Compliance Student Self-Audit & Attestation Form (Fall, Year 2: CO 26)

NUPTHMS students are responsible for maintaining current compliance requirements and “providing annual verification” including, but not limited to, American Heart Association (AHA) CPR, QuantiFERON Gold TB, flu, COVID-19, and Tdap.

If you would like to keep a copy of your submission for your records, please make sure to take a screen shot of your entries before submitting it.

Maintaining current records throughout the program is a prerequisite for participation in all interactions with patients, clients, and community volunteers in the classroom or the clinic. Any student without current documentation will receive a grade of zero for activities missed and will have a "Professional Practice" "Accountability" simple notification forwarded to the Student Progress Committee.

DEADLINE TO SUBMIT THIS FORM: SEPTEMBER 11, 2024, 11:59 PM CT
Demographic Data
Name Name First Last
Audit

You will need to review your compliance requirements in Exxat to complete this portion of the form.
Graduation Year

Year you will graduate from PTHMS.
1a. AHA BLS CPR Certification Date Completed 1a. AHA BLS CPR Certification Date Completed / MM / DD YYYY

The American Heart Association (AHA) Basic Life Support (BLS) CPR for healthcare professional is required.

Certification from non-authorized AHA BLS CPR instructors/providers will NOT be accepted as proof of CPR certification.
1b. Does your AHA CPR certification expire on or before December 6, 2024?

Your AHA BLS CPR EXPIRES every 2 years.

Your AHA BLS CPR certification is GOOD through the LAST DAY OF THE MONTH in which the course was completed.

For example, if you completed an AHA BLS CPR certification course on Nov 12, 2022, then your certification is GOOD through Nov 30, 2024 and it EXPIRES on Dec 1, 2024.

If you answered "YES" to this question, then you will need to UPDATE your AHA CPR certification BEFORE the expiration date OR Dec 6, 2024 - whichever comes first.

If you answered "NO", then you will not need to update your CPR certification until it expires or as otherwise directed by the CE team.
2a. QuantiFERON Gold Tb Test Date Completed 2a. QuantiFERON Gold Tb Test Date Completed / MM / DD YYYY

The QuantiFERON Gold TB Test with a QUALITATIVE (i.e. a report with a "positive" or "negative" result) serum titer report is required.

Two-step and T-spot TB testing will NOT be accepted. If you received a Two-step or T-spot TB test, you will be required to obtain a QuantiFERON TB Gold blood test.
2b. Does your TB test expire on or before December 6, 2024?

Your TB test is GOOD for 1 year from the date of the test - not the date of the result.

For example, if you completed your TB test on April 5, 2024, then your TB test expires on April 5, 2025.

If you answered "YES" to this question, then you will need to UPDATE your TB test BEFORE the expiration date OR Dec 6, 2024 - whichever comes first.

If you answered "NO", then you will not need to update your TB test until it expires or as otherwise directed by the CE team.
3a. Tdap Booster Immunization Date Completed 3a. Tdap Booster Immunization Date Completed / MM / DD YYYY

The Tdap booster immunization is required.

Tdap booster immunization (for adolescents and adults) is NOT the same at Dtap vaccine (for children). The Dtap without an accompanying Tdap will NOT be accepted as proof of immunity.
3b. Does your Tdap expire on or before December 6, 2024?

Your Tdap test expires 10 years from the date it was placed.

For example, if your test was placed on Nov 9, 2014, then your expiration date is Nov 9, 2024.

If you answered "YES" to this question, then you will need to UPDATE your Tdap test BEFORE the expiration date OR Dec 6, 2024 - whichever comes first.

If your expiration date is in the month of December after classes are complete, then you can wait to renew your Tdap; however, it must be up-to-date by the time you return to classes in January.

If you answered "NO", then you will not need to update your Tdap test until it expires or as otherwise directed by the CE Team.
4. Documentation of influenza vaccinations for the 2024-25 flu season must be uploaded to Exxat by September 18, 2024. Have you received your current flu vaccine?

4. Documentation of influenza vaccinations for the 2024-25 flu season must be uploaded to Exxat by September 18, 2024. Have you received your current flu vaccine? Yes, I’ve received it. No, but I have an appointment scheduled before the deadline. No, but I will schedule an appointment before the deadline.
Deadline to Upload Updated Compliance Documents:

For each question (i.e. 1b, 2b, 3b or 4) you replied "yes" to, you will need to upload your updated compliance document(s) NO LATER THAN 2 BUSINESS DAYS before each requirement's expiration date OR any onboarding deadline required for participation in patient or community volunteer learning activities, whichever comes first.

For each question (i.e. 1b, 2b, 3b or 4) you replied "no" to, there is no further action you need to take because your compliance requirement(s) is/are already up-to-date!
Attestation

You will need to need to respond to the following statements, provide comments (as needed), sign, and date to complete this portion of the form. Please submit the form to complete your self-audit & attestation.

Please respond to the following statements:
	YES	NO
I will have a plan to complete all compliance requirements prior to their expiration dates OR December 6, 2024 - whichever comes first.	I will have a plan to complete all compliance requirements prior to their expiration dates OR December 6, 2024 - whichever comes first.YES	I will have a plan to complete all compliance requirements prior to their expiration dates OR December 6, 2024 - whichever comes first.NO
I understand I must monitor and obtain updated document evidence of immunization, test, and certification compliance throughout the program and that maintaining current records throughout the program is a prerequisite for participation in all interactions with patients, clients, and community volunteers in the classroom or the clinic. Without current documentation, I understand I will receive a grade of zero for activities missed and will have a "Professional Practice" "Accountability" simple notification forwarded to the Student Progress Committee.	I understand I must monitor and obtain updated document evidence of immunization, test, and certification compliance throughout the program and that maintaining current records throughout the program is a prerequisite for participation in all interactions with patients, clients, and community volunteers in the classroom or the clinic. Without current documentation, I understand I will receive a grade of zero for activities missed and will have a "Professional Practice" "Accountability" simple notification forwarded to the Student Progress Committee.YES	I understand I must monitor and obtain updated document evidence of immunization, test, and certification compliance throughout the program and that maintaining current records throughout the program is a prerequisite for participation in all interactions with patients, clients, and community volunteers in the classroom or the clinic. Without current documentation, I understand I will receive a grade of zero for activities missed and will have a "Professional Practice" "Accountability" simple notification forwarded to the Student Progress Committee.NO
I will e-mail Rocio.Ramirez@northwestern.edu, Coordinator of Clinical Education, with questions, concerns, and/or updates about my compliance requirements as needed.	I will e-mail Rocio.Ramirez@northwestern.edu, Coordinator of Clinical Education, with questions, concerns, and/or updates about my compliance requirements as needed.YES	I will e-mail Rocio.Ramirez@northwestern.edu, Coordinator of Clinical Education, with questions, concerns, and/or updates about my compliance requirements as needed.NO

Comments:

If you checked "NO" to any of the statements in the preceding section of this form, then please provide clarifying comments for those statements.
My signature attests that I understand the compliance requirements and that I will hold myself accountable to these expectations throughout my enrollment in the NU DPT program.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Compliance Student Self-Audit & Attestation Form (Fall, Year 2: CO 26)

Compliance Student Self-Audit & Attestation Form (Fall, Year 2: CO 26)

DEADLINE TO SUBMIT THIS FORM: SEPTEMBER 11, 2024, 11:59 PM CT

Demographic Data

Audit

Deadline to Upload Updated Compliance Documents:

Attestation