Compliance Policies and Clinical Regulations


We, the students of the School of Nursing at the University of North Carolina, Chapel Hill, believe that professional behavior plays an important role in our ethical development as nurses. We are committed to demonstrating professional behavior in our roles both inside and outside of the School of Nursing. This goal will be supported through adoption of the following ideals:

We are committed to conducting ourselves in a manner that appropriately represents the prestigious institution which we attend. We seek to reflect the utmost respect for ourselves, and our instructors, classmates, mentors, patients, and the wider community. SON students will:

We assume responsibility for our own actions and are committed to personal growth into a professional role. SON students will:

We are committed to strictly upholding the UNC Honor Code and recognize its importance to the institution and to our professional growth. Students will:

We are committed to enhancing and preserving the health of the community through education and awareness. Students will:

Written: 2008 Class Board
Adopted: 2008 UG Student Body, spring 2008
Approved: Baccalaureate Executive Committee, April 2008


In order to comply with the “Regulation on Student Applicant Background Checks (#700.5.1[R]) policy adopted by the General Administration of The University of North Carolina as well as the contractual mandates of clinical agencies to which students are assigned for clinical education experiences, the School of Nursing (SON) requires all affiliated students1 to undergo a Criminal Background Check (CBC).  The CBC shall be performed: 1) at the initiation of this policy, 2) following admission acceptance but prior to program matriculation, 3) upon program re-entry subsequent to a leave of absence, program withdrawal or program separation greater than thirty consecutive days, and 4) when deemed necessary by School administration.  All offers of admission to the SON issued subsequent to August 2007 will stipulate the applicant’s admission as contingent upon the results of the CBC.  Any student who fails to comply with this requirement may not enroll in the SON.

The CBC must be performed, at students’ expense2, by a qualified vendor selected by the University or by the SON in concert with University specifications, and will meet the following criteria:

Students must sign a Release to Share Background Information and Agreement to Report Future Felony or Misdemeanor Convictions form, which enables the School to share information obtained in the CBC with clinical agencies for the purpose of securing a clinical placement as part of the student’s educational experience. Students must agree to report any felony or misdemeanor charges and convictions (including minor traffic violations), which occur during their enrollment in the SON to the appropriate Academic Assistant Dean (AAD) and/or Asst. Dean, Student Affairs (ADSA).  Failure to report and engage in the resolution of current or future felony or misdemeanor charges and/or convictions in a timely (within 10 business days) and complete manner, and failure to provide requisite information pertinent to disposed or pending cases are violations of the University’s Honor Code. All such offenses will be immediately reported to the Honor System via the Office of Student Conduct, and may serve as grounds for dismissal from the SON.

The SON agrees to use student information for the sole purposes of admission screening and to obtain clinical education placements. In the event the CBC report is positive revealing a felony or misdemeanor charge and/or conviction, the appropriate AAD will discuss the issue directly and immediately with the student prior to sharing the information with a clinical agency.  Prior to meeting with the AAD, the student will submit a thorough but succinct statement (approximately one page in length, signed and dated) describing the incidents denoted in the CBC report, how each case was resolved, and lessons learned from the experience. In the event the student determines the positive CBC report is erroneous, the student may request a repeat check be conducted at student expense using additional information provided by the student to aid in the vendor more accurately identifying the student and issuing a corrected report.

The School and University make the final decision as to whether a student with a positive report may proceed to matriculation.  The clinical agency makes the final decision about whether a student with a positive report may be placed at that site.  The Associate Dean of Academic Affairs will hear student appeals of administrative actions taken as a result of CBC findings.

All student reports conducted prior to the availability of electronic reports will be maintained in paper copy in the School’s permanent student files for a period of no less than ten years post-graduation. All student reports generated electronically will be maintained in a secure electronic database supported by the vendor.

1Affiliated students include: degree-seeking undergraduate or graduate students, post-doctoral fellows of the Schools’ T-32 NRSA fellowship programs, students admitted via The Office of Part-Time Studies with special permission to enroll in selected nursing courses, and students participating in the AHEC RN-Refresher Program.

