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New Visions HealthHandbook2016-2017
Northern Westchester HospitalNew York Presbyterian/ Hudson Valley Hospital Center
PNW :Putnam) Northern Westchester x
New Visions Health ProgramTech SouthJune 9* 2016
Dear Parent and Student,
Welcome to the New Visions Health Program here at Tech South. We look forward tothe coming 2016-2017 school year. We hope you will enjoy this program that explores varioushealth careers in our area hospitals. This handbook contains important information for thecoming school year.
For the beginning of the year each students will need to complete the attached physicalassessment form with the childhood immunization record, receive the flu shot and have a PPDplacement. Our students wear a navy blue lab coat while in the hospital. It can be purchasedonline or at S and H Uniform store in White Plains. The hospitals require that our students wearbusiness dress, no sneakers, t-shirts or leggings. Please complete the BLS CPR course during-the-summer. Included is the English assignments to be completed for the first day of school. Beforethe current school year ends please contact your school district's transportation department to seeif you are eligible for transportation to the hospital. Our clinical rotations will start middle ofOctober 2016 to the middle of May 2017. Your student can take their home school bus to andfrom BOCES on non-clinical days. Additional information will be available on our School wireswebsite at Http://pnwboces.schoolwires.org. Look under the instructors Collins/Farlow.
Have a wonderful summer and see you in September. Any questions please feel free toemail us at [email protected]
Ms. Susan Collins RN MSHedAndMrs. Veronica Farlow RN MSN
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PUTNAM NORTHERN WESTCHESTER BOCESNEW VISIONS HEALTH PROGRAM
NEW VISIONS HEALTH
STUDENT SCHEDULE
8:00AM-12:00PM Monday, Thursday, and FridayNew Visions Health Classroom
8:00 AM-11:30 PM Tuesday and WednesdayHospital Rotations
8:OOAM-10:OOAM ThursdayPolitics/ Economics
10:00AM-10:40 AM Monday/ThursdayGym
8:00AM - 10:00AM FridayEnglish
PUTNAM NORTHERN WESTCHESTER BOCESNEW VISIONS HEALTH PROGRAM
COURSE COMPONENTS
New Visions Health Program 2 HS credits• Health Occupations Education CORE 6 college credits• Structure and Function of the
• Human Body
• Clinical Rotations
English (Health Related) 1 HS credit3-6 college credits
Social Studies (Health Related) 1 HS credit• Economic .5 HS credit
• Political Science in America .5 HS credit3 college credits
Medical Terminology 4 college credits
NEW VISIONSSummer English AssignmentSummer 2016Ms. Buckhout
Welcome to the New Visions Program!
For English class, you will need to complete 4 (four) assignments. All assignments are due on the first day of your Techclass. Please read all directions carefully. Bring both a hard copy and an electronic version of your documents (saved to
Google Drive, email, flash drive, Dropbox, etc.).
By the first day of class, you will be required to submit the following assignments:
1. Literature Reading & Book Review2. 5 (five) Credible Article Submissions3. Resume
4. College Essay
All assignments can also be found on the Schoolwires website: pnwboces.schoolwires.net (no www). Choose Teachers &
Administrators, then Buckhout, then your class.
i. Literature Reading & Book Review
This summer, you have a choice of two books to read. One is fiction, and one is non-fiction:
A. All the Light We Cannot See, by Anthony Doerr (fiction)B. The Boys in the Boat, by Daniel James Brown (non-fiction)
Directions for the Literature Reading & Book Review:
1) Read one of the books listed above.2) Write a book review in which you:
a. Provide an objective summary of the book, one paragraph in lengthb. Identify two or more themes or central ideas of the text. Analyze the themes' or central ideas'
development over the course of the text. Include how they interact or build upon one another to
produce a complex story.c. Provide a recommendation - would you recommend this book to a friend? Why or why not? You may
use words like Highly Recommended, Recommended, or Not Recommended. Refer to specific literaryelements of the book, such as characters, plot, symbolism, theme, etc. in your recommendation.
