Fillable IMMUNIZATION REQUIREMENTS FORM (The Michener Institute of Education at UHN)

Fill Online, Printable, Fillable, Blank IMMUNIZATION REQUIREMENTS FORM (The Michener Institute of Education at UHN) Form

Use Fill to complete blank online THE MICHENER INSTITUTE OF EDUCATION AT UHN pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

IMMUNIZATION REQUIREMENTS FORM (The Michener Institute of Education at UHN)

On average this form takes 20 minutes to complete

The IMMUNIZATION REQUIREMENTS FORM (The Michener Institute of Education at UHN) form is 5 pages long and contains:

  • 0 signatures
  • 5 check-boxes
  • 78 other fields

Country of origin: CANADA
File type: PDF

Use our library of forms to quickly fill and sign your The Michener Institute of Education at UHN forms online.

BROWSE THE MICHENER INSTITUTE OF EDUCATION AT UHN FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Student Name: _________________________
Updated/Reviewed by an Occupational Health Physician May 2018
IMMUNIZATION REQUIREMENTS FORM
Please note: It is the responsibility of the student to keep a copy of the IRF form, laboratory reports, TB test
forms, and any other associated health requirements documents. In keeping with Michener’s Privacy Policy
,
these records are not archived and are destroyed once the student completes or permanently withdraws from
their program.
PER
SONAL INFORMATION: (SECTION A TO BE COMPLETED BY STUDENT)
Last Name:
Given Names:
Year of Admission:
Date of Birth: (MM/DD/YYYY)
Male
Female
Student #:
SIN #(WSIB Purposes):
Apt. #:
City:
Province:
Country:
Postal/Zip Code:
Personal Email:
Michener Email (if available):
Tel #:
Cell #:
Notify in Emergency:
Relationship:
Tel #:
Cell #:
A. ACC
OMMODATION/ACCESSIBILITY SERVICES
Students who have a documented need for Accommodation/Accessibility are required to complete the Accessibility
Services Registration Form. Please bring this Form with you to your health care provider for completion. The form and any
supporting documents must be uploaded to the student portal by Program due date. A follow up appointment with the
Health Nurse is required within 2 weeks of commencement.
B. POL
ICY FOR STUDENT PLACEMENTS
Health care providers have an obligation to protect patients and themselves from disease transmission that can
occur within the health care practice settings. Immunization is an important tool in preventing the transmission of
infections and assists in safeguarding the health of the student during their education and beyond.
1. Michener has mandated immunization requirements based on OHA/OMA Communicable Diseases Surveillance
Protocols, for all students requiring clinical practice in designated clinical sites as part of their program of study.
2. Clinical sites have the right to refuse access to students who do not meet the immunization requirements.
3. Failure to submit a signed and correctly completed Immunization Requirement Form (IRF) may lead to Academic
Standing penalty which may impact the student’s ability to progress in the program.
BPML800 --- Bridging Program for Med Lab
BPRA800- Bridging Program For Rad Tech
1
Student Name: _________________________
Updated/Reviewed by an Occupational Health Physician May 2018
It is the student’s responsibility to ensure the following:
1. The IRF is completed, legible and signed by a health care provider. Medical exemption must be attached if
applicable (no personal exemptions will be accepted).
2. Other requirements for clinical placement such as Standard First Aid/CPR-HCP (Health care provider) certification
Vulnerable Sector /Persons Check (VSC/VPS) and Mask Fit Test, must be submitted by posted deadlines.
C. IMMUNIZATION REQUIREMENTS (Please ensure the form is complete and legible)
Completion of Immunization requirements may entail more than one health care provider visit.
C1. Tetanus/Diphtheria/Pertussis
A single adult dose (on or after 18
th
birthday) of Tdap-tetanus, diphtheria, pertussis is required. If the student has
received the Tdap vaccination as an adult, a Tetanus and Diphtheria (Td) booster is recommended every 10 years.
There is no contraindication in receiving Tdap if you had recently received Td vaccination. It is not necessary to
wait until your next Td vaccination.
Tetanus/Diphtheria/Pertussis(Adacel) Date: ______________________________________
C2. Varicella
Provide:
(a) a laboratory report as evidence of positive immunity*, or
(b) documented evidence of receipt of 2 varicella vaccines at least 4 weeks apart or
(c) A laboratory confirmation of disease
*If negative immunity, a series of 2 varicella vaccines, given 4 weeks apart is required if conditions (b) or (c) are not
met. If immunization is required plan for
6-8 weeks, to complete the process.
OR
OR
(a) A laboratory report confirming immunity Result: ______________ Date: _______________
*Varicella series of 2 vaccinations required if there is inadequate immunity
(b) Varicella vaccines: dates of 2 vaccinations
1. Varicella date: ____________________________________________________________________
2. Varicella date: __________________________________________________(4-6 weeks after 1
st
dose)
(c) A lab report confirming evidence of the disease Result: ______________ Date: _________
C.3 Measles, Mumps, Rubella
2
Student Name: _________________________
Updated/Reviewed by an Occupational Health Physician May 2018
Provide proof of a series of two MMR immunizations with the initial MMR vaccination date on or after 1
st
birthday. A
2
nd
MMR vaccine will be required if only one MMR immunization is documented. For students unable to provide
documentation of previous MMR immunization, a laboratory report showing immunity is required; if negative
immunity, a booster series of 2 dose(s) of MMR vaccine administered 4 weeks apart is required. If immunization is
required plan for
8 weeks to complete the process.
OR