2Admitted students who initiate a CBC through the School but subsequently withdraw or defer enrollment, are responsible for the standard processing fee

3Students who resided outside the US due to active military deployment, service in the Peace Corps or employment with the US Foreign Service, may submit one of the following alternative forms of documentation in lieu of securing an international background check:

Note: University policy exempts students who are less than 16 years or greater than 65 years of age from completion of the CBC. The SON is unable to do so due to contractual requirements of affiliated clinical agencies.

Draft: 0704; Revised 1104; Revised 0705; Revised 0206; Revised 1007; Revised 1208, Revised 0309; Revised 0409. Revised 0809; Revised 1109; Revision 1011 (Clarifications approved by Office of University Counsel (UNC-Chapel Hill) and Office of General Counsel (The University of North Carolina General Administration); Revised 0212; Revised 0712; 0513, 0316; 1019


Infectious/Communicable Disease Policy Infectious/communicable diseases are common and may be a threat to students and faculty of the School of Nursing. During the performance of clinical practice/research activities, students may have contact with patients/subjects with various infections such as bloodborne transmitted disease (e.g., Hepatitis B [HBV], Hepatitis C [HCV], Human immuno-deficiency virus [HIV; AIDS]), airborne transmitted disease (e.g., tuberculosis[TB], measles, varicella), droplet transmitted disease (e.g., influenza, pertussis, mumps) and contract transmitted disease (e.g., methicillin-resistant Staphylococcus aureus). This contact may expose the student to infectious agents, and may result in the student transmitting an infectious disease to other students, faculty, patients, family members, and subjects. During pregnancy, the fetus may also be at risk depending on the infection (e.g., Varicella).

To help protect the health and safety of its students, as well as that of patients and subjects, the School of Nursing requires:

A. Initial infectious disease screening

B. Pre-exposure prophylactic immunization against specified infectious/communicable diseases

C. Post-exposure prophylactic follow-up/treatment following exposure to specified infectious diseases such as HBV, HIV, and tuberculosis


Students must comply with the communicable/infectious disease policy and protocols of the agency or facility with which they are assigned for clinical practice or research activity, as well as with the policies of the UNC-Chapel Hill School of Nursing, the University, state and Federal statues, regulations, and the contractual mandates of clinical affiliates.


  1. All students enrolled in the University, are required by North Carolina statute to present to the University on or before the first day of enrollment a certificate of immunization that indicates that the student has received the vaccinations required. Student failure to submit documentation as described shall constitute significant non-compliance. In accordance with University policy, the student shall have 30 calendar days from the first day of classes to obtain the required immunizations. Students who fail to comply with the immunization requirements by the end of the specified 30 calendar days will be administratively withdrawn from the University by the University’s Registrar.
  2. Student failure to submit documentation specific to School of Nursing required immunizations, health data and safety elements prior matriculation in the School of Nursing, shall result in the rescission of the student’s offer of admission to the School. Non-compliance that occurs after matriculation shall result in the student being withdrawn from lab/clinical practice/research assignments, loss of privileges in applicable Learning Management Systems, incurring an account hold and may impact enrollment.
  3. Students have the right to petition for an exemption from statutorily required or School required immunizations. Appeals must be based on a student’s health condition, medical disorder or religious beliefs. Documentation supporting the exemption should be submitted to OASS and include: (1) a written justification from the student’s personal medical provider explaining why the vaccination is contraindicated; OR (2) a notarized copy of the “Request for Exemption from Immunization Requirements: Religious Reasons” form.


Students may become ill, injured or exposed to infectious/communicable diseases while engaging in clinical practice/research activities. Illness, injury, or exposure to disease may require, but may not be limited to, counseling, prophylactic intervention, diagnostic procedures and/or follow-up treatment.

