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• Clinical Criteria

Forms for Nursing Students

• Waiver for annual background record check (pdf)
• Background information disclosure for caregivers (pdf)

Clinical Criteria

• A one time physical exam by your private physician or health care provider. This form must be completed, signed and on file in Health Services by the beginning of your clinicals.
• Tuberculin skin tests are done annually; this is encouraged to be done immediately in the fall. Documentation from your place of work is acceptable. For anyone who has had a positive TB skin test, we must have documentation of one negative chest x-ray  for TB and completion of a risk assessment annually. Students who have tested positive are required by Children's Hospital to have documentation of a negative chest x-ray within one year of their start at CHW. TB skin tests are given at no cost on Mondays and Tuesdays at MSOE Health Services (K250) during the school year from September through March. Please call (414) 277-7590 to schedule an appointment.
• The following immunizations must be completed and the dates must be recorded:
  1. Tetanus Diphtheria Booster - Must have booster with TD or Tdap within 10 years. Tdap (includes Acellular Pertusis/Whooping Cough) came on the market in 2005; it is recommended for all incoming freshmen and may be given 2 years from last TD update.
  2. Measles, Mumps, Rubella (MMR) - All nursing students born prior to 1/1/1957 must demonstrate immunity to Rubella (German Measles) by proof of one MMR vaccine or a positive Rubella titre per copy of lab report. If born after 1/1/57, immunity to both Rubella and Rubeola (measles) must be demonstrated by proof of two MMR vaccines or positive Rubella and Rubeola titres.
     
     Vaccinations may have been given separately. We must see two dates for measles, two dates for mumps and one date for Rubella. If unable to provide date of vaccinations, you must provide laboratory evidence of a positive titer. Titres can be ordered by your doctor.
  3. Hepatitis B - three doses; list all three dates. If no previous vaccinations, must be in process before beginning of Sophomore clinicals. 
  4. Varicella - history of actual disease or positive titer or two doses of vaccine given at least one month apart. (One dose is acceptable if recieved before 13 years of age but the Public Health Department is strongly recommending two doses as of 2008).

Many insurance plans or HMO's cover the cost of immunizations; if this is not available to you, please check out your local public health department for best cost containment, or visit MSOE Health Services Web site.

MSOE understands that some students cannot have immunizations due to health or religious reasons. If these pertain to you, please have your physician and or minister document this.

Please return your forms and any attachments to MSOE Health Services, 1025 N. Broadway, Milwaukee, Wis. 53202-3109. If you have questions, please call Health Services at (414) 277-7590.