a. Initial MMR vaccination dates, on or after 1st birthday, with doses given at least 4 weeks apart
1st MMR date: ____________________________ 2nd MMR date: ____________________________
Measles, Mumps and Rubella - Immunity (MMR laboratory report)
b. Measles blood test Date: __________________________ Result: ___________________________
Mumps blood test Date: __________________________ Result: ___________________________
Rubella blood test Date: __________________________ Result: ___________________________
c. MMR booster doses (if required) Date:_____________________________________
Date: _____________________________________
C.4 Hepatitis B:
Provide laboratory report as evidence of positive immunity. If negative immunity, a series of 3 injections may be
required with follow up blood test. If immunization is required plan for
6-9 months, to complete the process.
(Accelerated series should be completed in 3 months, with a follow up booster in 12 months to achieve life-long
immunity). * Blood test 1 month after 3
rd
dose. If previous immunization was remote (e.g. public school) and lab work
is negative - -- give one dose of vaccine and re-test 4-6 weeks later. If negative again, complete second series.
Dates of 3 vaccinations:
1
st
Series
1st hepatitis B Date: ______________________
2nd hepatitis B Date: _____________________
3rd hepatitis B Date: ______________________
2
nd
Series
1st hepatitis B Date: ______________________
2nd hepatitis B Date: _____________________
3rd hepatitis B Date: ______________________
AND
Proof of Immunity (Hep B laboratory report1)
Proof of Immunity (Hep B laboratory report 2 if required)
Non converter
Hep B laboratory report Date: ______________________________ Result: _______________________
* An additional Hepatitis B series of 3 vaccinations required if there is inadequate immunity up to a maximum
of 2 series. Series must be completed prior to the end of the first semester of study.
3
Student Name: _________________________
Updated/Reviewed by an Occupational Health Physician May 2018
D. TUBERCULOSIS SERVIELLANCE REQUIREMENTS.
2-Step TB test is required for all students regardless of BCG vaccination
, with the following exceptions:
(a) you have had a documented prior 2-step TB skin test, or
(b) you have a contraindication to TB skin test, or
(c) you had a negative one-step TB skin test within the last 12 months, then a single TB skin test is required.
If the skin test is positive a chest X-Ray report must be provided. May take 4 weeks to complete, the process.
History of TB infection:
Yes
No Approximate date: ____________________________________
Treatment date: ______________________________________
History of a positive TB test: Yes No Approximate date: _____________________________________
* If yes, a negative chest x-ray report, dated after the date of a medical assessment of the positive TB test must
be attached.
2-Step TB Test
Date administered Date read Results
1. _________________________ ___________________________ _______________mm
2. _________________________ ___________________________ _______________mm
Annual 1-Step: Most recent TB skin test must have been completed within the last year, include with 2-step
Date administered Date read Results
_________________________ ___________________________ _______________mm
Report attached. Chest X-Ray: Required only if TB test result > or equal to 10 mm (positive result).
Comments: ____________________________________________________________________________
E. RECOMMENDED VACCINATIONS
E.1 Influenza Vaccine - -- annually each fall, from October 1
st
- -- November 30. Michener highly recommends all
students be vaccinated with influenza vaccine(s). If there is an outbreak at the clinical site and you have
not been vaccinated, the clinical site has the right to refuse access.
4
Student Name: _________________________
Updated/Reviewed by an Occupational Health Physician May 2018
F. DO YOU HAVE ANY KNOWN ALLERGIES?
G. STUDENT AUTHORIZATION (To be completed by the student)
I __________________________________________________ authorize the health care professional listed
below to complete the Immunization Requirements Form. I give my consent that the information on this
form may be shared with Michener Health Services staff and clinical teaching sites as appropriate.
I also understand that it is my responsibility to inform the appropriate Michener personnel of any
communicable disease, special need or medical condition which may place me at risk or pose a risk to others
at The Michener Institute or on clinical placement.
_____________________________________ __________________________________
Student’s Signature Student ID Number
HEALTH CARE PROFESSIONAL AUTHORIZATION (To be completed by health care professional) I have read and
understood the requirements as instructed. I certify that the above information is complete and accurate.
___________________________________________
Name of Health Care Professional (please print)
Clinic Stamp & contact information (telephone #):
_____________________________________________ _______________________________________
Signature Date
No Yes If yes, indicate if life threatening
Medication: ______________________________________________________________________________
Environmental: ___________________________________________________________________________
Food: ___________________________________________________________________________________
Latex: __________________________________________________________________________________
Other: __________________________________________________________________________________
Do you carry an EpiPen? Yes No
5
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

IMMUNIZATION REQUIREMENTS FORM (The Michener Institute of Education at UHN)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 10 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document