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PRE-PLACEMENT REQUIREMENTS
I, Stephanie Cranston, 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)
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: Aug 02, 2016 Date of Step 1: Date: Date:
Result (pos/neg): neg Result: Result: Result:
Induration in mm: 0 Induration: Induration: Induration:
2. MEASLES: 2 MMR Immunizations MMR #1 Date: Apr 28, 1998 MMR #2 Date: Aug 28, 2002
OR Laboratory Evidence of Immunity (Titre): Date of Test: Aug 06, 2016 Result (pos/neg): pos
2. MUMPS: 2 MMR Immunizations MMR #1 Date: Apr 28, 1998 MMR #2 Date: Aug 28, 2002
OR Laboratory Evidence of Immunity (Titre): Date of Test: Aug 06, 2016 Result (pos/neg): pos
2. RUBELLA: 2 MMR Immunizations MMR #1 Date: Apr 28, 1998 MMR #2 Date: Aug 28, 2002
OR Laboratory Evidence of Immunity (Titre): Date of Test: Aug 06, 2016 Result (pos/neg): neg
2016-11-29 *** PASSPORT CONTINUED... *** Required Documentation for the Program Year 15:57
HEALTH AND SAFETY PASSPORT:
PRE-PLACEMENT REQUIREMENTS
4. HEPATITIS B VACCINATION
Hep B #1: Jan 18, 2010 Hep B #2: May 27, 2010 Hep B #3: Date of TITRE: Aug 03, 2016 Result(pos/neg): pos
Booster Dose: Repeat TITRE: Result(pos/neg): (if neg, 2nd series of immunization required)
6. POLIO:
1st Dose Date: 2nd Dose Date: 3rd Dose Date:
7. INFLUENZA VACCINE:
Date: Oct 25, 2016 Date: Date: Date:
Date:
2016-11-29 *** PASSPORT CONTINUED... *** Required Documentation for the Program Year 15:57
HEALTH AND SAFETY PASSPORT:
PRE-PLACEMENT REQUIREMENTS