STUDENT MEDICAL CLEARANCE AUTHORIZATION FORM

1 2018 Chamberlain University LLC. All rights reserved. 0618pflcpeC OLLEGE of NURSING National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | | Please visit for location specific address, phone and fax MEDICAL CLEARANCE AUTHORIZATION FORM (TO BE COMPLETED BY A PRIMARY CARE PROVIDER, NP OR PA)FORM PAGE 1 OF 3 Scan and upload your compliance documents to your Complio s Information:Print Name: Last FirstDate of Birth: / / STUDENT ID (D#).

2 Mm dd yyyy Chamberlain Competencies and Functional AbilitiesCore CompetenciesStandardExamples (not meant to be inclusive)Critical Thinking and Analytic ThinkingCritical thinking ability that includes the ability to recognize cause/effect and analyze potential solutionsSynthesize knowledge, recognize problems, problem-solve, prioritize, invoke long- and short-term memoryCommunication and Interpersonal SkillsConvey information orally and in writing using English as the primary language. Demonstrate therapeutic communication and relationship skillsWrite nurses notes, iSBAR, engage in patient conferences, interpret nonverbal cues.

3 Engage in conflict resolution, establish rapport, display non-judgmental attitudeEmotional IntelligenceDemonstrate self-awareness, self-management, social awareness and relationship managementIdentify, use, understand, and manage emotions in positive ways to relieve stress. Communicate effectively, empathize with others, overcome challenges, and diffuse conflictReadingRead, interpret and all comprehend written and electronic materialsRead and interpret policies, procedures, progress notes, textbooks, iSBAR, patient paper and electronic chartsMathematical AbilityDemonstrate proficiency in arithmetic functions, measurement and recording devices and reading/recording of numerical informationCalculate drug dosages, convert to metric system, read monitoring equipment, record numerical assessment/monitoring 2018 Chamberlain University LLC.

4 All rights reserved. 0618pflcpeC OLLEGE of NURSING National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | | Please visit for location specific address, phone and fax MEDICAL CLEARANCE AUTHORIZATION FORM (TO BE COMPLETED BY A PRIMARY CARE PROVIDER, NP OR PA)FORM PAGE 2 OF 3 Scan and upload your compliance documents to your Complio AbilitiesStandardExamples (not meant to be inclusive)Physical Stamina/ Gross Motor Skills/MobilityExhibit and demonstrate physical strength including ability to move, sit, stand and walk safely and endurance appropriate to professional nursing roles throughout assigned shiftsIndependently without assisted devices is able to: Physical ability to lift and transfer 50 pounds and carrying of objects up to 25 pounds.

5 Physical ability of bending or stooping 1 inch from the floor and of reaching overhead to retrieve or place items on patient/unit shelves; to intermittently push objects over 100 pounds; stand/walk for 8-12 hours; maintain balance. Move quickly from place to place, move freely in patient-care areasSensorySight: Distinguish color and visual images within normal range Hearing: Hear, with or without aids, voices, sounds and monitoring alarms necessary for safe practice Olfactory Sensation: Detect odors, unusual smells or smokeTactile Sensation: Interpret sensations, temperature and environmental temperatureSight: Determine color changes during physical assessment, observe patients in hallways, read computer/monitoring screens Hearing.

6 Monitor blood pressures, hear patients speaking, respond to equipment alarms, auscultate lung sounds Olfactory Sensation: Assess odors during physical assessment, detect odor or smokeTactile Sensation: Perform palpation for monitoring or procedures, respond to environmental temperature changesPhysical Health StatusMaintain physical health consistent with employment responsibilities and commitmentsThe STUDENT will monitor and report own health needs and recognize personal illness and maintain patient safety in transmission of illness. No evidence of fevers over 100 F; body in non-compromised working order (no casts, slings, boots, vomiting, diarrhea, crutches, assistive devices)Mental Health StatusMaintain focus and emotional stability in stressful situations and respond to needs of othersWrite legibly, grasp, pick up, manipulate small objects and syringes, calibrate equipment, perform patient assessment, change dressings, administer injectionsFine Motor/ Psychomotor SkillsPerform tasks congruent with nursing rolesWrite legibly, manipulate syringes and supplies, and calibrate 2018 Chamberlain University LLC.

7 All rights reserved. 0618pflcpeC OLLEGE of NURSING National Management Office | 3005 Highland Parkway, Downers Grove, IL 60515 | | Please visit for location specific address, phone and fax MEDICAL CLEARANCE AUTHORIZATION FORM (TO BE COMPLETED BY A PRIMARY CARE PROVIDER, NP OR PA)FORM PAGE 3 OF 3 Scan and upload your compliance documents to your Complio limitations or restrictions, physical or otherwise, that would prohibit this patient from full participation in all above listed competencies and functional abilities? c Yes c NoIf yes, explain: Primary Care Provider, NP or PA Signature: Print Name: Last FirstDate: / / Phone: mm dd yyyy Address.

8 Street City State ZipChamberlain University recognizes that nursing is an intellectually, mentally and physically demanding profession. Students seeking admission, and currently enrolled students, should be aware that they are expected to assimilate basic competencies and abilities throughout their education with or without reasonable accommodation. Chamberlain competencies and functional abilities required of all nurses are summarized in the table below. If you need accommodations, contact the Office of STUDENT Disability Services at or a safe environment for students and clients is the responsibility of everyone within Chamberlain University.

9 If any health impairment, physical condition or mental illness renders any STUDENT contagious and/or unable to meet the Chamberlain Competencies and Functional Abilities, the STUDENT must submit this STUDENT MEDICAL CLEARANCE AUTHORIZATION form. This form must be completed by the STUDENT s healthcare provider prior to returning to class, clinical or in some cases, the campus. STUDENT : STUDENT Signature: Date: STUDENT ID (D#): Campus.