Immunization Verification Form for Holland College Healthcare Programs
Admission/Office of the Registrar 140 Weymouth Street Charlottetown, PE ~ C1A 4Z1
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Section titled “Document text”Admission/Office of the Registrar 140 Weymouth Street Charlottetown, PE ~ C1A 4Z1
Immunization Verification Form for Holland College Healthcare Programs
Section titled “Immunization Verification Form for Holland College Healthcare Programs”{To be considered current, this form must be completed within 12 months prior to the start date of the Program.}
Student Name:
Student ID
Phone No:
Address:
Month/Year of Birth:
/
Send this completed form to Holland College Admissions Office prior to the program start-date. To be considered current, this form must be completed within 12 months prior to the start date of the Program.
The guidelines for immunization of adults who will be working in health care settings in Canada have been derived from the Canadian Immunization Guide and, in collaboration with, clinical and practicum partners (Canadian Immunization Guide - Canada.ca). The immunization requirements described on this form were accurate at time you obtained the form from Holland College. The College has no control over requirements established by clinical and practicum placement sites. Requirements may be changed at the discretion of the worksite and the worksite has the right to deem any record as not acceptable. If more information is needed, the program Clinical / Practicum Coordinator will contact you. If you have any questions, call the Health Studies Department at 1.902.566.9672.
This form is to be completed by a nurse practitioner, physician, or public health official following an examination of the immunization records of the above applicant. The nurse practitioner, physician, or public health official that administered your immunization as a child and during your school years can complete this form. If your records are not available, you will have to be screened and or immunized again.
If you are accepted into a program that requires immunization, you can book your immunizations and testing through the Holland College Health Clinic. To book an appointment, please email npclinic@hollandcollege.com or call 902-566-9392. You will need your health card and your vaccination record.
Rationale: Health care workers, including students in health care disciplines, who participate in work term, clinical and/or practicum experiences in hospitals, laboratories, and long-term, primary, home, community, and emergency health care agencies, vehicles, and/or worksites are at risk of exposure to communicable diseases because of their contact with patients or material from individuals with infections, both diagnosed and undiagnosed. Immunization directly protects vaccine recipients and indirectly protects vulnerable individuals who may not respond to vaccines or for whom vaccines may be contraindicated.
Students accepted in health care programs are required to have up-to-date immunizations and TB testing to be permitted to participate in clinical practice settings. There is up to a 6-month waiting time between some doses of immunizations. To ensure that you will meet all the requirements before or soon-after your program start-date, it is recommended that you begin the process as-soon-as-possible after your acceptance into the program . You can begin the program if the immunization and testing process has started with a plan in place for completion. Students accepted to a health program will not be allowed into clinical or practicum settings without the required immunizations and testing and therefore will not be able to complete the program.
Surname:
DOB: (Day/Month/Year)
Provincial Health Card #
Immunization and Mantoux Requirements
Section titled “Immunization and Mantoux Requirements”Given Name:
Phone Number:
Country/Province:
| Immunizations &Titre Requirements (Please attach a copy of the results) | Immunizations &Titre Requirements (Please attach a copy of the results) | Immunizations &Titre Requirements (Please attach a copy of the results) | Immunizations &Titre Requirements (Please attach a copy of the results) | Immunizations &Titre Requirements (Please attach a copy of the results) | Meets Requirements | |
Source: https://sam.hollandcollege.com/shared/QMS/Forms/QF201-250/QF222.pdf