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Navigating the requirements for entry into health science programs requires careful preparation, especially when it comes to fulfilling health and immunization prerequisites. The IRSC 515 form serves as a crucial element in this process for students aiming to embark on their journey within various health science disciplines at Indian River State College. This comprehensive form, divided into a front and back section, outlines necessary physical examinations and a series of immunizations that students must complete prior to their acceptance into programs such as Nursing, Dental Assisting, Pharmacy Technician, and more. The form mandates students to provide detailed personal information and undergo a physical examination by a physician or nurse practitioner, who is then responsible for filling out the examination results, confirming the student's capability to perform essential tasks in their chosen field. Additionally, the form requires documentation of immunizations against diseases like Tuberculosis, Measles, Mumps, Rubella, Tetanus, Diphtheria, Pertussis, Hepatitis B, and Varicella or respective immunity tests, ensuring students meet health standards necessary for clinical practice. This detailed approach underlines the college's commitment to maintaining a safe and healthy educational and clinical environment, emphasizing the importance of preparedness and compliance with health requirements for aspiring health science professionals.

Irsc 515 Example

Health Science Division

PHYSICAL EXAMINATION DIRECTIONS

IMMUNIZATIONS MAY TAKE 30 DAYS TO COMPLETE, SO MAKE AN APPOINTMENT AS SOON AS POSSIBLE.

FRONT OF FORM

1.Student to complete the top portion of the form.

2.Physician or nurse practitioner to complete the bottom portion of the form, sign, and date, including the complete address and phone number of the facility. Form will not be accepted without this information completed. (Cannot be a Chiropractor.)

BACK OF FORM

I.Tuberculin Test: Follow your healthcare provider’s procedure for Tuberculin Skin Testing Method. If Tuberculin Skin Test or Quantiferon Gold Test is positive, have chest X- ray taken or complete the symptom-free checklist if you have had a positive chest x-ray in the past. This test is valid for one year from the time of reading, and must be valid through the end of each semester. (If the TB expires during the semester, it must be updated prior to registering for the semester.)

II.MMR: (Measles, Mumps, Rubella Vaccine) - Proof of two vaccines (physician requires that there be one month between vaccines), or proof of immunizations by titer, or exempt from vaccine if born before 1/1/57. If born after 1/1/57, must have proof of two (2) MMR vaccines after age one (1).

III.Tetanus/Diphtheria/Pertussis: Proof of immunization within the last seven years. (If the Tetanus expires during the semester, it must be updated prior to registering for the semester.)

IV. Hepatitis B Vaccination: Proof of all three immunizations and surface antibody test 1-2 months after dose #3, or Positive Hepatitis B Titer or signature to decline immunization at this time.

V.Varicella Status: Known history of chickenpox with positive Varicella Titer, or 2 doses of the Varicella Vaccine.

VI. Physician or Nurse Practitioner must initial each section where data is entered then sign and date at the bottom.

All health information that is not documented on health forms must have:

1.Letterhead from institution or physician or nurse practitioner.

2.Signature of physician or nurse practitioner.

3.Date immunization or update was given.

IRSC 515A - Revised 9/17

INDIAN RIVER STATE COLLEGE HEALTH SCIENCE DIVISION

This record becomes College property. Students must make personal copies prior to submission; copies will not be provided once submitted.

Note: This information may be shared with clinical agencies.

Physical Examination

Health Science Program: Select One

 

___ Dental Assisting Technology

 

___ Nursing (ADN)

 

 

 

 

 

___ Dental Hygiene

 

___ Nursing (BSN)

 

 

___ EMT/Paramedic

 

___ Pharmacy Technician

 

 

___ Health Care Management

 

___ Phlebotomy

 

 

___ Health Info Technology

 

___ Phy. Therapy Asst. (PTA)

 

 

___ Health Services Management

 

___ Practical Nursing (LPN)

 

 

___ Medical Assisting

 

___ Radiography

 

 

___ Medical Lab Technology

 

___ Respiratory Care

 

 

___ Nursing Assistant

 

___ Surgical Technology

 

 

 

 

 

 

TO BE COMPLETED BY STUDENT BEFORE EXAMINATION

Last Name

First

Middle

(Area Code) Home Phone

Birth Date

 

 

 

 

 

 

 

 

Street Address

Apt.