  1. The School of Nursing is not liable for health care costs associated with a student’s illness or injury resulting from clinical practice/research activities.
  2. For any student who experiences a blood or body fluid exposure incident, the School of Nursing is responsible for medical costs incurred for counseling and both initial and serial diagnostic testing. The student is responsible for all follow-up care and treatment and/or any diagnostic tests/procedures conducted subsequent to the evaluation phase. Should such post-exposure testing become necessary, all results will be held in the strictest confidence by CHS. Designated CHS staff will document exposures they manage in charts maintained only for such exposures and available only for review by CHS designees and, when necessary, the legal counsel for the University. All specimens will be sent to the Roche Biomed Reference Laboratory using a code. For each “exposure” the following will be documented: the route(s) of exposure, the circumstances, and the name of the source and HIV and Hepatitis B status of the source.
  3. Any student who exposes another to his/her blood/body fluids and/or an infectious disease during clinical practice/research activities may be responsible for all costs incurred as a result of that exposure.

All School of Nursing students (undergraduate, graduate, and post-graduate) who engage in clinical practice/research activities are also required to submit documentation to OASS of current enrollment in a health insurance plan. Students may carry any health and accident insurance plan that provides coverage for blood/body fluid exposure. Students without current health insurance coverage are strongly encouraged to enroll in the UNC System-wide Student Health Plan. Enrollment in this Plan provides coverage for blood/body fluid exposures as well as other health related problems. For information related to specific coverage and coverage costs of the Plan, students are to contact:

Pearce & Pearce, Inc.
P.O. Box 2270, Florence, S.C. 29503
Phone: 888-722-1668

Students who fail to provide documentation of health insurance prior to the first day of enrollment in the School of Nursing will not be permitted to matriculate. Students failing to maintain on-going coverage while enrolled in the School, may not engage in any course related activities, and may be dis-enrolled until coverage has been re-established.


As required by the Occupational Health and Safety Administration (OSHA) students must undergo annual training in the use of universal precautions and transmission-based precautions applicable to individuals with infectious communicable diseases, including HBV, HCV, HIV and tuberculosis. Safety training will be undertaken utilizing the University’s training modules or those required by the UNC Health Care System. The specific communicable disease policies of the agency to which a student is assigned for clinical experience will be reviewed by faculty and students prior to conducting clinical practice/research activities in that facility. Evidence of certification is required by the School upon initial matriculation and annually thereafter, and for each clinical agency assigned. A copy of the certifying document must be maintained in the student’s permanent file in OASS.


Refusal to provide care to persons with HBV, HCV, HIV, Tuberculosis, and/or other infectious diseases is inconsistent with performance expectations for students at the School of Nursing and is antithetical with the ethics of the nursing profession. It is expected that students will provide care to persons with HBV, HCV, HIV, and Tuberculosis. In cases when continuing clinical practice/research activities present more than a minimal risk, such as when a student is immunosuppressed, the student may be temporarily reassigned.

Nursing’s mandate to provide care is exquisitely expressed in an ANA publication:

“Nursing is a caring profession, oriented toward patient advocacy. Because of nursing’s long history of standing ready to assist the ill and vulnerable in society, society has come to rely on nursing and to expect that it will rise to the health demands of virtually any occasion. In a sense, this reciprocity is crucial to the profession. All must know that care will be given when needed and that it will not be arbitrarily, prejudicially or capriciously denied.” (American Nurses Association Position Statement on Risk Versus Responsibility in Providing Nursing Care, December 8, 1994.)


