Verification of Student Health Requirement Compliance

This signed letter is due to St. Vincent’s Medical Center by the clinical start date, and verifies that the following students and instructors have met all of the requirements listed below.

  • Physical exam (per school requirement)

  • Proof of Immunization/ Immunity:

  • MMR (vaccine or titer)

  • Varicella (titer or vaccine),

  • PPD (within 12 months) & CXR if positive

  • Hepatitis B (or a signed declination on file)

  • Negative 10 Panel Urine Drug Screen (within 12 months)

  • Flu Vaccine (for students at clinical site Oct 1- March 31) 

(Additional documentation of flu vaccine or a signed declination must be submitted by December 1st for fall semester students or with this form for spring semester students. Students who decline will be required to wear a surgical mask when they are within 6 feet of a patient).

Documentation and proof of compliance is on file at the school and may be furnished to St. Vincent’s Medical Center upon request if needed. 

Please complete the form below listing all students who will be on site for clinical. Please list each group separately.

School Health Verification Form - Nursing