City

State

 

Zip Code

Emergency Contact:

 

 

 

 

 

 

 

 

Name

 

 

(Relationship to student)

(Area Code) Phone Number

I understand that I may be asked to submit additional data. I understand that any falsification or omission of information can result in my dismissal from the health science program.

 

Student’s Signature:

 

 

 

 

 

Date:

Student I.D. #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO BE COMPLETED BY EXAMINER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Systems Reviewed

Normal Findings

 

 

 

 

 

 

 

 

 

 

Blood Pressure

Yes

No

 

Do you consider this person to be physically and emotionally

 

Temp

Yes

No

 

 

 

 

 

 

 

 

 

capable of performing the essential tasks required?

 

Height

Yes

No

 

Weight

Yes

No

 

 

 

 

Yes No

 

Vision

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hearing

Yes

No

 

 

 

 

 

 

 

 

 

 

ENT

Yes

No

 

Examining Physician/Nurse Practitioner Signature:

 

 

Respiratory

Yes

No

 

 

 

 

 

 

 

 

 

 

Cardiovascular

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GI

Yes

No

 

 

 

 

 

 

 

 

 

 

GU/Reproductive

Yes

No

 

 

 

 

 

 

 

 

 

 

Neuro/Muscular

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Endocrine

Yes

No

 

 

 

 

 

 

 

 

 

 

Integumentary

Yes

No

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRINT

 

 

 

 

 

 

 

 

 

 

 

 

 

Practitioner/Facility Name and Address:

 

 

 

Phone: (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IRSC 515A - Revised 9/17

LABORATORY TESTS AND IMMUNIZATIONS

Student Name:

Program:

PLEASE INITIAL EACH SECTION AND SIGN BOTTOM OF PAGE

To be completed by Health Care Practitioner

I.

Tuberculin Skin Test

Date Administered:

OR

Date Read:

Positive Negative

Quantiferon Gold Test

Date Drawn:

 

 

Date Read:

 

Positive Negative

 

 

 

 

 

OR

 

 

 

 

Chest X-Ray

 

Date:

 

 

 

 

Positive Negative

II.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If born after 1/1/57, must have proof of two (2) MMR vaccines after age one (1).

 

MMR Vaccine

 

Date:

 

Date:

 

 

 

 

 

 

 

OR

 

 

 

 

Rubella Titer

 

Date:

 

 

Immune

Not Immune

 

Rubeola Titer

 

Date:

 

 

Immune

Not Immune

 

Mumps Titer

 

Date:

 

 

Immune

Not Immune

III.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tetanus/Diptheria/Pertussis

 

Date:

 

 

Valid within the last 7 years

OR

 

Tetanus Titer

 

Date:

 

 

Immune

Not Immune

 

 

Diptheria Titer

 

Date:

 

 

Immune

Not Immune

 

 

Pertussis Titer

 

Date:

 

 

Immune

Not Immune

IV.

Hepatitis B Vaccine

Date:

Date:

 

Date:

Surface Antibody Test:

Positive Negative

OR

 

Hepatitis B Titer

Date:

 

 

Immune

Not Immune

 

 

 

 

 

OR

 

 

Sign declination if all three (3) immunizations and Surface Antibody Test are not complete or titer results were negative.

I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus (HBV) infection. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease.

Signature (if declining) _______________________________________________________

V.

Varicella Titer

Date:

 

Immune

Not Immune

 

 

OR

 

 

Varicella Vaccine

Date:

 

 

 

 

Date:

 

 

 

VI.

 

 

 

 

I certify that the above tests and/or vaccinations were performed in this office or laboratory, or documentation was provided to me by the patient.

(If the above tests and/or vaccinations were NOT performed in this office, documentation of agency performing the tests and/or immunizations is provided).