  1. Diphtheria, Tetanus, Pertussis (childhood DTP) or Tetanus-Diphtheria (Adult TD) – 3 dose series.
  2. Tetanus-Diphtheria (Td) Booster – every 10 years, or if no Td Booster obtained in this time period, a Tetanua-Diptheria-acellular Pertusis (TDaP) vaccination is required
  3. Polio – 3 doses only if under 18 years of age.
  4. Mumps – (1) documented administration of two doses of live mumps virus vaccine, or (2) laboratory evidence of immunity
  5. Measles (Rubeola) – (1) documented administration of 2 doses of live measles virus vaccine, or (2) laboratory evidence of immunity
  6. Rubella (German measles) – (1) documented administration of two doses of live rubella virus vaccine, or (2) laboratory evidence of immunity.
  7. TDaP – documented administration of one dose of Tetanua-Diptheria-acellular Pertusis since 2005
  8. Varicella (Chicken Pox) – (1) Documentation of completed two-dose series vaccination, or (2) Laboratory evidence of a positive serologic titer
  9. Hepatitis B Virus (HBV) Vaccination
    1. Documented administration of three dose vaccination series, completed no later than 6 months from program matriculation for all students engaged in clinical practice/research activities
    2. Effective May 2001, laboratory evidence of immunity in the form of a post-vaccination serum antibody titer obtained 4-6 weeks following completion of the vaccination series. The titer many be obtained from CHS or primary care provider of choice.
  10. Seasonal influenza: documentary evidence of seasonal influenza vaccine submitted prior to admission and annually.
  11. Tuberculosis Screening
    1. Tuberculosis Skin Test ( TST: purified protein derivative of Mycobacterium tuberculosis) and results within the past 12 months , unless the test is contraindicated upon a health care provider’s written advice. Written verification of the test results and/or contraindication must be submitted to OASS and CHS. Effective May 2001, the University’s Campus Health Services is requiring a two-step initial TST. All matriculating students shall undergo the primary test as described above, then within no less than 7 days and no more than 12 weeks report to CHS or preferred primary provider for a second test. This approach establishes a baseline test reaction in each student. Annual testing is required thereafter.
    2. A student with a positive TST shall:
      1. If reaction is >5mm induration, adhere to the follow-up/therapeutic regimen of CHS or his/her health care provider
      2. If reaction is >10 mm induration, present documentation of: TST results, follow-up therapeutic regimen, treatment received (if any), and chest film results (if any). If treatment is initiated, a negative chest x-ray must be submitted one year post-diagnosis. An Annual TB Symptoms Questionnaire completed by CHS or the student’s health care provider is required annually thereafter
      3. A student who has diagnosed pulmonary symptoms suggestive of TB shall refrain from contact with patients/subjects until his/her health care provider submits written documentation that the health of patients/subjects is no longer jeopardized. Neither faculty, staff nor students of the School of Nursing may “read” a student’s TST.
      4. Persons allergic to the preservative in the TST, have been vaccinated with BCG or prefer an alternative to the TST, may instead undergo QuantiFERON-TB Gold testing initially and on an annual basis to diagnose current and latent cases of TB.
      5. All students traveling outside the US must obtain a TST 6-8 weeks subsequent to their return to the US L. Other vaccinations: Students participating in international travel which is funded by the University or for which course credit is awarded must adhere to the University’s policies related to international travel, including adherence to all health and security requirements established by the Centers for Disease Control and Prevention and/or the US Department of State.

NOTE: Immunizations A through F are stipulations of the North Carolina immunization statutes and upheld by the University of North Carolina at Chapel Hill:


An immunization record shall be established and maintained in OASS and in CHS.

  1. OASS shall maintain records of the following:
    1. TST results and associated documents, if any
    2. Documentary evidence of immunizations (DPT, TDaP, MMR, Varicella, Influenza, HBV and seasonal influenza)
    3. Signed vaccination contraindication and religious exemption forms
    4. Documentation of vaccinations required for international travel
    5. OSHA training and test results
    6. Anecdotal documentation of exposure incidents involving students
    7. ocumentation of physician’s recommendation of return to clinical setting following exposure or positive test results.
  2. Campus Health Services maintains official records of 1-4 above, plus:
    1. Polio vaccination
    2. Official records of exposure incidents involving students


Infectious Disease Coordinator

A faculty member designated by the Dean serves as the Infectious Disease Coordinator to facilitate communication and dissemination of information about infectious disease control. The Coordinator apprises academic administrators and faculty of CDC recommendations, University, School, and/or agency requirements and other applicable information. The Infectious Disease Coordinator may serve as a resource to students who are exposed to an infectious disease. The University’s CHS will maintain official records of students’ exposure incidents that may occur during clinical practice/research activities. CHS will serve as an available consultant for local providers when a needlestick exposure occurs off-site. In the consultant capacity, CHS will provide local providers with a student’s health record information and information related to the CHS blood and body fluid exposure protocol. CHS will not serve as infectious disease consultants in the case of off-site exposures, however, they will manage care of the student upon the student’s return to the UNC-Chapel Hill campus. It is the responsibility of the clinical faculty to notify the Infectious Disease Coordinator or designee when exposure incidents occur. Anecdotal records of exposure incidents will be submitted to OASS to be filed with the student’s record. The following documents addressing University policy and North Carolina law are available for students’ review/copy in the Office of the Infectious Disease Coordinator, Dr. Margaret Miller, Assistant Dean, Suite 1400, Carrington Hall:

  1. North Carolina Immunization Law General Statutes of North Carolina
  2. General Statutes of North Carolina
    1. Control Measures for Communicable Diseases
    2. Control Measures – HIV
    3. Control Measures – Hepatitis B
    4. Control Measures – Tuberculosis
  3. OSHA Occupational Safety and Health Standards, Bloodborne Pathogens
  4. Exposure Protocol for Students at UNC-Chapel Hill
  5. CDC Infection Prevention Guideline for Outpatient Settings
Exposure Incidents

An “exposure incident” refers to a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee’s duties [a student’s clinical practice/research activities] (OSHA). Students who follow the recommendations developed by the Centers for Disease Control (CDC Universal Blood and Body Fluid Precautions) have minimal danger of contracting any infection in the course of their clinical practice/research activities. When an incident occurs, students must follow the Exposure Protocol for Students at UNC-Chapel Hill as established by CHS.

Follow-Up to Exposure to Blood/Body Fluids

Initial and subsequent care and follow-up activities including recommendations related to counseling, prophylactic/treatment regimens, and continued or restricted practice activities following a student’s exposure incident will be determined by the student’s health care provider (in collaboration with the student) and other appropriate health care professionals. In the absence of a primary health care provider, the student should utilize CHS for health care.

All determinations regarding source of exposure including contact with source, notification of the source’s health care provider, testing of the source, and applicable laws/regulations regarding confidentiality will be made by the student’s health care provider.

1. In the case where source and student testing has been performed and evaluated, CHS will provide the student with information regarding the health care professional’s opinion.

2. “Exposure” incidents are reported to the appropriate sources by CHS. Documentation maintained by the School of Nursing is strictly anecdotal.

Student As Source of Blood or Body Fluid to Another Individual

The following steps are recommended when a student has exposed another individual (to his/her own blood/body fluids during practice, research or other care activities:

1. The exposed individual should immediately call the Campus Health Services Needlestick Hotline, 919-966-6573 during week-day hours (8am – 5pm). After hours call919-966-6573 and have the Health Link nurse page the on-call CHS physician. Students on-site should report to CHS immediately after the call. Off-site students should report to CHS immediately upon return to the UNC-Chapel Hill campus. Health care providers at CHS determine any needed follow-up for the exposed individual in accordance with their Bloodborne Pathogen Exposure Protocol.

2. In any instance where students practicing at UNC Hospitals are the source of a blood or body fluid occupational exposure to a patient, that exposure must be reported to Hospital Epidemiology (919) 966-1638. The information must also be reported to the appropriate unit of the non-UNC Hospitals agency(ies) to which the student is assigned.

References +

American Nurses Association (1992). American Nurses Association position statement on HIV infection and nursing students. In: Compendium of American Nurses Association position statements. Washington, DC.

American Nurses Association (1996). American Nurses Association position statement on risk versus responsibility in providing nursing care. In: Compendium of American Nurses Association position statements. Washington, DC.

Campus Health Services, University of North Carolina at Chapel Hill (2010). Information about tuberculosis (TB) screening tests, Retrieved from

Campus Health Services, University of North Carolina at Chapel Hill (2011). Bloodborne pathogen exposures – students (policy number: INF-N-03).

Campus Health Services, University of North Carolina at Chapel Hill (2011). Protocol for students of UNC-Chapel Hill, Retrieved from

Centers for Disease Control and Prevention (1997). Immunization of health-care workers: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC), Morbidity and Mortality Weekly Report, 46(RR-18)

Centers for Disease Control and Prevention (1998). Measles, mumps, and rubella – Vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: Recommendations of the Advisory Committee on Immunization Practices (ACIP), Morbidity and Mortality Weekly Report, 47(RR-8)

Centers for Disease Control and Prevention (2000). Poliomyelitis prevention in the United States: Updated recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 49(RR-5).

