Fillable Overview Health care students are at risk of (Vancouver Island University)

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Overview Health care students are at risk of (Vancouver Island University)

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Immunization Requirements—Health Care Programs
Page 1 of 9
Rev. 01/2022 Immuniz-Reqmts_Health-Care
Overview
Health care students are at risk of exposure to communicable diseases because of their contact with
patients/clients/residents or material from patients/clients/residents with infections, both diagnosed and
undiagnosed. Maintenance of immunity against vaccine-preventable diseases is an integral part of a health
care facility’s occupational health program. Optimal immunization for health care students will not only
safeguard their own health but may also protect patients/clients/residents from becoming infected by a heath
care student.
Students should be aware that lack of immunization might affect their ability to work/do their practicum in
some facilities and may affect their ability to progress in the program.
The priority for all students of health care programs should be to ensure that all routine immunizations,
including booster doses, are completed and booster doses are provided as needed on an ongoing basis.
Reference: BC Centre for Disease Control Immunization Program (2016). Communicable disease control
manual, Section III.
https://www.healthlinkbc.ca/healthlinkbc-files/immunization-health-care-workers
Immunization Process for Health Care Students
1. Students newly admitted to health care programs will submit proof of immunization upon registration for
their admission. Records must be signed or stamped by a health care provider.
2. Immunizations and TB testing may be arranged by appointment at:
- Local Health Units
- Travel Clinics
- Family Physician
- Pharmacists
- Other (e.g., Tillicum Lelum Aboriginal Friendship Centre, Nanaimo, BC)
Students should bring all childhood or previous immunization records to the appointment for
review.
3. Immunizations will be provided to students for the specific program they are entering, based on previous
immunizations, birth year, and previous vaccine preventable illness.
4. All students are responsible for keeping their own records of immunization and/or laboratory testing, and
updating their immunizations as needed.
5. Students who cannot be immunized because of allergies, pregnancy or for other reasons should provide a
letter from a health care provider to that effect.
Immunization Requirements—Health Care Programs
Page 2 of 9
Rev. 01/2022 Immuniz-Reqmts_Health-Care
Please note: There may be a fee for vaccination services.
Name:
(Last)
(First)
(Initial)
Maiden Name:
(If Applicable)
Address:
(City) (Prov) (Postal Code)
Tel. No. (Include area code):
Email:
Date of Birth (YYYY-MM-DD): / /
Personal Health No. (Care Card):
Program Name:
VIU Student No.:
Program Entry Date (YYYY-MM):
Immunization Requirements—Health Care Programs
Page 3 of 9
Rev. 01/2022 Immuniz-Reqmts_Health-Care
***** Please list all dates for immunizations in the following order: Year/Month/Day *****
Note: Vaccine providers should refer to the BC Centre for Disease Control (BCCDC) Communicable Disease
Control Manual available at www.bccdc.ca for the most current immunization guidelines and eligibility for
publicly-funded vaccines.
TD - Tetanus & Diphtheria
Primary Tetanus/Diphtheria-containing vaccine series (3 or 4 doses) in early childhood:
Yes No
If no, completion of 3 dose series:
Tdap (Adacel) dose #1: Date:
Td dose #2: Date:
Td dose #3: Date:
Td booster (must be within the last 10 years): Date:
Immunization Requirements—Health Care Programs
Page 4 of 9
Rev. 01/2022 Immuniz-Reqmts_Health-Care
Polio
Primary polio series (3 doses) in early childhood: Yes No
Polio dose #1:
Date:
Polio dose #2:
Date:
Polio dose #3:
Date:
Polio booster 10 years after primary series for health care students who may be exposed to feces:
Date:
Immunization Requirements—Health Care Programs
Page 5 of 9
Rev. 01/2022 Immuniz-Reqmts_Health-Care
Measles, Mumps, Rubella (MMR)
The need for MMR vaccine is dependent on birth year, previous illness, and previous immunization for
each of the antigens. Previous vaccines may have been given as Measles, Mumps and Rubella (MMR),
or singly, or in various combinations.
Measles, Mumps and Rubella (MMR) vaccine #1: Date:
Measles, Mumps and Rubella (MMR) vaccine #2: Date:
Immunization Requirements—Health Care Programs
Page 6 of 9
Rev. 01/2022 Immuniz-Reqmts_Health-Care
Chicken Pox (Varicella)
If Varicella disease history or date of vaccines cannot be confirmed, then a Varicella IgG titre must be
determined.
History of disease: Yes No Date (if known):
OR Varicella immunity (IgG antibody): Result: Date:
If susceptible: Varicella vaccine dose #1: Date:
Varicella vaccine dose #2: Date:
Immunization Requirements—Health Care Programs
Page 7 of 9
Rev. 01/2022 Immuniz-Reqmts_Health-Care
Hepatitis B Vaccine Series AND Immunity Antibody Test
Students are considered immune to Hepatitis B if they have completed a series of Hepatitis B AND have
one documented laboratory test showing immunity.
Hepatitis B immunity: Yes No Proof: Date:
If necessary, the Hepatitis B series may be initiated upon entry into the program.
Hepatitis B:
Dose #1: Date:
Dose #2: Date:
Dose #3 (if 3 dose program, or if needed): Date:
Repeat Hepatitis B series (as needed):
Dose #4: Date:
Dose #5: Date:
Dose #6: Date:
Hepatitis B vaccine is recommended for health care workers who may be exposed to blood or body fluids.
Individuals are considered to be immune if they have completed the hepatitis B vaccine series AND
have a lab result indicating immunity. Those who do not develop immunity (non-responders) to an initial
vaccine series should be offered a second series of vaccine. To check for immunity, hepatitis B antibody levels
should be tested 1to 6 months after completion of the vaccine series.
Immunization Requirements—Health Care Programs
Page 8 of 9
Rev. 01/2022 Immuniz-Reqmts_Health-Care
TB Screening
All health care students need to be screened for tuberculosis (TB).
Students should have proof of a negative TB skin test done within the past 12 months prior to
commencement of the program unless they are a known positive reactor.
TB skin test date:
TB read date:
Result: (mm) Read by:
(Signature of Health Care Provider)
TB chest x-ray (if needed): Result: Date:
Note: Refer to the BCCDC Tuberculosis Manual available at www.bccdc.ca for TB screening guidelines.
Immunization Requirements—Health Care Programs
Page 9 of 9
Rev. 01/2022 Immuniz-Reqmts_Health-Care
COVID 19 Vaccine
On October 14, 2021, the Provincial Health Office issued an order requiring health care staff and regulated
health professionals to be vaccinated against COVID-19.
To see the full provincial order please check here: https://www2.gov.bc.ca/assets/gov/health/about-bc-s-
health-care-system/office-of-the-provincial-health-officer/covid-19/covid-19-hospital-and-community-
vaccination-status-information-preventive-measures.pdf
This information is a requirement for Island Health and will be needed to enter practicum.
Proof of COVID Passport:
Immunization Requirements—Health Care Programs
Page 10 of
9
Rev. 01/2022 Immuniz-Reqmts_Health-Care
***** Students are responsible for submitting this form to the university as directed by their program
registration. *****
I certify that the above information is accurate and up to date:
Signature of Student
Date:
Name/Stamp of Health Care Provider Reviewing This Document
Signature of Health Care Provider
Date:
The above is a generic form created by Vancouver Island University for students based on the
recommendations of BC Centre for Disease Control (BCCDC).
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Completed 15 May 2022

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