University of West Georgia

School of Nursing

1601 Maple Street

Carrollton, Georgia 30118

Telephone: 678-839-6552

Fax: 678-839-6553

 

PHYSICAL ABILITY FORM

 

HEALTHCARE PROVIDER: I have performed a complete health examination on

____________________________________________________________________________________

(print studentís name).†

I have determined that the above named student is free from any infectious or contagious disease and is physically and medically capable of performing patient care activities (extensive walking, bending, lifting, with exposure to potentially toxic and infectious environments).

 

I attest that the above named patient/student has the following documentation in my records:

TUBERCULOSIS (Check one)

 

® Tuberculosis Skin Test, Mantoux, Purified Protein Derivative (PPD)

 

Date of injection _______________ Date of reading (48-72 hours of date of injection) ___________________ Result ____________

 

® Patient has a history of positive PPD or bacilli Calmette-Guerin (BCG) vaccine. My initials signify that this student/patient has no active disease or possibility of infectious process.

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† ††††††††††††† ††††††††††††††††† †Initials: _________

 

TETANUS VACCINATION (Td)

 

Date of last Tetanus (Td) injection ____________________

 

If not within the past 10 years, one is recommended by the CDC and required by most clinical agencies.

 

CERTIFICATION FOR VARICELLA VACCINE/IMMUNITY (Chicken Pox) (check one)

 

® Varicella vaccination

 

® Proof of immunity by Serological testing for Varicella Zoster Virus (VZV)

 

® History of varicella infection

 

Date of Varicella ______________________

 

 

Comments: ________________________________________________________________________________

 

†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††

 

Signature of Nurse Practitioner, Physician Assistant, or Medical Doctor:

 

___________________________________________ Date of Physical Examination: ______/______/______

 

Facility address:__________________________________________________________________†††††††††††††††††††††††

 

††††††††††††††††††††††† † _____________________________†† Provider telephone #: (_______)____________________