Centers for Disease Control and Prevention (2006). A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC) Part п: Immunization on Adults, Morbidity and Mortality Weekly Report, 55(RR-16)

Centers for Disease Control and Prevention (2007). Prevention of varicella: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 56(RR-4).

Centers for Disease Control and Prevention (2011). Guide to infection prevention for outpatient settings: Minimum expectations for safe care. Retrieved from

General Assembly of North Carolina (2010). North Carolina Immunization Law General Statutes of North Carolina. Chapter 130A, Article 6, Part 2 Immunization. Retrieved from:

Jagger, J. De Carli, G., Perry, J. L., Puro, V., & Ippolito, G. (2003). Occupational exposure to blood-borne pathogens: Epidemiology and prevention. In R. P. Wenzel (Ed.), Prevention and control of nosocomial infections (4th ed, pp. 430-466). Philadelphia, PA: Lippincott Williams & Wilkins

North Carolina Office of Administrative Hearings (2003). Control measures for Hepatitis B (10A NCAC 41A .0203). Retrieved from

North Carolina Office of Administrative Hearings (2005). Control measures- General(10A NCAC 41A .0201). Retrieved from

North Carolina Office of Administrative Hearings (2007). Control measures – HIV (10A NCAC 41A .0202). Retrieved from

North Carolina Office of Administrative Hearings (2011). Control measures – Tuberculosis (10A NCAC 41A .0203). Retrieved from

Occupational Safety and Health Administration (2011). Occupational safety and health standards: Bloodborne pathogens (1910.1030). Retrieved from

Weber, D. J., Rutala, W. A., & Schaffner, W. (2010). Lessons learned: Protection of healthcare workers from infectious disease risks. Crit Care Med, 38(S8), S306-S314. doi:10.1097/CCM.Ob013e3181e69ebd.


Infectious/communicable diseases are common and may be a threat to students and faculty of the School of Nursing (SON). During the performance of clinical practice/research activities, students may interact with clients/research participants with tuberculosis (TB), hepatitis B (HBV), HIV/AIDS, and other infections. This contact may expose the student to infectious agents and may result in the student transmitting an infectious disease to other students, faculty, clients, family members, and research participants. During pregnancy, the fetus may also be at risk. Conversely, the student’s health status may adversely impact the student’s abilities to interact with clients/research participants. Should an exposure or high-risk situation occur, clinical or research experiences may require alteration to provide optimal student learning and to ensure the well-being of both client and student.

Additionally, state and federal statutory regulations, University policy and accreditation standards for affiliated clinical agencies require that nursing students demonstrate particular cognitive and clinical competencies consistent with minimum practice standards. As such, the School is contractually mandated to ensure all students attain and maintain full compliance with each required competency detailed in this policy. Further, the School is contractually obligated to share individual student compliance data with health care agencies to which students have been assigned for clinical educational experiences.


Each enrolled student is accountable for maintaining his/her own health, protecting him/herself and the clients/research participants with whom he/she interacts from communicable/infectious disease, and attaining and maintaining competency with identified practice standards. Further, students must attain and maintain compliance with SON/UNCCH requirements from matriculation through the last day of class in the semester of graduation, and to clinical agency requirements minimally six weeks prior to and throughout the semester of assignment. In all cases, compliance is achieved by submitting documents to the School’s external compliance vendor by posted due dates. Any element slated to expire during a given semester must be completed prior to the start of the term.



Students admitted to the SON are of expected to be of strong character and high integrity who epitomize professional standards and consistently demonstrate policy compliance. However, should a student(s) fail to satisfy initial requirements or meet compliance standards continually throughout the program of study, the following will occur:

Note: Students are accountable for all course content, assignments or tests missed while Sakai access is withdrawn. Faculty are not responsible for disseminating missed content or providing alternative assignments or testing opportunities.


