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HEALTH AND SAFETY PASSPORT:

PRE-PLACEMENT REQUIREMENTS

First Name Terri Last Name Middleton


Birth Date 1991-01-20 Program Respiratory Therapy
Acad Year 2017-2018

I, Terri Middleton, agree to release the information below to Practicum Services and the Placement Office at Conestoga College and to
clinical/field placement agencies. I understand that my Program Coordinator will be allowed to know the status of my compliance. (No actual
result will be given to Coordinators)

Student Signature: Date: Dec 06, 2017 Student #: 3002060

Year 1 Year 2 Year 3 Year 4

1. TUBERCULIN TESTING:
2 Step TB skin test 2 Step TB skin test 1 Step TB skin test 1 Step TB skin test
Date of Step 1: May 31, 2017 Date of Step 1: Date: Date:
Result (pos/neg): neg Result: Result: Result:
Induration in mm: Induration: Induration: Induration:

Date of Step 2: Jun 07, 2017 Date of Step 2:


Result (pos/neg): neg Result:
Induration in mm: Induration:
Hx of positive test: Hx of positive test:
1 Step TB skin test 1 Step TB skin test Chest X-ray (if required) Chest X-ray (if required)
Date of Step 1: Date of Step 1: Date: Date:
Result (pos/neg): Result: Result: Result:
Induration in mm: Induration:
Date of TB Date of TB
Date of TB Blood Date of TB Blood Blood Test: Blood Test:
Test: Test: Result: Result:
Result (pos/neg): Result (pos/neg):

Hx of positive test: Hx of positive test: Physician Statement Physician Statement


Chest X-ray (if required) Chest X-ray (if required) Date: Date:
Date: Date: Clear of TB Clear of TB
Result: Result: signs/symptoms: signs/symptoms:
Physician Statement Physician Statement
Date: Date:
Clear of TB signs/symptoms: Clear of TB signs/symptoms:

2. MEASLES: 2 MMR Immunizations MMR #1 Date: Feb 11, 1992 MMR #2 Date: Jun 10, 1996

OR Laboratory Evidence of Immunity (Titre): Date of Test: Result (pos/neg):


2. MUMPS: 2 MMR Immunizations MMR #1 Date: Feb 11, 1992 MMR #2 Date: Jun 10, 1996

OR Laboratory Evidence of Immunity (Titre): Date of Test: Result (pos/neg):


2. RUBELLA: 2 MMR Immunizations MMR #1 Date: Feb 11, 1992 MMR #2 Date: Jun 10, 1996

OR Laboratory Evidence of Immunity (Titre): Date of Test: Result (pos/neg):

2017-12-06 *** PASSPORT CONTINUED... *** Required Documentation for the Program Year 08:30
HEALTH AND SAFETY PASSPORT:
PRE-PLACEMENT REQUIREMENTS

First Name Terri Last Name Middleton


Birth Date 1991-01-20 Program Respiratory Therapy
Acad Year 2017-2018
*** Page 2, PASSPORT CONTINUED ***

3. TETANUS/DIPTHERIA/PERTUSSIS: Date of last immunization:


Tetanus/Diptheria #1: Tdap: Tetanus: Expiry:
Tetanus/Diptheria #2: Tdap: Jun 02, 2017 Diptheria: Expiry:
Tetanus/Diptheria #3: Expiry: Jun 02, 2027 Pertussis:

4. HEPATITIS B VACCINATION
Hep B #1: Sep 29, 2003 Hep B #2: Oct 13, 2004 Hep B #3: Date of TITRE: Jun 07, 2017 Result(pos/neg): pos
Booster Dose: Repeat TITRE: Result(pos/neg): (if neg, 2nd series of immunization required)

Hep B #1: Hep B #2: Hep B #3: Date of TITRE: Result(pos/neg):


Booster Dose: Repeat TITRE: Result(pos/neg):

Hep B Non-Responder (as per Physician and/or 2 immunization series completed)

Hep B requirement complete Documentation verified by Practicum Nurse Technologist

5. VARICELLA: One of the following is required:


* Laboratory Evidence of Immunity (Titre): Date of Titre: Jun 09, 2017 Result (pos/neg): pos
* Varicella Vaccine (2 doses required) 1st Dose Date: 2nd Dose Date:

6. POLIO: 1st Dose Date: 2nd Dose Date: 3rd Dose Date:

Year 1 Year 2 Year 3 Year 4

7. INFLUENZA VACCINE:
Date: Nov 07, 2017 Date: Date: Date:

8. CPR: Level: Level: Level:

Level: HCP Date: Sep 10, 2017 Date: Date: Date:

9. STANDARD FIRST AID:

Date: Sep 10, 2017 Date: Sep 10, 2017 Date: Sep 10, 2017 Date:

10. RESPIRATOR FIT: Date: Date: Date:

Date: Model: Model: Model: Model:

Date: Date: Date:

Date: Model: Model: Model: Model:

11. FOOD HANDLER CERTIFICATE:


Date: Date: Date: Date:

2017-12-06 *** PASSPORT CONTINUED... *** Required Documentation for the Program Year 08:30
HEALTH AND SAFETY PASSPORT:
PRE-PLACEMENT REQUIREMENTS

First Name Terri Last Name Middleton


Birth Date 1991-01-20 Program Respiratory Therapy
Acad Year 2017-2018
*** Page 3, PASSPORT CONTINUED ***

12. POLICE CHECK: Level: Level: Level:


Level: VSS Status: Clear Status: Status: Status:
Date: Jul 25, 2017 Date: Date: Date:

13. NONVIOLENT CRISIS


INTERVENTION:
Date: Date: Date: Date:

14. GENTLE PERSUASIVE


APPROACHES:
Date: Date: Date: Date:

Police Check Level: VSS=Vulnerable Sector Screening; CRC=Criminal Record Check


Police Check Status: No CC=No criminal convictions; CC=Criminal convictions Student will have original police record check to accompany this document.

Name: Janet Parrott-Sobczuk, RN Title: Practicum Nurse Technologist

Signature: Date: Dec 06, 2017

*** End of Document *** Status: Complete

2017-12-06 Required Documentation for the Program Year 08:30