Online forms: Nurse Aide II Acute Care Health Record

Directions: have your physician fill out and sign the Health Record (front) and Certification of Immunizations. Both must be submitted to the Allied Health Office at Butler Community College by the first day of class.

The clinical experience for AH125 – Nurse Aide II Acute Care students may require prolonged standing and walking; frequent heavy lifting, pushing, pulling, carrying; occasional climbing, stooping, balancing, kneeling; constant need for good vision and hearing; ability to tolerate stressful situations; and occasional exposure to hazardous material.

II. REQUIRED IMMUNIZATIONS- MUST BE ON FILE IN THE ALLIED HEALTH OFFICE.

III. TUBERCULIN SKIN TEST REQUIRED ANNUALLY.

If you would prefer to fill this form in offline, then please download the following blank PDF form, and post it back to us at the address above.