For this book review, you may use first person "I." Your book review should be about 500 words, typed in 12pt. font,
double-spaced.
NEW VISIONSSummer English AssignmentSummer 2016Ms. Buckhout
4. College Essay
The writing prompts for the CommonApp contain some new language. Below are the instructions and prompts taken
directly from the CommonApp website. Keep in mind, you may be asked to make changes to this essay; however, it
should be as close to finished as possible.
Instructions:
The essay demonstrates your ability to write clearly and concisely on a selected topic and helps you distinguish yourselfin your own voice. What do you want the readers of your application to know about you apart from courses, grades, andtest scores? Choose the option that best helps you answer that question and write an essay of no more than 650 words,using the prompt to inspire and structure your response. Remember: 650 words is your limit, not your goal. Use the fullrange if you need it, but don't feel obligated to do so. (The application won't accept a response shorter than 250 words.)
1. Some students have a background, identity, interest, or talent that is so meaningful they believe their
application would be incomplete without it. If this sounds like you, then please share your story.
2. The lessons we take from failure can be fundamental to later success. Recount an incident or time when you
experienced failure. How did it affect you, and what did you learn from the experience?
3. Reflect on a time when you challenged a belief or idea. What prompted you to act? Would you make the same
decision again?
4. Describe a problem you've solved or a problem you'd like to solve. It can be an intellectual challenge, a research
query, an ethical dilemma-anything that is of personal importance, no matter the scale. Explain its significance
to you and what steps you took or could be taken to identify a solution.
5. Discuss an accomplishment or event, formal or informal that marked your transition from childhood to
adulthood within your culture, community, or family.
(http://blog.commonapp.Org/2015/03/31/2015-2016-essav-prompts/l
Should you have any questions about any of the assignments, please email me at: sbuckhout(5)pnwboces.org or call 914-
248-3830.1 will be checking my voice mail and email.
Enjoy your summer!Ms. Buckhout
SUNY Writing & ResearchBuckhoutEvaluating the Credibility of Your Sources
Evaluating the Credibility of Your Sources
Remember, your use of sources is a means of supporting the argument
you make. This means that the sources you reference need to be
credible and authoritative. How do you know that your sources are of
value? Ask yourself the following questions:
1. Is the source objective?
Evaluate Consistency. Sources that apply different standards to those who agree and disagree with them are
suspect. If your source praises one politician for "changing to meet the needs of his constituency," but then
criticizes an opposing politician for "changing his position with opinion polls," it is likely that the source is
biased.
2. Who wrote it?
Research the author. A source is more credible if written by someone with a degree or other credentials in the
subject of interest, if no author or organization is named, the source will not be viewed as very credible.
However, if the author is presenting original work, evaluate the merit of the ideas— not the credentials.
Some questions that you should ask about the author are:
o Where does the author work?
o If the author is affiliated with a reputable institution or organization, what are its values and goals? Do
they benefit financially by promoting a particular view?
o What is his or her educational background?
o What other works has the author published?
o What experience does the author have?
o Has this author been cited as a source by other scholars or experts in the field?
SUNY Writing & ResearchBuckhoutArticle Submission Assignment
For this assignment you will:Find and read a credible article relating to the field in which you will be studying at Tech (i.e. Engineering or Health).
On a separate sheet of paper, typed, double-spaced:
1. Create a proper MLA citation for the article.
2. Provide a link to the article.
3. Explain why the article is credible, using the FIVE criteria in Evaluating the Credibility of Your Sources.
4. Explain why you chose this article and how it relates to your field of interest.
You do NOT have to submit the article - only the write-up.
