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 (0074885) 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.

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

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)