Health Care Provider’s 
Certification of New Student’s Health 
  
Instructions for Providers:  
The person bearing this form has been extended an offer of admission to one of the following programs at Red Rocks Community College: 
 
 Registered Nurse (RN) Refresher 
 Nurse Aide 
 Phlebotomy 
 Medical Assisting 
 
To matriculate in the program, it is necessary for the candidate to demonstrate that he or she is free of any medical conditions that could endanger the health or well-being of patients or other students, or prevent him/her from performing the physical tasks of emergency medical care.  Generally, the following tasks are required: 
 
• Ability to be fitted with a respirator mask in case of continued exposure to an airborne pathogen;  
• Ability to lift, carry and balance heavy loads; 
• Ability to interpret written and oral instructions, calculate weight and volumes ratios, and read small print, all under stressful situations;  
• Ability to use good judgment and remain calm in high stress situations;  
• Ability to function efficiently throughout an entire work shift;  
• Good manual dexterity, with ability to perform tasks related to patient care.   

At the expense of the student, please interview and examine this prospective student, and complete the form below.  In the event that you feel the student does have a health condition which could endanger the health or well-being of patients, faculty or students, please discuss that condition with the student and instruct the student to call the appropriate program director as listed below for further instructions. 
 
MOT Clinical Coordinator:
Stephanie Bacon  	303-914-6289
 
Phlebotomy:   
Rita Stoffel    	303-914-6625 

Nurse Aide:
Catherine Wright	303-914-6627

Please complete and sign the back of this sheet. 
Thank you!

 

Name of patient: _________________________________ Date of Birth: _________________ 
 
I understand that the above-named patient has been tentatively extended an offer of admission to a health care training program.  
  
Following an appropriate history and physical examination, it is my opinion that the above-named patient: 
  
___ Does not have a health condition which could endanger the health or well-being of patients, faculty or students, including the patient himself/herself.  
  
___ Does appear to have a health condition which could endanger the health or well-being of patients, faculty or students, including the patient himself/herself.  
 
___ Is pregnant, but has permission to attend and clinicals and waive immunizations at this time. 
 
ADDITIONAL REQUIREMENTS 
 
Please also provide documentation of the following tests/vaccinations: 
 
1. Chicken pox or Varivax vaccination -- Date of illness or vaccination: ________________ 

2. Tetanus -- Date of last vaccination or booster: _____________   

 (Must be within the last 10 years) 
 
3. MMR -- Last vaccination or booster      Date: _____________ Date: _____________ 

Students born after 1957: Dates of no fewer than two MMR vaccinations at least one month apart at age 12  
                                         months or older. 
Student born before and during 1957: Age contracted or date of exposure to. 
 
4. Tuberculosis Testing (PPD only acceptable test, less than one year old) 

Date Tested: _____________ 	  Date Read: _________ Positive/Negative (circle one) 
If positive, date re-tested:  ________ Date Read:  ________ Positive/Negative (circle one) 
If positive, date of Chest X-Ray:  _________________________________________________ 
If positive, start date/end date of treatment:  _________________________________________ 
 
5. Hepatitis B Vaccine (3-shot series) 

Date 1st vaccine received ______________ Titer Date (if applicable):  _______________ 
Date 2nd vaccine received ______________ Results:  _____________________________ 
Date 3rd vaccine received ______________ 
 
6. Seasonal Influenza Vaccine -- Date of vaccination: __________________ 

    _________________________________________         _______________________ 
   Signature of provider         					 Date 
  
    _________________________________________         _______________________ 
   Printed name of provider          					 Degree:  MD, DO, PA, NP 
 
   __________________________________________ 
     Telephone number