Licensed Health Care Practitioner Signature:_______________________________ License #: ________________________

Print Name:_________________________________________________________ Date: ____________________________

IRSC is an EA/EO educational institution.

IRSC 515A - Revised 9/17

Download PDF Form

Document Specifics

Fact Detail
Student and Practitioner Information The form requires both the student and the examining physician or nurse practitioner to fill out specific sections, including contact information and signatures.
Immunizations and Tests It outlines the requirements for Tuberculin Skin Test, MMR (Measles, Mumps, Rubella) vaccine, Tetanus/Diphtheria/Pertussis, Hepatitis B, and Varicella (Chickenpox) status including tests or immunization records.
Physical Examination Requirements The bottom portion of the form mandates a complete physical examination by a licensed health care provider, who must verify the student's physical and emotional capacity to undertake health science program tasks.
Documentation and Certification All immunization and test information must be validated through signature by a licensed health care practitioner, and this form becomes the property of Indian River State College once submitted.

Guide to Writing Irsc 515

Filling out the IRSC 515 form is a crucial step for students entering health science programs, ensuring they meet the necessary health and immunization requirements. This process involves both the student and a healthcare provider, covering everything from a physical examination to a series of immunizations. Completion of this form helps maintain the safety and health standards within the educational setting, preventing the spread of diseases. Attention to detail and timely submission are key, as immunizations may require up to 30 days to complete.

Steps to Complete the IRSC 515 Form:

  1. At the top of the form, fill in your personal information, including your last name, first name, middle initial, home phone number, birth date, street address, apartment number, city, state, zip code, emergency contact name, relationship to you, and emergency contact phone number.
  2. Read and understand the statement regarding the submission of additional data and the consequences of falsification or omission of information. If you agree, sign and date in the designated area and provide your student ID number.
  3. Schedule an appointment with a physician or nurse practitioner (excluding Chiropractors) to complete the physical examination and immunization sections. Ensure the appointment is early enough to accommodate the 30-day requirement for immunizations.
  4. Allow your healthcare provider to review various systems (e.g., blood pressure, vision, hearing, etc.) and determine if you are physically and emotionally capable of performing the essential tasks required in your program. The provider must initial each reviewed item.
  5. Complete the immunization section on the back of the form, which includes:
    • Tuberculosis Test: Provide the date administered and result, or a chest x-ray result if applicable. Remember, the test must be valid through the end of each semester.
    • MMR (Measles, Mumps, Rubella): If born after 1/1/57, proof of two vaccines post-age one or proof of immunity must be submitted.
    • Tetanus/Diphtheria/Pertussis: Ensure your immunization is valid within the last seven years.
    • Hepatitis B Vaccination: Provide dates and results for all three shots and the surface antibody test, or submit a declination signature.
    • Varicella Status: Indicate a known history of chickenpox with a positive titer or vaccination dates.
  6. Have the healthcare provider initial each section where data is entered regarding immunizations, then sign and date the form. The provider must include their license number and print their name for verification.
  7. Before submitting the form, make personal copies for your records. The college does not provide copies once the form has been submitted.

Remember, submission of this form with accurate and up-to-date information plays a vital role in ensuring a safe and healthy learning environment for all students and faculty in the health science programs. It’s not just about fulfilling a requirement; it’s about contributing to a culture of health and well-being.

Understanding Irsc 515

  1. What is the IRSC 515 form?

    The IRSC 515 form is a document used by the Health Science Division at Indian River State College. It's designed to record a physical examination and immunization data for students entering health science programs. The form is divided into sections for personal details, examination findings by a physician or nurse practitioner, and a detailed record of laboratory tests and immunizations related to Tuberculosis, MMR, Tetanus/Diptheria/Pertussis, Hepatitis B, and Varicella (Chickenpox).

  2. Who needs to complete the IRSC 515 form?

    Students who are applying for or enrolled in any Health Science program at Indian River State College must complete the IRSC 515 form. This includes, but is not limited to, programs such as Nursing (ADN and BSN), Dental Assisting, Pharmacy Technician, Health Care Management, Medical Assisting, and more.

