue, JH 238 Cleveland, OH 44115-2214 Place Physician's Office Stamp in the Box on the Right for Validation*: *An Official Letter from the Physician/Nurse Practitioner detailing the above may be substituted for a validation stamp. CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 14 SEASONAL INFLUENZA (FLU SHOT) VACCINATION *STUDENTS BEGINNING SPRING SEMESTER MUST HAVE THIS COMPLETED BEFORE START OF SEMESTER. FLU SEASON TYPICALLY BEGINS MID SEPTEMBER. VACCINATIONS ARE NOT AVAILABLE BEFORE THIS TIME. Student Name:__________________________________________________________ CSU ID Number: _______________________________________________________ Please provide the following: Date Administered ____________________________________ Lot # ______________________ Exp. Date ________________ Site of Injection: □ Left Deltoid □ Right Deltoid Administered by __________________________________________ (Signature) __________________________________________ (Please Print Name) _______________________________________________________________ Office Address: City, Sta te Zip Code This information must be legible and include professional credentials Documentation must be submitted to the School of Nursing by October 15th Annually. *An Official Letter from the Physician/Nurse Practitioner detailing the above may be substituted for a validation stamp. To be completed by a physician/nurse practitioner. Please return to: School of Nursing 2121 Euclid Avenue, JH 238 Cleveland, OH 44115-2214 Place Physician's Stamp in this Box for Validation* CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 15 Insurance Requirements and Forms: Student Liability Insurance • Cleveland State University covers students through a blanket student liability insurance plan when they are enrolled in the nursing program while participating in clinical experiences under the direction, supervision, and control of the Cleveland State University School of Nursing. The limits of liability are $1,000,000 each claim, $3,000,000 aggregate. o All students enrolled in a CSU Bac calaureate Nursing Program will be covered with this insurance when the Semester registration is paid. Health Insurance Verification • Each student must carry some form of health insurance for his/her own protection. • The student may obtain insurance from a private agency or participate in CSU's Student Health Insurance Plan. Insurance plan brochures are available in the Health & Wellness Services Department, 2112 Euclid Avenue, Room 205 (IM Building) , or on their website: http://www.csuohio.edu/offices/health/HealthInsurance.html • Please document below information related to your Health Insurance coverage. Student's Name (Last, First, M.I.) CSU I.D. Number Policy Holder's Name (if different from Student): __________________________________ Company Name: ____________________________________________________________ Dates of Coverage: ______________________________________________ Policy Number: _________________________________________________ Group Number: ___ ______________________________________________ Automobile Information for Parking at Clinical Sites Student Name: _________________________ CSU ID Number_____________________ Vehicle Year: _____________ Make/Model: _______________________ Vehicle Plate # ____________ State Issued: ________________ CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 16 Additional Clinical Agency Requirements: 1. Proof of a clean background check. 2. Current CPR Certiufication—Basic Life Support for Health Care Provider. Fingerprinting and Background Check • If you have been fingerprinted within the past 12 months, please provide an official copy of the results. • It is in your best interest to complete your background check as early as possible. It usually takes between three to six weeks for the School of Nursing to receive your results. If printed On CSU Campus, please provide the date that you were printed. • If you are a U.S. Citizen who has lived in the state of Ohio for five (5) or more years you are only required to provide the Civilian (BCI) Check. • If you are a U.S. Citizen who has lived in the state of Ohio for fewer than five (5) years, do not reside in Ohio at this time, or you are NOT A U.S. Citizen:  You are required to provide BOTH a Civilian (BCI) Check & Federal (FBI) Check Fingerprinting Locations On CSU Campus – Education Student Service Center, Julka Hall, Room 170-A (216) 687-4625 Monday – Thursday 9:00am – 12:00 pm and 1:00 pm – 4:00 pm  Cash/Check Payments: Bring invoice below to the Office of Treasury Services in Main Classroom, 1899 East 22nd Street, (MC), room 115 and pay the fee (below)  Take your receipt, driver's license/state ID, and Request for Background Check Form (page 16) to Julka Hall (JH), room 170-A to be fingerprinted  Credit Card Payments: are accepted in Julka Hall (JH), room 170-A  Take your payment, driver's license/state ID, and Request for Background Check Form (page 16)  Results are sent directly to the School of Off Campus – Identify fingerprint locations on National WebCheck • www.OhioAttorneyGeneral.gov/WebCheck or www.