Source Evaluation Cheat Sheet:
Examples of sources that are often the most credible:
o Official government websiteso Institutional sites that represent universities, regulatory agencies, governing bodies, and respected organizations -
with specific expertise (e.g., the Mayo Clinic)o Peer-reviewed journals
o Reputable news sources _ _
Examples of sources that are often considered less credible:
o Blogso Web forumso Individual or business websiteso Materials published by an entity that may have an ulterior motive
Factors to Consider Most Reliable Possibly Reliable Least Reliable
Type of source
Official websitesInstitutional sites
Academic journals
Published material Unfamiliar website
Author's background Expert in the field Educated on topic Uncredited
Date published Recently revised Outdated None
Depth of reviewPeer-reviewed by reliable
sources
Good publicresponse; general
approvalControversial reviews
Sources citedCitations referencing
other well-cited worksCredible sources None
Objectivity Balanced, neutral Sponsored source Clearly biased
Objective:
Education:
Skills:
Experience:
NAME123 Resume StreetCity, NY zipcode
To pursue further education in the field of Early Childhood Development and Special Education
YorktownHigh SchoolYorktown Heights, NYDate of Graduation: June 2014
Leadership, ability to multitask, motivated, dedicated, punctualMicrosoft Office
Junior AssistantBright Beginnings Preschool (July 2013-present)
• Assist lead teacher in a classroom of 10 children, ages 3 to 5* Took lead on instructing children with special learning assignments
© Responsible for taking groups of children on field tripse
Swim CoachYorktown Swim & Dive Team (July 2011 - present)
® Assist Head swim coach with 10 children, ages 7 to 10, in learning to swim
BabysittingVarious families (2009 — present)
® Care for, feed and play with children
Awards: Honor Roll (2011, 2012, 2013)USA Swim IMX Program Achievement Award (2013)
Leadership Positions:Varsity Swim Team Captain (Fall 2013)Yorktown High School Big Buddy (Fall 2013)
Advanced Academic Courses:AP Italian (2012/2013,2013/2014)AP Environmental Science (2013/2014)Honors English (2011/2012, 2012/2013)Wind Ensemble (2013/2014)
Community Service:First Presbyterian Church of YorktownMission Trip to Louisiana (July 2012)
• Helped repair homes for the victims of Hurricane KatrinaMember of FPCY Church Session (Jan. 2011 - Jan. 2012)
• Provide input to help the governing body of the churchMidnight Run (April 2011)
• Made food, donated clothing; delivered to homeless in New York City
Extra Curricular Activities:Yorktown High School Band (2010 - present)
• Saxophone, Bassoon• Participated in NYSSMA (2011)
Athletics: USA Swimming, Patriot Swim Team (2009 - present)Yorktown High School Girls Varsity Swim Team (2011 - present)Yorktown Summer Swim & Dive Team (2006 - present)
PUTNAM NORTHERN WESTCHESTERBOCES TECH CENTER
NEW VISIONS HEALTH CAREER PROGRAM
MISSION STATEMENT
The New Vision Program is to provide the students with an in-depth study ofthe U.S. health care system through classroom integrated instruction anddiverse clinical rotation immersion.
I. NEW VISIONS PROGRAM DESCRIPTION
New Visions in health careers is an in-depth study of the U.S. Health caresystem. Students observe staff in their actual work situations. This conceptallows students to explore a variety of health career professions whileintegrating their academic knowledge with the experience of working in ahospital. Students spend approximately 4 hours of each day in eitherdepartment rotations throughout the hospital or in a traditional classroomsetting.
PROGRAM OBJECTIVES
The New Visions student must:
1. Apply previous academic knowledge and skills to professional tasks andproblems.
2. Develop career plans based on the knowledge gained throughexperiential learning.
3. Begin preparation for professional health care careers (two or four yearcollege).
IL STATEMENT OF COURSE OBJECTIVES
1. To familiarize the student with the scope, methods and techniques ofhealth occupations, allowing students to make informed decisionsregarding post-secondary choices.
2. To introduce the student to the study of health care careers and the healthcare system's impact on present day society.
3. To help the student achieve a clarification and understanding of his/herown concept of health careers and the health care system.
m. GENERAL EDUCATION OBJECTIVES MET BY THECOURSE
A. Develop essential skills in communication in both speaking and writingin the classroom and workplace.
1. Critical ThinkingStudents will have to follow through with reading assignments fromthe basic text, hand-outs and current newspaper articles relevant to thehealth care system and health care careers.