  3. How is the IRSC 515 form divided?

    The IRSC 515 form consists of two major parts:

    • The front of the form, where student information is entered along with a health practitioner's confirmation of physical and emotional capability to perform essential tasks required by the health science program.
    • The back of the form, detailing immunization records and laboratory test results for specific vaccines and tests such as Tuberculin Skin Test, MMR, Tetanus/Diphtheria/Pertussis, Hepatitis B, and Varicella.

    A licensed health care practitioner must complete and sign the bottom of the form, verifying the tests and vaccinations.

  4. What are the key requirements listed on the IRSC 515 form?

    The form includes several specific requirements:

    • A complete physical examination by a physician or nurse practitioner (excluding chiropractors) with details about the student's capability to meet the physical and emotional demands of their program.
    • Proof of immunizations for TB, MMR, Tetanus/Diphtheria/Pertussis, Hepatitis B, and Varicella, or relevant testing indicating immunity. Certain exemptions and declinations are permitted under specified conditions.
    • Information must be valid through to the end of each semester, with updates provided as necessary.

  5. Can a chiropractor complete the IRSC 515 form?

    No, the form explicitly states that a chiropractor cannot complete it. The physical examination portion of the IRSC 515 form must be completed by a licensed physician or nurse practitioner who provides their signature, the date of examination, and the complete address and phone number of the facility where the examination took place.

Common mistakes

Filling out the IRSC 515 form correctly is crucial for those entering the Health Science Division. However, people often make mistakes that can delay their entry into their desired programs. Here are nine common errors to avoid:

  1. Not scheduling an appointment early enough for immunizations, which may take up to 30 days to complete.

  2. Allowing incomplete information on the top portion of the form that the student is responsible for filling out.

  3. Failing to ensure that the physician or nurse practitioner completes the bottom portion of the form, signs, and dates it, including the address and phone number of the facility.

  4. Submitting the form without the necessary signature from a qualified healthcare professional (excluding Chiropractors, as they are not accepted).

  5. Omitting the Tuberculin Skin Test results or not following through with a chest X-ray if the initial test is positive.

  6. Not providing proof of the required two MMR vaccinations after age one for individuals born after 1/1/57.

  7. Forgetting to update the Tetanus/Diphtheria/Pertussis immunization information, which must be valid within the last seven years.

  8. Neglecting to complete the Hepatitis B section by either showing proof of vaccination and surface antibody test or by signing a declination.

  9. Failing to verify Varicella status with a known history or vaccination dates.

These mistakes can hinder the submission process, delay acceptance into the program, and ultimately affect the start of a student’s journey in the Health Science field. Ensuring that all sections are filled out correctly and completely, with all necessary documentation and signatures, is essential for a smooth application process.

Documents used along the form

The IRSC 515 form is instrumental for health science students at Indian River State College, ensuring they meet the necessary physical and immunization requirements for their program. Accompanying this form, several other documents and forms often play a critical role in supporting and validating the information it contains. These additional documents are not only crucial for a comprehensive health record but also conform to program and legal requirements.

  • Immunization Records: These records are primary documents that prove a student has received the necessary vaccines. They must include dates and results, mirroring the information on the IRSC 515 form.
  • TB Test Results: This document provides detailed results of Tuberculin Skin Test or Quantiferon Gold Test. If any result is positive, a chest X-ray report or a symptom-free checklist must also be included.
  • Hepatitis B Vaccination Documentation: This includes records of all three immunizations and the surface antibody test, validating the Hepatitis B section of the IRSC 515 form.
  • Varicella Documentation: Proof of immunity to Varicella, either through vaccination records showing two doses or a positive Varicella Titer result, is required to confirm the Varicella Status section of the form.
  • Chest X-Ray Report: Needed if the Tuberculin Skin Test or Quantiferon Gold Test is positive, this report provides evidence that the individual does not have active tuberculosis, aligning with the requirements stated on the back of the IRSC 515 form.

In supporting the IRSC 515 form, these documents collectively ensure that health science students can safely engage in their chosen programs. Each document plays a specific role in validating the student's health status, providing a comprehensive picture that aligns with program requirements and protects both the student and the institution.

