Health And Safety Passport

HEALTH AND SAFETY PASSPORT: PRE-PLACEMENT REQUIREMENTS

First Name Sandy Chiu-Wei Birth Date 1996-04-13 Acad Year 2018-2019

Last Name Ho Respiratory Therapy Year 1 Program

I, Sandy Chiu-Wei Ho, 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:

Year 1

Mar 26, 2019

Year 2

Student #:

8272882

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 29, 2018

Date of Step 1:

Date:

Date:

Result (pos/neg):

neg

Result:

Result:

Result:

Induration in mm:

0

Induration:

Induration:

Induration:

Date of Step 2:

Jun 09, 2018

Date of Step 2:

Result (pos/neg):

neg

Result:

Induration in mm:

0

Induration:

Date of TB Blood Test:

Date of TB Blood Test:

Result

Result

Hx of positive test:

Hx of positive test:

Chest X-ray (if required)

Chest X-ray (if required)

Date:

Date:

Result:

Result:

Physician Statement

Physician Statement

Date:

Date:

Clear of TB signs/symptoms:

Clear of TB signs/symptoms:

1 Step TB skin test

1 Step TB skin test

Date of Step 1:

Date of Step 1:

Result (pos/neg):

Result:

Induration in mm:

Induration:

Date of TB Blood Test:

Date of TB Blood Test:

Result (pos/neg):

Result (pos/neg):

Hx of positive test:

Hx of positive test:

Chest X-ray (if required)

Chest X-ray (if required)

Date:

Date:

Result:

Result:

Physician Statement

Physician Statement

Date: Clear of TB signs/symptoms:

2.

MEASLES:

MUMPS:

RUBELLA:

2019-03-26

MMR #1 Date:

Laboratory Evidence of Immunity (Titre):

2 MMR Immunizations OR

MMR #1 Date:

Laboratory Evidence of Immunity (Titre):

2 MMR Immunizations OR

2.

Clear of TB signs/symptoms:

2 MMR Immunizations OR

2.

Date:

MMR #1 Date:

Laboratory Evidence of Immunity (Titre):

***PASSPORT CONTINUED... ***

Jul 15, 1997 Date of Test: Jul 15, 1997 Date of Test: Jul 15, 1997 Date of Test:

MMR #2 Date:

Apr 13, 2000

Result (pos/neg): MMR #2 Date:

Apr 13, 2000

Result (pos/neg): MMR #2 Date:

Apr 13, 2000

Result (pos/neg):

Required Documentation for the Program Year

13:43

HEALTH AND SAFETY PASSPORT: PRE-PLACEMENT REQUIREMENTS

First Name Sandy Chiu-Wei Birth Date 1996-04-13 Acad Year 2018-2019

Last Name Ho Respiratory Therapy Year 1 Program

*** Page 2 of 3, PASSPORT CONTINUED ***

3. TETANUS/DIPTHERIA/PERTUSSIS: Date of last immunization: Tetanus/Diptheria #1:

Tdap:

May 21, 2010

Tetanus:

Expiry:

Tetanus/Diptheria #2: May 29, 2018

Tdap:

May 29, 2018

Diptheria:

Expiry:

Tetanus/Diptheria #3:

Expiry:

May 29, 2028

Pertussis:

4. HEPATITIS B VACCINATION: Hep B #1: Apr 13, 1996

Hep B #2: May 16, 1996 Hep B #3: Oct 12, 1996

Booster Dose:

Repeat TITRE:

Hep B #1:

Hep B #2:

Booster Dose:

Hep B #3:

Repeat TITRE:

Hep B Non-Responder

Date of TITRE: May 18, 2018 Result(pos/neg): pos

Result(pos/neg):

(if neg, 2nd series of immunization required)

Date of TITRE:

Result(pos/neg):

Result(pos/neg):

(as per Physician and/or 2 immunization series completed)

Hep B requirement complete

Document reviewed by Practicum Nurse Technologist

5. VARICELLA: One of the following is required: * Laboratory Evidence of Immunity (Titre):

Date of Titre:

* Varicella Vaccine (2 doses required)

1st Dose Date:

May 24, 2018

Result (pos/neg):

pos

2nd Dose Date:

6. POLIO: 1st Dose Date:

2nd Dose Date:

Year 1

3rd Dose Date:

Year 2

Year 3

Year 4

7. INFLUENZA VACCINE: Date: Oct 29, 2018

Date:

Date:

Date:

8. CPR:

Level:

Level:

Level:

Date:

Date:

Date:

10. RESPIRATOR FIT:

Date:

Date:

Date:

Date:

Model:

Model:

Model:

Date:

Date:

Date:

Model:

Model:

Model:

Date:

Date:

Date:

Level: HCP or BLS

Date:

Date:

Sep 15, 2018

Model:

Model:

11. FOOD HANDLER CERTIFICATE: Date:

2019-03-26

***PASSPORT CONTINUED... ***

Required Documentation for the Program Year

13:43

HEALTH AND SAFETY PASSPORT: PRE-PLACEMENT REQUIREMENTS

First Name Sandy Chiu-Wei Birth Date 1996-04-13 Acad Year 2018-2019

Last Name Ho Respiratory Therapy Year 1 Program

*** Page 3 of 3, PASSPORT CONTINUED ***

12. POLICE CHECK:

Level:

Level:

Level:

Level: VSS

Status: Clear

Status:

Status:

Status:

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Date:

Sep 02, 2018

13. FETAL HEALTH SURVEILLANCE: Date:

14. GENTLE PERSUASIVE APPROACHES: Date:

15. NEONATAL RESUSCITATION: Date:

16. NON-VIOLENT CRISIS INTERVENTION: Date:

9. STANDARD FIRST AID: Date: Mar 26, 2017

Date:

Mar 26, 2017

Police Check Level: VSS=Vulnerable Sector Screening; CRC=Criminal Record Check Police Check Status: No CC=No criminal convictions; CC=Criminal convictions

Name:

Janet Parrott-Sobczuk, RN

Student will have original police record check to accompany this document.

Title:

Practicum Nurse Technologist

Date:

Mar 26, 2019

Status:

Complete

Signature:

*** End of Document ***

2019-03-26

Required Documentation for the Program Year

13:43