2. ReadingStudents will have to follow through with reading assignments fromthe basic text, hand-outs and current newspaper articles relevant to thehealth care system and health care careers.
3. Interpersonal skillsStudents will develop necessary skills to enhance performanceworking with others in the health care environment
B. Strengthen student awareness in:
1. Natural ScienceThe students will learn about anatomy and physiology.
2. Health OccupationStudents are exposed to a variety of health occupations in the clinicalsetting.
3
3. Medical TerminologyStudents will learn and utilize entry level Medical Terminology
4. Economics of the Health Care SystemThe students will be exposed to current issues in national health careeconomics and the economics of the specific department they will be
exposed to/immersed in.
5. Social StudiesThe students will be exposed to relevant health care legislation andResearch Public Policy specific to health care.
6. EnglishThe students will be exposed to literature consisting of biographical,autobiographical, non-fictional, and fictional related to medicine,health care and medical ethics.
7. Organizational and Time Management Skills,Students will be exposed to and expected to work toward improvingthese skills for successful adjustment to post-secondary education.
KEY PROGRAM ELEMENTS
1. Location: The New Visions classroom is strategically located atNorthern Westchester Hospital Center (NWHC), in Mount Kisco,N.Y. And Hudson Valley Hospital Center (HVHC) in CortlandManor, N.Y.
2. Interdisciplinary Approach: Students study senior level Englishand social studies within the health care system. They learn torelate their academic and occupational skills to a variety ofsituations.
3. Broad-Based Professional Curriculum: Students develop a widevariety of career oriented skills and competencies. Students learnto develop "soft and transferable skills"; skills vital for success inpost-secondary education and future employment, (i.e.punctuality, accountability, responsibility, and team work)
4
APPENDIX A
Hospital Dress Code for New Visions
These dress requirements are to be followed whenever the student is withinthe hospital. The student will adhere to any department specific dressregulations.
1. Jeans are NOT allowed at any time in the Hospitalenvironment.
This includes blue or any other denim pants.2. No sleeveless tops, cropped tops, T-shirts, netted shirts or sweat
shirts.3. No shorts of any kind4. No mini-skirts5. Shoes/sneakers are to be clean and neat. No clogs or sandals.6. Name tags are to be worn at all times. Lab coats to be warn at all
times.
7. Personal appearance (hygiene, hair, jewelry) will be maintained ina professional manner.
It is important to remember that you will be in a professional environment,and it is expected that you will dress and act accordingly.
IMMUNIZATION REQUBREMENTS
Due to the extent of patient contact, New Visions students must receive thefollowing immunizations fiom their family doctor prior to beginning theprogram.
1. Physical examination2. MMR Booster (or proof of immunity by Rubeola Titer)3. Mantoux (PPD) test4. Tenants shot5. Rubella Titer6. Hepatitis B vaccine/waiver7. Varacella
6
APPENDIX B
STUDENT CONTRACT FOR CLINICAL ROTATIONSNEW VISION: HEALTH CAREER EXPLORATIONSThis contract is to be strictly observed at all tunes during your clinical rotation.• In the medical professions, there has evolved through the years a, system of ethics that
is observed and practiced by all persons in the medical family.1. I will make it my responsibility to know, understand, and keep within the
guidelines of each clinical rotation in order to ensure the health and well being ofeach patient.
• Invariably the people with whom we deal are in different stages of ill health, whichcreates in each of them a different outlook. They may become anxious, nervous, and
often impatient.2. I will make every effort to he courteous, efficient and accurate when helping
patients through this stressful time in their lives.• Patients may gain confidence in us and share their innermost thoughts. We also come
to know a great deal about a patient from hearing reports and reading charts.3. I understand that discussing:
a. A confidence
b. A diseasec. A diagnosis or prognosisd. A family historye. A treatment
Of a patient with other students or friends is in violation of a "sacred trust of _confidentiality." I will uphold the patient's "right to privacy" as I would amember of my own family.
