Medical Student Compliance with Administrative Tasks Policy

PURPOSE
To outline the compliance requirements with administrative tasks expected of all medical students

AUDIENCE
All medical students

LCME STANDARD
12.8 Student Exposure Policies/Procedures

POLICY

Definitions

• Hepatitis B: Three injections with a follow-up positive titer. Titer must show numerical value or description of what a positive result is. If titer is negative, repeat series and titer required.
• Influenza: Annual influenza vaccine each fall.
• MMR (Individual Measles, Mumps, and Rubella): Two immunization dates (dated at least 28 days apart) or positive titer.
• Tdap (Tetanus, Diphtheria, Pertussis): One vaccine within the last 10 years.
• Tuberculosis (TB) Screening: First PPD within the last 365 days and second PPD or Quantiferon within 90 days before the start date. (For positive a PPD or Quantiferon test, a chest x-ray is required within 90 days before the start date.)
• Varicella (check pox): Two vaccination dates (dated at least 28 days apart) or positive titer.

1. Medical students must comply with the required immunization, training, and administrative compliance items listed in the charts below. These are requirements of the University and the UC Davis School of Medicine (the School), based on UC Davis Health Employee Health Services (EHS) policies, the Association of American Medical Colleges (AAMC), and the Center for Disease Control and Prevention (CDC) guidelines.
2. The University or School may require additional immunizations based on public health needs (e.g., COVID vaccination).
3. Immunization requirements include, but are not limited to the following:

4. Training and administrative requirements include, but are not limited to:

PROCEDURE

1. Students are notified of immunization and select training requirements upon acceptance into the M.D. program via the Admissions portal and again a few times via correspondence from the Office of Student Development and the Registrar’s Office. All requirements are also posted on the UC Davis School of Medicine Registrar’s Office webpage.
   
2. All compliance items are tracked through the myRecordTracker© service. The Registrar’s Office staff provide access to myRecordTracker© via their UC Davis student email account. Incoming students cannot sign up for myRecordTracker© until their UC Davis email address is active. Continuing students will use myRecordTracker© for renewable compliance items throughout their time in the M.D. program.
3. Students must remain current with all compliance requirements. Failure to complete compliance items on time may lead to non-participation in courses, in ability to register, delayed verifications, transcript holds, a temporary pause in access to systems such as Elentra and EMR, and referrals to the Director of Medical Student Professionalism, the Associate Dean for Students, the student's academic coach, or the Committee on Student Promotions (CSP). Lapses in compliance may be reported on the Medical Student Performance Evaluation (MSPE).
4. Students holding leadership positions (e.g., co-directors of student clinics, class president, student representative, etc) who are found to be out of compliance will be required to step down from those leadership positions until they are in compliance.

Compliance Management Process

1. All students receive three automated reminder emails from their myRecordTracker© account notifying them of their upcoming compliance requirement(s) due date and provide a link to access the items. The notification intervals are 30 and 15 days before the due date, and on the due date.
2. Students are required to upload evidence of completing their required item(s) to their myRecordTracker© account by the item’s due date or expiration date.
3. If the requirement is not met by the due date, the student will receive up to three additional automated reminder emails from their myRecordTracker©  account. These notification intervals are 5, 15, and 30 days past the due date.
4. Students also receive additional reminders to complete their online trainings from the UC Learning.
5. If a student has not uploaded evidence of completing their requirements by the due date or expiration date, the Registrar’s Office staff will send the student a reminder notification from HS-Compliance email address. The notification will provide the student a one-week extension to complete their overdue compliance item(s) and the opportunity to contact the Registrar's Office to provide additional information, along with an offer to receive assistance from the Registrar's Office staff.
   1. If the overdue compliance item(s) is not completed by the extended due date, the student will receive a second notification from the HS-Compiance email address and will be given an additional week to complete the requirements. The student will be informed their system access (e.g., Elentra, EMR, etc.) will be paused immediately following the missed extended due date and will not be resumed until the compliance item has been met. Reinstating system access could take more than 1 day. The Registrar's Office notification will include the Associate Dean for Students and the Director of Student Affairs as recipients.
   2. If the student remains out of compliance after the extended deadline, the student will receive another notification from the HS-Compliance email address informing them their system access has been paused until the requirement is met. The recipients of this notification will include the Associate Dean for Students, the Director of Student Affairs, the Director of Medical Student Professionalism, and the student's academic coach. This notification will be considered the equivalent of a Physicianship Form (see the Professionalism Policy) and will be tracked by the Director of Medical Student Professionalism.
   3. If the student remains out of compliance or has not been in contact with the Registrar's Office, a personalized email from the Director of Medical Student Professionalism will be sent. The email will include instructions for scheduling a meeting with the Director. Items to be discussed will include reasons for the professionalism lapse, outlining ways to avoid future lapses, consequences of not meeting due dates, and professionalism expectations.
   4. Documentation may be shared with the Associate Dean for Students and the Vice Dean for Medical Education.
   5. Students who remain out of compliance for more than 30 days of the extended due date may be referred to CSP. Repeat referrals to CSP for non-compliance may lead to comments being included in the MSPE.

RESPONSIBILITY
Registrar’s Office

REFERENCES
2175 Employee Immunization Program
myRecordTracker©
Professionalism Policy
Registrar’s Office web pages
Association of American Medical Colleges (AAMC)

POLICY OWNER
Registrar
Associate Dean for Students

REVIEWED BY
Registrar*
Associate Dean for Students
Director for Medical Student Professionalism
Vice Dean for Medical Education

REVIEWED DATE and REVIEW CYCLE
June 2024, 3-year review cycle

* Indicates the Policy Owner