1. Student Packet Submission Nursing Clinical Groups
Student Packets include the following COMPLETED forms:
From main page of website:
Child Abuse Reporting Requirements (2 pages)
Elder and Dependent Adult Abuse Reporting Requirements
Confidentiality Agreement (3 pages)
Drug-Free Workplace – Employee Acknowledgement (2 pages)
HealthConnect Confidentiality and Non-Disclosure Agreement
Kaiser Permanente Contractors/Security/Volunteer/Student Health Initial Screening Questionnaire
Compliance/HIPAA Security Program
KP Learn Completion Certificates:
SCAL 2017 New Employee: Safety & Environment of Care Training
Orange County Annual Training and Review 2017
Annual Compliance Training 2017
Safe Patient Handling (Hospital INITIAL ASSIGNMENT CA ONLY) 2017
KP HealthConnect Inpatient Training for Nursing Students – SCAL
Copy of:
BLS Card (Front & Back)
To be completed by Instructors only:
Health and Safety Verification Excel Spreadsheet
CPMKPHC Student-Instructor Access Data Spreadsheet (HealthConnect Access)
KP Learn Module: Pyxis MedStation ES System Tutorials ( )
Copy of Nursing License
Please Note: ONLY complete packets scanned and submitted electronically as a single PDF will be processed. Partial packets will not be accepted and will delay your acceptance into the program.

2. Student Packet Submission Nursing Clinical Groups
Dates to be entered on the Health & Safety Verification form submitted by the Nursing Instructor:
TB Testing
Proof of 2 negative TB tests within the last 24 months:
1 negative must be within the last 12 months
If positive TB test, we require documentation of a negative chest X-ray within 1 year of the start of your current school program
MMR
Positive Titer – OR--2 Vaccination Dates
Vaccination is mandatory if non-immune and no vaccine record.
Declinations are not accepted.
Varicella
Positive Titer – OR--2 Vaccination dates
Hepatitis A (Food Service students ONLY)
Hepatitis A antibody titer –OR--2 Vaccinations, 6 months apart
Hepatitis B
Antibody Titer is REQUIRED by ALL students!
If titer is Negative:
3 Vaccination dates –OR-- Declination form
Declination forms are highly discouraged
Seasonal Flu
Required of ALL students on campus during flu season.
Declinations not accepted for ANY reason.
Tdap
Provide Date of vaccination within last 10 years
Declination form available Declination forms are highly discouraged

3. Student Packet Submission Nursing Clinical Groups
Dates to be entered on the Health & Safety Verification form submitted by the Nursing Instructor. Note: A date entered on the Health & Safety Verification form means all items have been screened and are negative/no findings have been identified. DO NOT ENTER A DATE ON THE FORM FOR POSITIVE RESULTS OR ANY FINDINGS.
10 Panel Urine Drug Screening Requirements:
Amphetamines
Barbiturates
Benzodiazepines
Cocaine
THC (Marijuana)
Methadone
Methamphetamines
Opiates
PCP
Tricyclic Antidepressants
Background Check Requirements:
Verification of legal name
Verification of social security number
Verification of address
Seven years of residence/background/criminal history in residing counties
Sex offender database search
Felony and misdemeanor criminal record search
Federal Criminal Records search
Search through applicable professional certification or licensing agency for infractions if student currently holds a professional license or certification (e.g. respiratory therapist, CNA)