® I will adhere to the dress code of the hospital.» I will check in with my teacher before and after each day's rotation.» I will telephone my teacher and my supervisor if I will be late or absent.® I will not visit other departments.• I will not leave the unit without checking with the person in charge.« I will not discuss my private life while in the present of patients.• I will respect and properly care for all equipment and supplies.• I will complete and understand the self study prior to my assigned rotation.® I will adhere to any direction from the clinical supervisor immediately without
question while in the clinical setting and report any accident.® I understand that if I violate this contract, disciplinary measures will be taken and
termination from the program may be necessary.
Student's Signature Parent's Signature Coordinator's Signature
7
APPENDIX €
CONFIBENTIALITY STATEMENT
I understand and agree that in the performances of my
Duties as a New Visions: Health Career Explorations
student of Putnam/Northern Westchester BOCES at
Northern Westchester Hospital, I must hold in
Confidence all patient and staff information gained
during clinical experience. Further, I understand that
any violation of confidentiality may result in my
immediate dismissal from the program.
SIGNATURE DATE
TEACHER WITNESS
8
JOURNAL GUIDELINES
CLINICAL ROTATIONS
Paragraph INarrative account of your day. Include any new knowledge gained that day with
emphasis on the technical
Paragraph 2Should represent personal feelings when reflecting on the day. (Ex. Comments on
patient and staff interactions)
Paragraph 3Analyze the role of the professional staff observed
JOURNAL EVALUATION
Based on the following:
NeatnessCompleteness (Daily entries)OrganizationQuality of observations/IdeasTypes of tasks performed/observed
PUTNAM NORTHERN WESTCHESTERBOARD OF COOPERATIVE EDUCATIONAL
SERVICES
NEW VISIONS HEALTH CAREER EXPLORATION PROGRAM
I. NEW VISIONS INTERDIC1PLINARY IMMERSION HEALTHCAREER PROGRAM
New Visions Staff Department: Health Occupations
IE COURSE DESCRIPTIONNew Visions in health careers is an in-depth study of the U.S. HealthCare System. Topics include hospital organizational structure,personnel patters, facility layout, introduction to health careers, legaland ethical issues, safety promotion, asepsis, and introduction tomedical terminology, communication, introduction to anatomy and
physiology.
HI. STATEMENT OF COURSE OBJECTIVES1. To familiarize the student with the scope, methods and techniques
of health occupations.2. To introduce the student to the study of health care careers and the
health care system's impact on present day society.3. To help the student achieve a clarification and understanding of
his/her own concept of health careers and health care system.
IV. GENERAL EDUCATION OBJECTIVES MET BY THE COURSEA. Develon essential skills in communication in both sneaking and
writing in the classroom and workplace.1. Critical Thinking
Students will be acquainted with current economic issues inhealth care which must be analyzed and interpreted in orderto draw conclusions.
2. ReadingStudents will have to follow through with readingassignments from the basic text, hand-outs and currentnewspaper articles relevant to the health care system and
health care careers.3. Medical Terminology, (Please see previous)
10
Strengthen student awareness in:1. Natural Science
The students will learn about anatomy and physiology.2. Health Occupations
Students are exposed to a variety of health occupations inthe clinical setting
3. Economics of the health care systemThe student will be exposed to current issues in nationalhealth care economics and the economics of the specificdepartment they will be exposed to/immersed in
4. Social StudiesThe students will be exposed to relevant health carelegislation and Bills in addition to exposure to theHippocratic Oath Nightingale.
5. EnglishThe student will be exposed to literature consisting ofbiographical, autobiographical, non-fictional, and fictionalrelated to medicine, health care and medical ethics.
11
NEW VISIONS COURSE REQUIREMENTS
PORTFOLIO REQUIREMENTSOne of the requirements of this course of study is to maintain a portfolio. This willenable the teacher to follow student progress in a more objective manner. The portfoliorepresents a yearlong collection of many different assignments that depict the student'sefforts, progress and achievements. This is designed to provide a comprehensive view ofstudent performance and self-reflection. Rotation packets, revised journals, research
papers, field notes, and summaries of medical journal articles axe representative of thework that will be included in the portfoho. .
