Immunization Verification Form for Atlantic Police Academy Programs
Admission/Office of the Registrar 140 Weymouth Street Charlottetown, PE ~ C1A 4Z1
| Type | 1629822412 |
| Size | 78 KB |
Referenced from: Health Clinics
Document text
Section titled “Document text”Admission/Office of the Registrar 140 Weymouth Street Charlottetown, PE ~ C1A 4Z1
Tel: 902-629-4217 (1-800-446-5265)
Immunization Verification Form for Atlantic Police Academy Programs
Section titled “Immunization Verification Form for Atlantic Police Academy Programs”{This form must be completed within 12 months of the Program Start Date.}
Student Name:
Phone No:
Address:
Month/Year
of Birth:
/
Please send this completed form to Holland College Admissions Office with your acceptance documents.
The immunization requirements described on this form were accurate at time you obtained the form from the College. The College has no control over requirements established by clinical and work 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.
The following immunizations are required for students in Atlantic Police Academy programs.
This form is to be completed by a physician or public health official following an examination of the immunization records of the above applicant. Meets requirements
- DPTP (Diptheria, Pcertussis {whooping cough}, Tetanus, Polio) - Booster for Tetanus/Diptheria required every 10-years.
- Yes
- Measles/Mumps/Rubella (MMR) - two doses of vaccine required by all individuals born after 1970.
- Yes
- Hepatitis B vaccine for individuals. This is a series of three doses prior to starting the program. Immunity by means of titre is required.
- Yes
- It is recommended that students enrolling in the Atlantic Police Academy programs be immunized annually with the influenza vaccine. Please indicate the last date of immunization:
__________________________________
- Yes
Physician or Public Health official declaration:
Section titled “Physician or Public Health official declaration:”After an examination of the immunization records of the individual named above, it is my opinion that the ’ studen t’ has met the immunization guidelines listed above.
Signature (Physician/ Public Health):
Date:
Physician/Public Health Contact Information: (Please Print)
Name:
Business Phone No:
Clinic/Office Business Address:
The personal information requested on this form is collected under the authority of Section 31(c) of the PEI Freedom of Information and Protection of Privacy Act and will be protected under Part 2 of that Act. It will be used to verify the immunization of applicants to the Atlantic Police Academy programs at Holland College. If you have any questions about the collection or use of this information, please contact the Chief Privacy Officer at privacy@hollandcollege.com or 902-566-9542, 140 Weymouth Street, Charlottetown, PE, C1A 4Z1.
Rationale:
Section titled “Rationale:”Immunization with Hepatitis B and other vaccines is recommended for people who are at increased risk of occupational infection such as fire, police, security, and correctional workers. Students in these occupations should complete their vaccine series before possible occupational exposure.
Students accepted in Atlantic Police Academy programs are required to have the up-to-date immunizations listed below in order to be permitted to participate in the program. Students accepted to the program will not be allowed to participate without the required immunizations and therefore will not be able to complete the program.
The Physician or Public Health Nursing office that administered your immunization as a child and during your school years will need to complete this form. If your records are not available, you will have to be immunized and screened again. Please note that there is a waiting time between some doses of immunizations, as long as 6 months for the series of Hepatitis B vaccines. In order to ensure that you will meet all the requirements for admission before your program start-date, it is recommended that you begin the process As-Soon-As-Possible after your acceptance into the program .
(Canadian Immunization Guide, 2012 -2014. http://www.phac-aspc.gc.ca/publicat/cig-gci/p03-worktravail-eng.php#a7)