Similar forms

One document closely resembling the IRSC 515 form is the College Student Immunization Record. This form, often required for entry into colleges and universities, tracks a student's vaccination history against diseases such as MMR (Measles, Mumps, Rubella), Tetanus, Diphtheria, and Pertussis, similar to the IRSC 515. It plays a vital role in ensuring public health within educational communities by verifying that students have received necessary immunizations before they engage in campus life. Both documents require healthcare provider validation and student acknowledgment, ensuring the accuracy and integrity of the health information provided.

Another analogous document is the Pre-Employment Physical Examination Form, which is used by employers to determine if an applicant is physically and emotionally capable of performing the job for which they are applying. Much like the IRSC 515 form, this document includes a section for personal and emergency contact information, a comprehensive review of the applicant's physical health including vision, hearing, and cardiovascular health, and requires the signature of a licensed healthcare provider. Although its primary focus is on physical fitness for job duties, rather than immunization status, it similarly ensures individuals meet specific health standards before participation.

The Military Entrance Processing Station (MEPS) Medical Pre-Screen Form serves a similar purpose to the IRSC 515 form in the context of military enlistment. This document gathers detailed personal medical history, immunization records, and results from physical examinations to assess an individual’s fitness for military service. Like the IRSC 515, it requires thorough health screening, including tests for Tuberculosis, Hepatitis, and vaccines for MMR and Tetanus, before an individual can proceed to the next steps of enrollment or participate in military training programs, emphasizing the importance of health in high-demand environments.

The International Certificate of Vaccination or Prophylaxis (ICVP), commonly known as the Yellow Card, is a document recognized internationally that records vaccines administered to an individual, including the Yellow Fever vaccine. Similar to the IRSC 515, it serves as an official record of vaccination but extends its relevance to international travel requirements. Although the ICVP focuses more broadly on travel-related vaccinations, both documents ensure the individual's health and safety by documenting their immunity to specific infectious diseases.

Finally, the Employee Health Record is another document resembling the IRSC 515 form, used within organizations to track the health and immunization status of employees, particularly in healthcare or educational settings. This form might document vaccinations, TB skin tests, and the presence of antibodies, akin to the detailed immunization and health screening requirements seen in the IRSC 515 form. It ensures that employees are in good health and meet the necessary immunization requirements to protect themselves and those they come into contact with during their employment, mirroring the preventative and safety measures highlighted in the IRSC 515 form.

Dos and Don'ts

When filling out the IRSC 515 form for the Health Science Division, it's crucial to pay close attention to the instructions to ensure accurate and complete submission. Here are the dos and don'ts to guide you through the process:

Do:

  1. Make your appointment early: Since immunizations may take up to 30 days to complete, schedule your medical appointment as soon as possible to avoid delays.
  2. Ensure completeness and accuracy: The student must fill out the top portion, and a physician or nurse practitioner, excluding chiropractors, must complete the bottom portion. Ensure all information, including the complete address and phone number of the facility, is fully and accurately provided.
  3. Verify immunizations and tests: Double-check that all required tests and immunization data such as Tuberculin Skin Test, MMR, Tetanus/Diphtheria/Pertussis, Hepatitis B, and Varicella Status are complete and current as specified on the form.
  4. Keep personal copies: Before submitting the form, ensure you make personal copies. Once submitted, it becomes college property, and copies will not be provided.

Don't:

  1. Delay your medical appointment: Don't wait until the last minute to schedule your medical appointment, as completing your immunizations and tests within the required time frame is crucial.
  2. Submit incomplete forms: Avoid submitting the form without the complete address and phone number of the facility or missing signatures, as this will result in your form not being accepted.
  3. Use unauthorized healthcare providers: Do not have the form filled out by a healthcare provider that is not a physician or nurse practitioner, such as a chiropractor, since this will invalidate your submission.
  4. Omit making personal copies: Do not forget to make copies for your personal record before submitting, as you will not receive copies from the college after submission.