The SON values international education, research and service experiences. Students participating in international travel funded by UNCCH or for which course credit is awarded must adhere to the UNCCH’s policies related to international travel, including adherence to UNCCH policy related to high-risk or prohibited destinations (see: In addition, all such students must be administratively cleared by Office of Student Affairs (OSA) prior to, and upon return from, any travel outside the United States. UNCCH policy also requires student adherence to all health and security requirements established by the Centers for Disease Control and Prevention ( and/or the US Department of State ( Neither UNCCH policies nor SON requirements related to international student travel may be modified by individual faculty, campus departmental/school personnel or staff of external organizations. Exceptions to policies or requirements are not allowed. (Approved: SON Academic Affairs Council, 09/08/09; reaffirmed AAD/AAPC 10/19)


It is the legal responsibility of the SON to maintain documentary evidence of policy compliance in each student’s permanent file. Further, the SON communicates requirement expectations to students through an external compliance vendor – a secure, web-accessible, name/email authenticated database and document repository (currently, CastleBranch). The system provides easily identifiable compliance requirements for the SON, UNCCH and clinical agencies by containing forms, instructional documents, tutorials, web links, etc. necessary for meeting compliance standards. Through this 24/7 accessible system students independently monitor their compliance status and receive reminders of impending deadlines and expirations.


Matriculation to the nursing program requires satisfying the following requirements. Documentation must be submitted for official review through the School’s external compliance vendor:


(Based on NC BON regulations and/or CDC guidelines; detailed requirements available via external compliance vendor)




*Designated forms are submitted to the external compliance vendor and Office of Student Affairs for inclusion in student’s permanent file
** Background check and drug test must only be completed by School’s approved external vendor
^ Universal requirements (applicable to all students)

Prepared: 12/09; rev 03/11; rev 02/12; rev 05/13; rev 05/16; rev 07/17; rev 8/18 (approved AAPC); rev 10/2019 (app. AAD/AAPC 1019)


All students are required to present proof of CPR certification. Evidence of certification in the form of a copy of the American Heart Association certification card is required:

Students must maintain current CPR certification throughout enrollment in the School in Nursing. An expired CPR certification will result in immediate restriction from the clinical setting thus jeopardize student standing in the program. Courses are available through most hospitals, AHECs, and local American Heart Association affiliates. Local vendors providing individual instruction for certification and re-certification offer a flexible option.

Revised: 0305, 02/06, 10/06, 04/09; 02/11; 03/16; 10/19


Assessment of Current Health Statusxx*
Varicella Vaccination Series or Titerxxx
TB Test Results (Two-Step)xxx
Hepatitis B Vaccination Series & Serologic Titerxx*
TDap (if Tetanus > 2 years old)xxx
Seasonal Influenza vaccinationxxx
CPR Certificationxx*
Confidentiality Statementxxx
Health and Accident Insurancexxx
RN Licensen/ax*
Professional Liability InsuranceSON Policyx*
CCEP AHEC Core Orientationxxx
Honor Code Tutorialxxx
Academic Integrity Tutorialxxx
HSL Overview Tutorialxxx
RenewablePre-Licensure BSNMSN/PMSN/DNPPhD*
TB Test – Annuallyxxx
Seasonal Influenza Vaccinationxxx
Health Insurance – Annually or at expirationxxx
CPR Certification – Upon expirationxx*
RN License – Upon expirationn/ax*
Professional Liability Insurance – Upon expirationn/ax*
CCEP AHEC Core Orientationxxx

*Additional requirements for PhD students engaged in clinical practice or research activities involving human subjects are determined by the algorithm on page 2.

Written/Approved: 5/02; Revised 02/03; Revised 04/03; Revised 06/03; Revised 02/04; Revised 04/04; Revised 08/04; Revised 0705; Revised 0206; Revised 10.06; Revised 0307; Revised 06/07; Revised 04/08; Revised 11/08; Revised 12/08; Revised 3/09; Revised 4/09; Revised 08/09; Revised 10/09; Revised 08/10; Revised 03/11; Draft rev 05/11; Revised 0212; Revised 05/13; Revised 03/16; Revised 10/19