(your state)attorneygeneral.gov/webcheck • 1-800-282-0515 • You will be given a list of Deputy Registrar locations across Ohio (or your state) Cleveland State University College of Education and Human Services Electronic Fingerprinting Invoice BCI: $30.00 FBI: $30.00 BCI & FBI: $60.00 ACCOUNT#: 0060-0010-0512-40-Lab_Fees CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 17 Request for a Background Check via Electronic Fingerprinting () Graduate () Undergraduate () BCI () FBI () BCI and FBI Personal Information (please print) Name________________________________ State/Province_____________________ Date of Birth___________ SSN___________ Zip/Postal Code ___________________ Address______________________________ Phone#___________________________ City_________________________________ Program/Major_____________________ Driver Lice nse Exp Date: __________________________________________________________ Race (Please circle one): American Indian, Asian, Black, Middle Eastern, White, Unknown Reason for background check: Required for clinicals________________________ Which CSU Dept. is requesting the background check:____School of Nursing ____________ Direct Copy to (circle only one): Ohio Department of Education Address for results to be mailed to: Ohio Board of Nursing ___________________________________________ Ohio Board of CSWMFT ___________________________________________ Ohio Board of OTPTAT ___________________________________________ ___________________________________________ I certify that the personal identifiers provided on this form are accurate and I voluntarily and knowingly authorize the Ohio Bureau of Criminal Identification & Investigation to conduct a criminal records check for the information relating to me. I also voluntarily and knowingly authorize BCI&I to disseminate criminal arres t, conviction and juvenile delinquency adjudication records to Cleveland State University. I voluntarily and knowingly release and discharge the Ohio Attorney General's Office, BCI&I and their employees from all claims and liability related to this authorized criminal record review and dissemination. Signature: ____________________________________________ Date: ____________________________ Administrator Initials: __________ Date prints taken: __________ Date prints received: __________ Fingerprinting On CSU Campus: None Cleveland State University School of Nursing 2121 Euclid, JH 238 Cleveland, OH 44115 CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 18 Cardiopulmonary Resuscitation All students are required to maintain CPR certification – Basic Life Support (BLS) for the Healthcare Provider. You may complete the course through any provider authorized by the American Heart Association. Two sources are listed below for your convenience: o You must submit documentation of current CPR certification. o If you have already completed the correct course within the past twelve months, please provide documentation (24 months from the date of certification it must be renewed). o Your CPR certification for Healthcare Provider MUST BE renewed every twenty four (24) months throughout the program. A copy of your two-year re-certification card must be submitted upon completion of the course biennially. CPR Course Locations On CSU Campus – Sigma Theta Tau, International Nu Delta Chapter • www.csuohio.edu/nursing/progandhealth.html • (216) 875-9874 Off Campus (Ohio) – CPR Ohio • Register online or by phone:  www.cprohio.com  (216) 251-0747 • East: Landerwood Plaza North, 30539 Pinetree, Suite 225, Pepper Pike, OH 44124 • West: Emerald Crossing, 4760 Grayton Road, Suite 3, Cleveland, OH 44135 Off Campus (Outside Ohio) • Contact any local provider authorized by the American Heart Association. Agency Confidentiality and Related Forms Sig ned forms are required to be assigned for clinical experiences. The attached forms must be completed, signed and submitted with the other documents and forms described in this packet. Other hospitals, such as Cleveland Clinic and University Hospital Case Medical Center have an on-line system for signing their confidentiality form. o MetroHealth Medical Center -- Acknowledgement Form – fill in your name and sign. Please leave the date blank. o St. Vincent Charity Hospital -- ID Badge Form – fill in name and automobile information CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 19 The Nursing Enterprise Affiliated Student Acknowledgement of Confidentiality Policy Form