Health Certificate - Download as DOC

							                                       St. David’s School of Nursing
                                                     at
                                           Texas State University

                            Bachelor of Science in Nursing (BSN) Program
                                          Health Certificate

Students admitted (pending the successful completion of their Health Certificate and Immunizations and Tests
Form) to the School of Nursing will receive these forms by the first Friday in March. They will be instructed to
make an appointment with their healthcare provider to document:

   All immunizations are completed including date of booster.
    Notes: See Immunizations and Tests Form.
           Clinical affiliations may require additional immunizations and/or tests.
   Student is in good physical health and free from diseases listed on the Immunizations and Tests Form.

Completed Health Certificate and Immunizations and Test Form must be received by the School of
Nursing by 5:00PM on Monday, August 2, 2010.

School of Nursing Student: _________________________________________________________________
                                            Last           First             MI
Address: ________________________________________________________________________________
                         Street                     City         State       Zip
Telephone: (___)___________________________ Date of Birth: _________/________/_________________

Blood pressure: __________________________________________________________________________

I have examined: _________________________________________________________________________
                                      (School of Nursing Student’s Name)

and find this student to be in good physical health. I also find the above named student is free from the
diseases listed on the Immunizations and Tests Form.

Restrictions or Limitations: __________________________________________________________________

Date:                         _________________ Telephone: (____)_______________________________

Healthcare provider signature: _______________________________________________________________

Printed name: ____________________________________________________________________________

Healthcare provider’s address: ______________________________________________________________
                                Street               City       State       Zip


Please return this completed Heath Certificate and the Immunizations and Tests Form to:
                              Nursing Admission and Retention Coordinator
                                      St. David’s School of Nursing
                                          Texas State University
                                 Round Rock Higher Education Center
                                       1555 University Boulevard
                                    Round Rock, Texas 78665-8017

Completed Health Certificate and Immunization Form must be received by the School of Nursing by
5:00PM on Monday, August 2, 2010.