Page Belmont University Faculty Immunization & Clinical Requirements Instructions INSTRUCTIONS Instructions for creating your Immunization Record on Clinical Requirements Record Tracking System Create your account by clicking “Online Registration” and fill out all of the necessary information Please allow 1-2 business days for an Email from the Tracking System informing you that your account has been activated Please download all necessary forms Upon completion, send all necessary forms and documents to American DataBank by scanning and uploading them directly into your ITS Profile, by faxing them to 303-749-5516 or emailing them to belmont@americandatabank.com Instructions for entering your Immunization & Clinical Requirements to the Tracking System American Heart Association BLS for Healthcare Providers Certification: Every Years You must have an AHA BLS for Healthcare Providers Please enter the Certification Issue Date in the Tracking System Please make sure to send a copy of Certification (Front & Back with your Signature) to American DataBank via Fax or Email Tennessee RN License: Every Years You are required to have a valid Tennessee RN License Please provide the License Issued Date in the Tracking System Please make sure to send a copy of your RN License to American DataBank via Fax or Email Belmont General Release Information: One Time You must sign the Belmont General Release Form (Find on www.belmontnursingbackgroundcheck.com) Please enter the Release Form Sign Date in the Tracking System Please make sure to send your signed Belmont General Release Form to American DataBank via Fax or Email TB Skin Test Results: Annual You must have done a PPD once per year Please enter your Annual PPD Date and Result in the Tracking System If your PPD is Positive (or you have history of Positive PPDs), you are required to have a Chest X-Ray (Good for Years) Please enter the Chest X-Ray Date and Result on this Form and in the Tracking System Annually, any year you are not submitting a new Chest X-Ray (after your PPD Positive), you must submit a Symptom Free Survey This survey can be any form used by your provider which states that you are not currently suffering the symptoms of active tuberculosis Please provide proof of the annual step TB test in the form of official documentation from your medical provider to American DataBank via Fax or Email If you have had a Chest X-Ray, please provide copies of official medical results If you had a PPD Positive, and are not turning in a new Chest X-Ray, please provide a copy of a TB Symptom Free Survey Tdap (Tetanus, Diphtheria and Pertussis): Every 10 Years You must have Tdap within last 10 years Please provide the proof of Tdap An individual Tetanus dose will not suffice Please enter the Tdap Date on this Form and in the Tracking Systemon this Form and in the Tracking System MMR: One Time You must have Titers for Mumps, Measles, and Rubella with an Immune Result Enter the Date and Result of the Titer in the Tracking System Please be sure to send copies of official Titer Lab Work to American DataBank via Fax or Email IF your Titer is Not Immune, then, you must have One Doses of each Mumps, Measles, and Rubella Vaccination Enter the Date of Vaccination in the Tracking System After the Dose of Vaccination, you are required to have a Titer again to check the Immunity If your Titer is still “Not Immune” then you must sign the Medical Waiver Please enter your Repeat Titer Date and Result in the Tracking System Please be sure to send the Vaccine & Repeat Titer Lab Work to American DataBank via Fax or Email Those who are “Not Immune” for the Repeated Titer, please be sure to send the signed Medical Waiver to American DataBank via Fax or Email Varicella: One Time You must have Titers for Varicella with an Immune Result Enter the Date and Result of the Titer in the Tracking System Please be sure to send copies of official Titer Lab Work to American DataBank via Fax or Email IF your Titer is Not Immune, then, you must have Two Doses of Varicella Vaccination Enter the Date of Vaccination in the Tracking System After the Doses of Vaccination, you are required to have a Titer again to check the Immunity If your Titer is still “Not Immune” then you must sign the Medical Waiver Please enter your Repeat Titer Date and Result in the Tracking System Please be sure to send the Vaccine & Repeat Titer Lab Work to American DataBank via Fax or Email Those who are “Not Immune” for the Repeated Titer, please be sure to send the signed Medical Waiver to American DataBank via Fax or Email American DataBank LLC – supportits@americandatabank.com www.belmontnursingbackgroundcheck.com Revision on 6/13/2012 Page Belmont University Faculty Immunization & Clinical Requirements Instructions Instructions for entering your Immunization & Clinical Requirements to the Tracking System (Continued ) Hepatitis B: One Time You must have a Titer for Hepatitis B with an Immune Result Please enter the Date and Result of the Titer in the Tracking System Please be sure to send copies of official Titer Lab Work to American DataBank via Fax or Email IF your Titer is Not Immune, then, you must have Shot Series of Hepatitis B Please enter the Shot Series Date in the Tracking System After the 3rd Shot, you are required to have a Titer again to check the Immunity If your Titer is still “Not Immune” then you must sign the Medical Waiver Please enter your Repeat Titer Date and Result in the Tracking System Please be sure to send the Shot Series Report & Repeat Titer Lab Work to American DataBank via Fax or Email Those who are “Not Immune” for the Repeated Titer, please be sure to send the signed Medical Waiver to American DataBank via Fax or Email Seasonal Flu Shot: Annual You are required to have a Seasonal Flu Shot Please enter the Seasonal Flu Shot Date in the Tracking System Items you must submit to American DataBank for Tracking: Labwork printouts for all titers: Varicella, Measles, Mumps, Rubella, and Hepatitis B Proof of all Shots, PPDs: Belmont Student Health Form or other proof signed/stamped/printed by your healthcare provider If you need to get a Chest X-Ray or to submit a Symptom Free Survey, American DataBank needs a copy of that printed report (or the Survey) Copy of your CPR card: Must be the American Heart Assoc BLS CPR Card, you must send a copy of the front and back, and you must sign the back of the card Copy of your Tennessee RN License: Be sure to send in a copy of your current RN license Belmont Release of Information American DataBank LLC – supportits@americandatabank.com www.belmontnursingbackgroundcheck.com Revision on 6/13/2012