Immunization Verification Form for Wildlife Conservation Technology Program
Admission/Office of the Registrar 140 Weymouth Street Charlottetown, PE ~ C1A 4Z1
| Type | 1629822412 |
| Size | 73 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 Wildlife Conservation Technology Program
Section titled “Immunization Verification Form for Wildlife Conservation Technology Program”{This form must be completed within 12 months of the Program Start Date.}
Applicant Name:
Phone No:
Address:
Month/Year
of Birth:
/
Pre-exposure rabies immunization with either HDCV or PCECV should be offered to people at potentially high risk of contact with rabid animals, e.g., certain laboratory workers, veterinarians, animal control and wildlife workers, spelunkers, and persons hunting and trapping in high-risk areas. (Canadian Immunization Guide.)
Tetanus is an acute and often fatal disease caused by an extremely potent neurotoxin produced by Clostridium tetani. The organism is ubiquitous in soil but has also been detected in the intestines of animals and humans. Wounds that are contaminated with soil or animal/human feces and that are associated with tissue injury and necrosis are most frequently associated with tetanus. It is recommended that all Canadians receive a primary immunizing course of tetanus toxoid in childhood followed by routine booster doses every 10 years. Adults who have not previously received a primary tetanus toxoid series require three doses as part of an adult primary immunization regimen. (Canadian Immunization Guide.)
Students accepted in the Wildlife Conservation Technology program are required to have up-to-date immunizations for Tetanus and Rabies in order to be permitted to participate in laboratory and field exercises. Students accepted to the programs 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 - for rabies three doses of HDCV or PCECV are required and should be given on days 0, 7 and 21. 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 you receive your acceptance notification from the College.
Please send this completed form to Holland College Admissions Office after you have been notified of your acceptance. 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 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. If you have any questions, call the Admissions Office at 1.800.446.5265.
The following guidelines for immunization of adults who will be working with animals and in wildlife settings in Canada have been derived from the Canadian Immunization Guide.
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
- Tetanus-diphtheria vaccine every 10-years. Individuals with direct patient contact should receive acellular pertussis (whooping cough) combined with that vaccine on one occasion during adulthood.
- Yes
- Rabies vaccine every two years or when the antibody titres fall below 0.5 IU/mL (see Public Health Agency of Canada for full details: http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-rabi-rage-eng.php)
- 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 ‘applicant’ meets the guidelines listed above.
Signature (Physician/ Public Health):
Date:
Physician/Public Health Contact Information: (Please Print)
Section titled “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 Wildlife Conservation Technology program at Holland College. If you have any questions about the collection or use of this information, please contact Holland College’s Chief Privacy Officer at privacy@hollandcollege.com or 902-566-9542, 140 Weymouth Street, Charlottetown, PE, C1A 4Z1.