Student Health Assessment

Prior to your first clinical date at St. Anthony, please complete the confidential form below.

All fields marked with * are required.

St. Anthony Regional Hospital Student Health Assessment

Please complete the confidential form below prior to your first clinical date at St. Anthony. 

Please upload a copy of all past immunizations, including all those received as an infant or child and / or you may continue to sections below. 

Immunization & Vaccination History
COVID-19 Vaccination

To comply with the federal mandate, St. Anthony is requiring students to have completed the COVID-19 vaccination series before the start of their student experience. 

If YES, please provide the information about your particular COVID-19 vaccine. 

Influenza Vaccine

Please enter the date of your last flu vaccine if your Student Experience falls between October 1st through March 31st.

Measles, Mumps, Rubella (*MMR) A total of two MMR's or a blood test (titer) showing positive immunity is required.
Hepatitis B

Hepatitis B vaccinations are not a requirement, but recommended for anyone at risk for exposure to blood and/or blood products. A declination must be completed if applicable. 

Varicella (Chicken Pox)

Two Varicella vaccinations OR a positive titer will be accepted.

Tuberculosis (Please provide official TB skin test results)
  • Students consistently scheduled for 5 or more hours per week are required to have 2-step TB skin test. At least one  step (skin test) must be completed within the 12 months prior to working at St. Anthony.
  • If needed, students may obtain a TB skin test from the St. Anthony Employee Health Nurse for a fee of $25. 

Tuberculosis Screening (REQUIRED) Answer each question

Have you had any of these signs/symptoms in the last year?  (All questions must be answered.)

Past Training Received

I certify that all of the statements provided here are true and correct to the best of my knowledge.