I, _______________________________________________hereby acknowledge that I (print name) have received a copy of The MetroHealth System's Confidentiality Policy (II-5). I have read the Confidentiality Policy and I understand that I have an affirmative obligation to protect proprietary or confidential infor mation of The MetroHealth System, including but not limited to patient care, employee or business information. I further agree to comply with this policy and understand that, as a student affiliated with The MetroHealth System my duty is to refrain from requesting, accessing, photocopying, faxing, openly discussing or otherwise using any confidential information or materials for a purpose other than the performance of my assigned work. I understand that the duty of confidentiality continues after my clinical experience(s) with The MetroHealth System has ended and that my disclosure of confidential information after my clinical experience(s) can proved grounds for legal action. I fully understand that violations of the Confidentiality Policy is a serious matter and in addition to civil or criminal penalties which may apply, the consequences could include the inability to continue in the clinical rotation or the inability to return to The MetroHealth System for future clinical rotations and the notification of the school. _____________________________________________ ____________ Signature Date ______Cleveland State University_________________ ______________________ School Instructor Name 3/03 CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 20 7/04 STUDENT I.D. BADGE DATA SHEET FIRST NAME ___________________________________________________________________ LAST NAME ____________________________________________________________________ SCHOOL _____Cleveland State University ___________________________________________ Job Title: STUDENT Dept: ____________________ Expiration Date: _____________ Clinical Rotation Period FROM: _______ / _______ / _______ TO: _______ / _______ / _______ Clinical Instructor: ___________________________ E-mail: ___________________________ VEHICLE REGISTRATION Year: ___________ Make: _______________________ Model: ________________________ License Plate #: _________________________ Vehicle Color: ______________________ >>>> >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> The following to be completed by Protective Services <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< BADGE # ____________________ BADGE DESIGN: STUDENT VEHICLE REG.# _____________ DATABASE GROUP: STUDENT ACCESS Building 24 HR General Parking Radiology 24 HR PED Access 4A 4B ANC Access Any other access required to perform within Department assigned Revised 1.26.2010 CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 21 Uniform Information Basic and Accelerated Students will need to have a lab coat and full uniform. The lab coat and uniforms must be ordered from Affordable Uniforms. Please contact store to check for current hours. Both must be ordered at least 6 weeks prior to clinical orientation. They are located at: 4916 Turney Road Garfield Hts., OH 44125 (216) 271-9597 7647 Mentor Avenue Mentor, OH 44060 (440) 918-9800 24777 Lorain Road North Olmsted, OH 44070 (440) 801-1576 You will need to purchase the following items. Those with a "*" must be purchased through Affordable Uniforms. Other items can be purchased from the company or through your own sources. WOMEN MEN *Uniform (either skirt or pant suit style). * Lab coat *Uniform shirt and white trousers * Lab coat BOTH *CSU Name Pin *CSU Student Nurse Patch (one for each uniform and lab coat) Stethoscope White Nurse's Shoes (No canvas tennis shoes, open heel, or clogs may be worn. "All white" leather tennis shoes without color markings are allowed. Shoes must have closed toe and heel to meet OSHA requirements.) Please Note: • Your uniform and lab coat do not come with the CSU patch sewn on. You will need to purchase separate patches and sew them on the upper left sleeve of each uniform and lab coat. Affordable Uniforms will sew on the patches for an extra charge. • Be sure to allow plenty of room in your tops to be able to move your arms freely, even if wearing a sweater. • Uniforms are paid for at the time you place your order. CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 22 CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 23 Prices effective January, 2016 and are subject to change. Please call store for hours of operation and current prices. CLEVELAND STATE UNIVERSITY ♦ SCHOOL OF NURSING 24 Student Checklist to Ensure Health Data is Up To Date Hep B Documentation of a positive titer Flu Vaccine Documentation of completion each year Varicella Documentation of a positive titer MMR Documentation of a positive titer TB Documentation of the 2-step