School of Nursing: Student Compliance Program Policy


School of Nursing: Student Compliance Program Policy

Unit Policy



To define mandatory health, safety and legal elements of student compliance, and describe School of Nursing (SON) and student responsibilities for ensuring student accountability with satisfactorily fulfilling of all elements.

Scope of Applicability

All enrolled nursing students.



Infectious/communicable diseases are common and may be a threat to students and faculty of the 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.

Student Responsibilities

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 and University of North Carolina at Chapel Hill (UNC-Chapel Hill) 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.

Consequences of Non-compliance

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:

  • Upon program entry, any student who fails to attain compliance by the first day of class, may not matriculate. (Exception: students admitted less than two weeks prior to the first day of class must meet compliance by end of the first week of class).
  • Continuing students deemed non-compliant by posted compliance deadlines and/or first day of class in any term, will be withdrawn from enrolled clinical course(s), and, following advisement by the appropriate program Associate Dean, will establish an alternate study plan and re-enroll in needed clinical courses in a later semester.
  • Students who attain compliance initially but fail to properly maintain compliance with School, University, or agency-specific requirements will jeopardize their Sakai access, incur an academic hold on their UNC-Chapel Hill account, have their clinical privileges revoked, and incur a grade penalty in all enrolled courses. If the student doesn’t respond within 72 hours, the student will be reported to the respective Progression Review Committee for violation of unprofessionalism by violation of this policy. The PRC will review within 48 hours and take definitive action on the student’s status which may include course dis-enrollment, semester suspension, or program dismissal.

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.

  • Repeated failure to attain or maintain compliance with SON/UNC-Chapel Hill/agency compliance requirements may result in student disenrollment. Note: no grace period exists following the confirmed expiration date or posted submission deadlines.

International Travel

The SON values international education, research and service experiences. Students participating in international travel funded by UNC-Chapel Hill or for which course credit is awarded must adhere to the UNC-Chapel Hill's policies related to international travel, including adherence to UNC-Chapel Hill's policy related to high-risk or prohibited destinations. 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. UNC-Chapel Hill policy also requires student adherence to all health and security requirements established by the US Centers for Disease Control and Prevention and/or the US Department of State. Neither UNC-Chapel Hill 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)

School of Nursing Responsibilities

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, UNC-Chapel Hill, 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.

Health requirements

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

  • Assessment of current health status* (includes physical examination and psycho-emotional evaluation); original form must be submitted to OSA for inclusion in permanent student file
  • Measles/Mumps/Rubella^: evidence of definitive immunity
  • Diphtheria/Pertussis/Tetanus^: evidence of lifetime and current immunity Varicella^: evidence of definitive immunity
  • TB screening^: current evidence of negative screening prior to matriculation and annually Hepatitis B: evidence of definitive immunity
  • Seasonal influenza vaccination^: evidence of annual vaccination

Safety requirements

  • Current AHA-BLS Certification
  • Annual OSHA training/testing
  • Annual validation of personal health/accident insurance coverage^
  • Background check^** conducted in strict accordance with SON policy, Student Criminal Background Check Policy based on legal name, date of birth and student provided SSN, and covering the lesser period of the past seven years or since the student’s 16th birthday, to include a search of:
    • all geographic addresses, both domestically and internationally, associated with the student’s complete residential history, places of employment, and educational institutions attended
    • all felony and misdemeanor charges and convictions;
    • the national Sexual Offender/Predator Database check,
    • the Office of the Inspector General’s List of Excluded Individuals/Entities (LEIE) and the General Services Administration’s Excluded Parties list (EPLS), and
    • the UNC-Chapel Hill Suspension and Expulsion Database, National Student Clearinghouse and NC Department of Public Instruction enrollment database (as available).
  • Annual 12-Panel Urine Drug Screen** Includes: AMP (amphetamine), BAR (barbiturates), BZO (benzodiazepines), COC (cocaine), THC (marijuana), MTD (methadone), mAMP methamphetamine), MDMA (ecstasy), OPI (opiate), PCP (Phencyclidine) PPX (Propoxyphene), and OXY (oxycodone).

Legal requirements

  • Confidentiality Statement^*
  • Annual HIPAA training/testing ^
  • Annual evidence of professional liability insurance (only UNC-Chapel Hill policy accepted; coverage level: $1M per occurrence/$3M aggregate)
  • Unrestricted RN License (as applicable to student classification)
  • AHEC Core Orientation completed annually

University/School of Nursing Policy documents

* 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)


  • Doctor of Philosophy (PhD) students must meet compliance requirements commensurate with the intensity of client/human subject contact they experience through research or employment activities. These students comply with all universal requirements prior to matriculation, submitting appropriate annual renewal documentation as needed. If the student’s situation changes, as with employment or dissertation work, the student must consult with the Assoc. Dean, Student Affairs, and attain compliance with applicable requirements prior to engaging in an elevated level of client/subject contact.
  • Requirements by contact level:
    • No contact: matriculation requirements; exceptions: drug screening, demonstrated Hepatitis B immunity, professional liability insurance, AHA-BLS certification, NC RN license, and AHEC Core Orientation.
    • Indirect contact, or non-invasive direct contact: matriculation requirements; exceptions: demonstrated Hepatitis B immunity, professional liability insurance, AHA-BLS certification, and NC RN license.
    • Invasive direct contact, to include serving as Teaching Fellow: matriculation requirements without exception.

Related Requirements

External Regulations and Consequences

Unit Policies, Standards, and Procedures

Contact Information

Policy Contact

Kathy Moore, Assistant Dean Student Affairs

Important Dates

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)


Article ID: 132433
Thu 4/8/21 9:31 PM
Mon 3/4/24 2:20 PM
Effective Date
If the date on which this document became/becomes enforceable differs from the Origination or Last Revision, this attribute reflects the date on which it is/was enforcable.
02/12/2021 2:29 PM
Issuing Officer
Name of the document Issuing Officer. This is the individual whose organizational authority covers the policy scope and who is primarily responsible for the policy.
Issuing Officer Title
Title of the person who is primarily responsible for issuing this policy.
Senior Associate Dean for Academic Affairs
Last Review
Date on which the most recent document review was completed.
07/22/2022 12:00 AM
Last Revised
Date on which the most recent changes to this document were approved.
02/12/2021 2:29 PM
Next Review
Date on which the next document review is due.
07/22/2024 12:00 AM
Date on which the original version of this document was first made official.
11/05/2019 11:00 PM
Responsible Unit
School, Department, or other organizational unit issuing this document.
School of Nursing