JOURNAL REQUIREMENTSStudents will keep a record of each day for the school year. Each daily journal entryshould he two to three paragraphs. The first paragraph should describe any newknowledge gained that day with emphasis on the technical. The second paragraph shouldrepresent personal feelings when reflecting on the day; comment on patient and staffinteractions, for example. Journals will be started the first day of school.
ROTATION PACKETSFor every rotation students will complete a set of comprehensive objectives relevant tothe area to which they are assigned. Additionally, students will complete all assignedreadings prior to the rotation, research and write a paper where designated, file their dailyjournals in the rotation packet. Rotation packets will be given to students prior torotations with the exception that objective questions will be researched prior to beginningthe rotation.
RESEARCH PAPERSAs assigned, research papers are to be at least 5 pages doubled-spaced and typed. Youare to follow the format in your English book at your high school. Deviation will loweryour grade. Emphasis in this course will not only be on health care but also on writingskills. Presently, you are to be working on your college entrance essay.
WEEKLY CURRENT ARTICLEEach week you are expected to discuss and hand in a current article relating to healthcare. This synopsis need not be long; however, it; may help a classmate or yourself withwriting the research paper so please mount it on a sheet of paper to be filed as a futurereference.
ADDITIONAL WORKSWe will be reading a number of books and short stories. You will be asked to critiquethese works.
12
NEW VISIONS COURSE OUTLINE
I. Introduction and Orientation to the FacilityA. Course Requirements
B. Rules of ConductC. Grading
II. Introduction to Health CareersIII. Qualities of the Health Care WorkerIV. Communication Skills
A. Types of communicationB. Factors that Influence CommunicationC. Therapeutic Communication SkillsD. Communication Within the Health Care Team
V. QSHA StandardsA. Fire and SafetyB. Universal Precautions/AsepsisC. Body Mechanics/Accident prevention
VI. Medical TerminologyVII. Legal and Ethical Issues
A. ConfidentialityB. Ethical and Legal Responsibilities/LiabilitiesC. FutureTssues. Advance Directives. HJ.V. Teenage Pregnancy, Transplants
VIII. Introduction to Anatomy and PhysiologyIX. Medical Documentation
A. Organization of a medical chartB. Permanent record
X. Medical DocumentationA. AT Review and VocabularyB. Assigned Readings and Writings in relation to Health Care IssuesC. Accessing information. Library Skills
XI. EconomicsA. Effects of Health Care CostsB. Insurance Plans
C. Consumerism
D. Health Care for the Future
XII. TechnicalA. Rotations through Ancillary DepartmentsB. Field Trips
XII. CPR/First Aid - certification obtained during summer prior to start of NewVisions.
GRADING: Will be a combination of:
Writing Skills:25%A. Rotation PacketsB. Journal EntriesC. Cmrent Article and Book CritiquesD. Portfolio
Testing: 25% Periodic Testing of Materials such, as:A. QuizzesB. Unit Tests. Midterm and Finals
Class Participation/ Attitude 25%A. Class Participation and PreparednessB. Team Exercises
Papers: 25%A. The first semester will be the college entrance essay. It will be due before the
Christmas recess.
B. One paper each quarter will be assignedQuarter 1 Career Exploration ProjectQuarter 2 Mental 1 Icalth ProjectQuarters Nutrition ProjectQuarter 4 An in depth Medical Ethics Research Project
14
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PUTNAM/NORTHERN WESTCHESTER BOCES200 BOCES Drive, Yorktown Heights, NY 10598
The Tech Center at Yorktown - Health Services(914) 248-2413 Email: [email protected]
PRE-ENTRANCE MEDICAL RECORD
Date: •
Name of Applicant: Last Name First Name Initial
Date of Birth: : ¦ Course ¦ ; Month Day Year
the medical examiner is requested to make a careful physical examination, otherwisedefects found after admission may lead to the rejection of the applicant.