on admission and a 1-step every year thereafter T-Dap/DT Documentation of Immunization complete Polio Vaccine Documentation of Immunization complete Health Exam Documentation complete Eye Exam Documentation complete (see page 12) Dental Exam Documentation complete (see page 13) Checklist to Ensure Other Requirements Have Been Met CPR (BLS) is up to date and remains current ~ Copy Attached Background Check ~ Da te Completed: ___________________ Health Insurance Verification Complete CSU Uniform Order Completed Affiliate Hospital Confidentiality Forms Completed (highlighted section only) Ability to Perform Nursing Tasks Form completed Student Handbook ~ Memorandum of Understanding Student Handbook ~ Informed Consent Before you submit the documents indicated above, make a copy

November 17, 2017 Re: Nursing Honors Curriculum Courses Dear Members of the University Curriculum Committee: On behalf of the TWU College of Nursing Undergraduate Academic Affairs Committee (UACC), I am writing in support of the Nursing Honors Curriculum Proposal, which includes the addition of four new courses that award nursing students academic credit for completed honors coursework within the discipline. The proposed courses were developed by the Nursing Honors Program Coordinator and the Nursing Honors Faculty Team, in collaboration with the Honors Scholar Program Director, College of Nursing Administrators, and national consultants, Dr. Ellen Buckner and Carol Huston. The Nursing Honors Curriculum Proposal was approved unanimously by the College of Nursing Undergraduate Academic Affairs Committee on October 2, 2017. The proposal has followed the proper component procedures for approval, under the guidance of the College of Nursing Executive Committee. The proposal wa s presented at faculty meetings and posted for faculty discussion prior to going forward for a faculty vote, which is currently in process. If you have any questions regarding the proposed nursing honors courses, please don't hesitate to contact me. Sincerely, Jennifer Milligan Assistant Clinical Professor JMilligan@twu.edu 214-689-6704 Nursing Honors Capstone Curriculum Proposal July 2017jw TWU Nursing Honors Proposed Initiatives for Sustainability July 2017 The TWU Honors Scholar Program has experienced significant growth in numbers in the past five years. The following strategic changes to the honors program for nursing majors were developed by the Nursing Honors Faculty Team and aim to create processes that facilitate student success, support and sustain the program's projected growth, provide a mechanism for developing a new honors program for transfer nursing students, and maximize the university's return on the program's investment. The proposed changes stem f rom a comprehensive program evaluation, findings in the literature, and data gathered on best practices in honors education and nursing honors education at the national level, in collaboration with Carol Huston and Ellen Buckner from the Sigma Theta Tau International Experienced Nurse Faculty Leadership Academy. The proposed strategic initiatives create a structure and formal processes to sustain the program on all three TWU campuses, increase student and graduate engagement, identify new funding sources, and develop/maintain academic-clinical partnerships. These strategic initiatives are in alignment with and support the TWU Strategic Plan 2022. These proposed changes have been voted on and approved by the TWU Honors Advisory Council and the CON UAAC. Objectives:  Establish processes that promote sustainability, efficiency, and increased productivity  Increase mutually beneficial outcomes for students, faculty, HSP, CON, TWU  Emerge as a leader in honors education at the national level  Provide innovative opportunities that attract and retain talented faculty  Increase recruitment and retention of attractive, highly qualified students (FTIC & transfer)  Develop a new "Touchstone Honors Program" for qualified transfer nursing majors seeking a TWU honors experience  Preserve program quality and benefit, without undue financial burden to students Strategies: 1. Establish strategic curricular changes that: a. facilitate completion of honors diploma requirements b. provide faculty workload credit and support achievement of faculty goals c. facilitate academic success, rather than compete with nursing courses 2. Create strategic "high engagement" capstone experiences that: a. align with TWU Strategic Plan 2022 b. maximize the honors experience through systematic integration of honors tenets: leadership, scholarship, service, and research c. yield an increase in mutually beneficial outcomes to students, faculty, HSP, CON, TWU, and community partners d. are faculty-driven, increasing productivity, purpose, and satisfaction