CRIMINAL BACKGROUND CHECK RELEASE by 2du89zN

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									                                             Mary Greeley Medical Center EMT Student Checklist

Below is a list of required document information to be submitted to Mary Greeley Medical Center prior to the first day of class.
        □    Copy of a current Healthcare Provider BLS (Basic Life Support) card
        □    Copy of a current Mandatory Reporter Child/Dependent Adult Abuse certificate. Certificate must be a combination of
             Child & Adult Abuse, and must have an Approval # listed on the certificate.
        □    Immunization Records

If you have not had a TB Skin test within the last 12 months or one of the required immunizations, you will need to see
your primary physician and be immunized. Your physician will then provide you with the physician/clinic documentation. It will
be helpful to contact past/current schools/universities, employers, and Physicians/Clinics for your records.
        Hepatitis B – Strongly recommended for all students who come in contact with blood or blood products.
                 Physician/Clinic documentation of three-dose vaccine series or
                 Serological proof of immunity (blood titer done by your physician)

        Pertussis (Whooping Cough) – Strongly recommended for all students that have direct patient contact.
                 Physician/Clinic documentation of vaccination (this is combined with Tetanus and Diptheria vaccination called Tdap)

        Influenza – Required for all students
                 Physician documentation of vaccination for flu season 2011.

        Two Measles, Mumps and Rubella (MMR) - Required of ALL students born on or after 1/1/57
                 Physician/Clinic documentation of illness or
                 Physician/Clinic documentation of two-dose vaccine series since age two (2 Measles vaccine, 2 mumps vaccine, 2 Rubella vaccine) or
                 Serological proof of immunity (blood titer done by your physician – 1 Mumps Titer, 1 Measles Titer, 1 Rubella Titer) OR
                 2 MMR vaccines

        TB Skin Test – Required of ALL students
                 Documentation of negative TB Skin test within the last 12 months. Must include date read and result.
                 Persons with current positive TB test or history of positive TB test must provide results of a chest x-ray within the past two years

        Varicella (Chicken Pox) – Required of ALL students
                 Personal history/physician documented proof of disease or
                 Serological proof of immunity (blood titer done by your physician) or
                 Physician/Clinic documentation of two-dose vaccine series
                 Please document the following about Varicella (chicken pox)

                 _____I had the disease and am immune to Varicella                                 Age or year when you had the disease _________

                Signature: ___________________________________                                     Date: __________________

If you have any questions, please feel free to contact me.

Thank you!




Mindy Wendt
HR Generalist
Mary Greeley Medical Center
515.956.2868
wendt@mgmc.com
                                CRIMINAL BACKGROUND CHECK RELEASE

PLEASE PRINT


I                                                   , (First, middle, last name as it appears on your social security card)
certify that the information that I have provided is true and correct to the best of my knowledge and belief. I authorize Mary Greeley
Medical Center to investigate my criminal history. In connection with this investigation, I authorize all corporations, companies, and
law enforcement agencies to release information that they may have about me and release them from any liability or responsibility
from doing so. This authorization, in original or copy form, shall be valid for this and any future investigation conducted by Mary
Greeley Medical Center. I understand that any information will be held in strict confidence except as allowed by law.

PRINT Prior Name(s) (I.E.: Maiden name(s), alias)

Social Security #:                                                                 Date of Birth: _________________

Current Street Address: ______________________________________________                 City: _____________________

State: _________________Zip: __________


□Please check here if you have lived outside of Iowa in the past seven years
Please list all previous addresses that you have resided at in the past seven years:


City: ____________________________________________State: _____________________Zip: ______________________


City: ____________________________________________State: _____________________Zip: ______________________


City: ____________________________________________State: _____________________Zip: ______________________


City: ____________________________________________State: _____________________Zip: ______________________


City: ____________________________________________State: _____________________Zip: ______________________




Signature:                                       ________________________         Date:    ____________________________

								
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