SPECIAL NOTE FOR PHYSICIAN Office Use Only(Completed)
1. Tuberculin skin test required annually.for TB screening. All informationmust be completed and documented on the attached form.
2. Rubella (German Measles), Rubeola (Measles), Varicella (Chicken Pox)and Mumps blood titers must submit reference ranges on lab results slipsto prove immunity. Titers must have been obtained within ten (10) years.
-- — - -- - -
3. Hepatitis B blood titers must be submitted with reference range for proofof immunity or must have a signed Hepatitis B waiver declination.Hepatitis B surface antibody testing and results.
- —
4. Serology - RPR (titer results).5. CBC and urinalysis must be completed annually.6. Tetanus toxoid: students should be encouraged to receive booster if
ten (10) year period is past.
A. MEDICAL HISTORY OF APPLICANT - please check (V) off box where applicable.Self Family Self Family
Hoarseness ConvulsionsCough Heart DiseaseShortness of Breath onModerate Exertion
Diabetes
K Hepatitis: Type Hay FeverTuberculosis: Type AsthmaEpilepsy Eczema
Mental Disorder Allergic to FoodEmotional Instability Allergic to MedicationsHeadache Allergic to LatexRheumatic Fever Allergic to Bee StingOther:
• PUTNAMNorthern .
Westchester tsmfmsel
BOCES I *
PutnamNorthern
Westchester
BOCESPUTNAM/NORTHERN WESTCHESTER BOCES200 BOCES Drive, Yorktown Heights, NY 10598
The Tech Center at Yorktown - Health Services(914) 248-2413 Email: [email protected]
CONSENT/DECLINATION FORM FOR HEPATITIS B VACCINATION
I understand the benefits and risks of Hepatitis B Vaccination. I understand that I mustreceive at least 3 intramuscular doses of vaccine in the arm over a 6-month period toconfer immunity. However, as with all medical treatment, there is no guarantee that I willbecome immune or that I will not experience an adverse side effect from the vaccine.
I understand that pre-vaccine blood testing for immunity is available.
I understand that participation is voluntary and my consent or refusal of vaccination doesnot waive any rights that pertain to me as a student.
I decline to be immunized at this time. In the event of an accidental exposure, I willreport the incident immediately to the Health Office and consult with my health careprovider regarding post-exposure prophylaxis.
Student Name (Please Print):
Student Signature: ;
Student Date of Birth: Date:
CertificationI certify that I have explained the reasonable risks and benefits of Hepatitis B Vaccine to
(insert student's name) in a manner which permits
the patient to make a knowledgeable decision.
Witness: Date:(Print Name)
Signature:
PutnamWestchesterPUTNAM/NORTHERN WESTCHESTER BOCES
^ ^ 200 BOCES Drive, Yorktown Heights, NY 10598BOCES X ^^2 Tech Center at Yorktown - Health Services
(914) 248-2413 Email: [email protected]
REQUIRED TUBERCULOSIS SURVEILLANCE (B SKIN TESTING - PPD)
Student Name:
Date:
SITE: RF A L F A 5TU
Manufacturer:
Lot #:
Date Planted:
Administered by:
Exp. Date:
TO BE EVALUATED IN 48 TO 72 HOURS (2-3 DAYS)
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
READING MUST BE IN MM mm***Reading may not be given as a range, or as "Positive" or "Negative."
Measure induration (bump), not erythema (redness).
Print Name:
Signature: _
Date:
Putnamwestcitester WKEtL PUTNAM/NORTHERN WESTCHESTER BOCES
—— 200 BOCES Drive, Yorktown Heights, NY 10598BOCES X Tech Center at Yorktown - Health Services
(914) 248-2413 Email: [email protected]
INFLUENZA VACCINE RECORD
Date:
Student Name:(Last) (First) (Middle Initial)
Program: ÿ Full-Time Day ÿ Part-Time I ÿ Part-Time II
Date Vaccine Administered:
Lot Number:
Manufacturer:
Expiration Date:
To Be Completed by Physician
Physician's Name: (Please Print)
Signature: Date:
