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Faculty of Health Sciences
HEALTH CARE SUPPORT WORKER
Including Health Care Assistant and Community Mental Health Worker
IMMUNIZATION & TB RECORD
***Please PRINT clearly***
STUDENT #:
FULL NAME:
Surname First Name Second Name
Your Permanent Mailing Address
Street
City Prov.
Postal Code
Telephone
Cell
Email _______________________Local Person to Contact in the Case of Emergency
Name
Street
City Prov.
Postal Code
Telephone
Cell
DEPARTMENT REQUIREMENTS
Participation in clinical experience requires assessment of your immunization status. You are required to meet Health Authority Requirements for immunizations for students in practice settings. If Health Authority immunization requirements are not met you will not have access to clinical agencies and, subsequently, the inability to complete required clinical courses.
INFORMATION
Immunizations can be obtained from your Family Physician, Walk-in Clinic Physician, local Public Health Unit, Nurse Practitioner or Travel Clinic.
*Ensure Immunization Record is complete and signed to avoid delays in processing your application.*
PROOF OF IMMUNIZATION
You are responsible to keep a copy of your immunization record as you may be required to provide proof of immunization when in a clinical setting. . Copies of all immunization and lab serology documents need to be submitted along with the completed Immunization Record.
CONSENT (to be signed by the Applicant)
I hereby authorize (give permission to) my Family Physician/Nurse Practitioner or Walk-in Clinic Physician/ Nurse Practitioner to provide ¼ϲʹٷվ Faculty of Health Sciences any information regarding my immunization, and any information and/or opinions regarding my health.
Applicants Signature:_____________________________________________________ Date:____________________
This record must be completed in full and returned by the
deadline date indicated on your acceptance letter to:
¼ϲʹٷվ
David Lam Campus
Office of the Registrar
1250 Pinetree Way
Coquitlam, BC V3B 7X3
KEEP A COPY OF THIS FORM FOR YOUR RECORDS
Student Name (Please Print): _____________________________ Student Number: ________________________
To the Applicant: You are required to complete the following immunizations. Immunizations are required for your own protection and the protection of patients and families you care for as a student. If Health Authority immunization requirements are not met you will not have access to clinical agencies and, subsequently, the inability to complete required clinical courses which would prevent your progression in the program. *If booster is required, serology should be done first as proof, as this can exempt you from additional medical fees.
A. Admission Requirements: items 1 & 2 are required prior to program admission
HEPATITIS B Immunity: (HBsAb Blood test results ________) Health Care Provider Signature:____________
OR
HEPATITIS B Vaccine: Primary Series (3 doses)
1st of Series 2nd of series 3rd of Series
DD MM YY DD MM YY DD MM YY
_______________ _______________ _______________
Health Care Provider Initials Health Care Provider Initials Health Care Provider Initials
____________ ________ ________
TUBERCULOSIS Skin Test: Sept intake: not earlier than May 1; Jan intake: not earlier than Sept 1; Mar intake: not earlier than Nov 1).
Skin Test Result +ve -ve Date _______________ Health Care Provider Signature:
OR
Chest X-Ray (required if skin test is positive):
Chest X-Ray Result: +ve -ve Date _______________ Health Care Provider Signature:
B. Clinical Requirements: items 1 - 5 are required prior to clinical experiences - deadline for these is approximately one month into semester one date provided during the program orientation.
1. TETANUS-DIPHTHERIA-PERTUSSIS (Tdap) Vaccine
Primary series with a TD (Tetanus/Diphtheria). Booster every 10 years
Primary Series Booster
Month/Year Day/Month/Year
_______________ _______________
2. POLIO Vaccine
Basic immunization series plus single booster dose 10 years after primary series. *This is required as a health care worker.
Those with no basic series should have the series completed regardless of interval since last dose
Primary Vaccine Booster
Day/ Month/Year Day/ Month/Yea
_______________ _______________
3. MEASLES-MUMPS-RUBELLA (MMR) Vaccine
Two doses if born on or after January 1, 1957 or immunity to MMR confirmed by RECENT SEROLOGY (report to be attached). *previously experienced illness still requires serology or booster.
1st Dose 2nd Dose
Day/ Month/Year Day/Month/Year Day/Month/Year
_______________ _______________ _______________
4. VARICELLA (CHICKENPOX) Vaccine
Two doses or immunity confirmed by RECENT SEROLOGY (report to be attached) *previously experienced illness still requires serology or booster..
1st Dose 2nd Dose
Day/Month/Year Day/Month/Year Day/Month/Year
_______________ _______________ _______________
5. INFLUENZA Required yearly beginning each fall. Day/Month/Year
_______________
Signature of Public Health Nurse or Doctor or Nurse Practitioner: __________________ Date ______________________
Please note: Each item/vaccination must be signed individually by a health care provider if not completed or recorded initially.
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