Misconceptions

Many people hold misconceptions about the process and requirements detailed in the IRSC 515 form, especially students embarking on their journey in the health sciences. Understanding these misconceptions is crucial for a smooth transition into the program. Here are five common misunderstandings and the truths behind them:

  • Chiropractors can sign the form: It is a common belief that any healthcare provider can complete and sign the bottom portion of the IRSC 515 form. However, the form explicitly states that this section must be completed, signed, and dated by a physician or nurse practitioner. Chiropractors are not authorized to complete this form.
  • The physical examination and immunization records are optional: Some students might think that the physical examination and immunization details are not strictly required. On the contrary, the form must be fully completed to be accepted. This includes a thorough physical examination by a qualified healthcare professional and up-to-date immunization records or exemption proof where applicable.
  • All students need to provide MMR vaccination proof regardless of age: There's a stipulation on the form that students born before January 1, 1957, are exempt from the MMR vaccine requirement. This exception acknowledges the likelihood of immunity among individuals from this age group, negating the need for vaccination proof unless born after this date.
  • Tuberculosis (TB) test results have an indefinite validity: Another misunderstanding is the duration of validity for the TB test results. The form specifies that the Tuberculin Skin Test or Quantiferon Gold Test, and if applicable, chest x-ray, must be valid for one year from the time of reading and must remain valid through the entire semester. If the TB test expires during the semester, an update is required before registering for the next semester.
  • Submission of the form guarantees privacy of health data: While privacy is a significant concern for many students, the form indicates that the information provided may be shared with clinical agencies as part of the program requirements. Although the college becomes the owner of the record upon submission, this clause underscores the importance of students making personal copies for their records.

Dispelling these misconceptions ensures that students are better prepared and can avoid delays in their acceptance into health science programs. It’s essential for students to carefully read the instructions on the IRSC 515 form, understand the requirements, and submit a complete and accurate form to facilitate a smooth admission process.

Key takeaways

When it comes to filling out and using the IRS 515 form for health science programs at Indian River State College, there are several key takeaways that can help ensure the process goes smoothly. Here are the essential points to remember:

  • The IRS 515 form is divided into two main sections: the front, for student and practitioner information, and the back, for detailed immunization and test records.
  • Students are required to complete the top portion of the front side of the form. This includes personal information such as name, address, and emergency contact details.
  • Healthcare professionals – specifically physicians or nurse practitioners, excluding chiropractors – must fill out the lower portion of the form, which includes the physical examination results. They must also include their full address and phone number.
  • The form is stringent about immunization records, especially regarding Tuberculin Tests, MMR (Measles, Mumps, Rubella), Tetanus/Diphtheria/Pertussis, Hepatitis B, and Varicella Status. Detailed instructions are provided for each.
  • A positive Tuberculin Skin Test or Quantiferon Gold Test requires a follow-up chest X-ray or a completed symptom-free checklist for those with a past positive chest x-ray. This test is valid for only one year and must remain valid throughout the semester.
  • For MMR immunizations, those born after 1/1/57 must show proof of two doses after age one, with a month between vaccines, or provide proof of immunity through titers.
  • Tetanus/Diphtheria/Pertussis immunization must be valid within the last seven years and updated as necessary to remain valid throughout the semester.
  • Hepatitis B vaccination requires proof of all three doses and a subsequent positive surface antibody test or a positive titer. Alternatively, individuals can formally decline the vaccination on the form, acknowledging the continued risk of Hepatitis B.
  • Varicella status can be confirmed through a known history of chickenpox with a positive titer or through two doses of the Varicella Vaccine.
  • Each section documenting tests and vaccinations needs to be initialed by the physician or nurse practitioner. Additionally, they must sign and date the bottom of the form upon completion.
  • The form, once completed and submitted, becomes the property of the College. Students are encouraged to make personal copies for their records as no copies will be provided after submission. It's also noted that the information may be shared with clinical agencies.

In preparing and submitting the IRS 515 form, attention to detail and adherence to the specified requirements are crucial for a successful entry into health science programs. Ensuring all immunization and test records are up to date and correctly documented will facilitate a smoother process.

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