HEALTH AND SAFETY PASSPORT:

PRE-PLACEMENT REQUIREMENTS

First Name Deepa Last Name Govind

Birth Date 1989-07-20 Program Respiratory Therapy
Acad Year 2016-2017

I, Deepa Govind, 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: Apr 07, 2017 Student #: 7023211

Year 1 Year 2 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: Jun 14, 2016 Date of Step 1: Date: Date:
Result (pos/neg): pos Result: Result: Result:
Induration in mm: 6 Induration: Induration: Induration:

Date of Step 2: Jun 22, 2016 Date of Step 2:

Result (pos/neg): pos Result:
Induration in mm: 17 Induration:
Hx of positive test: Hx of positive test:
1 Step TB skin test 1 Step TB skin test Chest X-ray (if required) Chest X-ray (if required)
Date of Step 1: Date of Step 1: Date: Date:
Result (pos/neg): Result: Result: Result:
Induration in mm: Induration:

Hx of positive test: Hx of positive test:

Chest X-ray (if required) Chest X-ray (if required) Physician Statement Physician Statement
Date: Jul 11, 2016 Date: Date: Date:
Result: neg Result: Clear of TB Clear of TB
signs/symptoms: signs/symptoms:
Physician Statement Physician Statement
Date: Jul 26, 2016 Date:
Clear of TB signs/symptoms: yes Clear of TB signs/symptoms:

2. MEASLES: 2 MMR Immunizations MMR #1 Date: Oct 22, 1990 MMR #2 Date: Dec 15, 2006

OR Laboratory Evidence of Immunity (Titre): Date of Test: Jul 22, 2016 Result (pos/neg): pos
2. MUMPS: 2 MMR Immunizations MMR #1 Date: Oct 22, 1990 MMR #2 Date: Dec 15, 2006

OR Laboratory Evidence of Immunity (Titre): Date of Test: Jul 22, 2016 Result (pos/neg): pos
2. RUBELLA: 2 MMR Immunizations MMR #1 Date: Oct 22, 1990 MMR #2 Date: Dec 15, 2006

OR Laboratory Evidence of Immunity (Titre): Date of Test: Jul 22, 2016 Result (pos/neg): pos

3. TETANUS/DIPTHERIA/PERTUSSIS: Date of last immunization:

Tetanus/Diptheria #1: Tdap: Tetanus: Expiry:
Tetanus/Diptheria #2: Tdap: Aug 01, 2011 Diptheria: Expiry:
Tetanus/Diptheria #3: Expiry: Aug 01, 2021 Pertussis:

2017-04-07 *** PASSPORT CONTINUED... *** Required Documentation for the Program Year 19:50
 HEALTH AND SAFETY PASSPORT:
PRE-PLACEMENT REQUIREMENTS

First Name Deepa Last Name Govind

Birth Date 1989-07-20 Program Respiratory Therapy
Acad Year 2016-2017
*** Page 2, PASSPORT CONTINUED ***

4. HEPATITIS B VACCINATION
Hep B #1: Jul 24, 1989 Hep B #2: Aug 24, 1989 Hep B #3: Jan 27, 1990 Date of TITRE: Result(pos/neg):
Booster Dose: Jun 16, 2016 Repeat TITRE: Sep 18, 2016 Result(pos/neg): pos (if neg, 2nd series of immunization required)

Hep B #1: Hep B #2: Hep B #3: Date of TITRE: Result(pos/neg):

Booster Dose: Repeat TITRE: Result(pos/neg):

Hep B Non-Responder (as per Physician and/or 2 immunization series completed)

5. VARICELLA: One of the following is required:

* Laboratory Evidence of Immunity (Titre): Date of Titre: Jun 10, 2016 Result (pos/neg): pos
* Varicella Vaccine (2 doses required) 1st Dose Date: 2nd Dose Date:

6. POLIO: 1st Dose Date: 2nd Dose Date: 3rd Dose Date:

Year 1 Year 2 Year 3 Year 4

7. INFLUENZA VACCINE:
Date: Nov 04, 2016 Date: Date: Date:

8. CPR: Level: Level: Level:

Level: HCP Date: Jul 28, 2016 Date: Date: Date:

9. STANDARD FIRST AID:

Date: Jul 28, 2016 Date: Jul 28, 2016 Date: Jul 28, 2016 Date:

10. RESPIRATOR FIT: Date: Date: Date:

Date: Model: Model: Model: Model:

Date: Date: Date:

Date: Model: Model: Model: Model:

11. FOOD HANDLER CERTIFICATE:

Date: Date: Date: Date:

12. POLICE CHECK: Level: Level: Level:

Level: VSS Status: Clear Status: Status: Status:
Date: Jul 02, 2016 Date: Date: Date:

13. NONVIOLENT CRISIS

INTERVENTION:
Date: Oct 06, 2016 Date: Date: Date:

2017-04-07 *** PASSPORT CONTINUED... *** Required Documentation for the Program Year 19:50
 HEALTH AND SAFETY PASSPORT:
PRE-PLACEMENT REQUIREMENTS

First Name Deepa Last Name Govind

Birth Date 1989-07-20 Program Respiratory Therapy
Acad Year 2016-2017
*** Page 3, PASSPORT CONTINUED ***

14. GENTLE PERSUASIVE

APPROACHES:
Date: Sep 30, 2016 Date: Date: Date:

Police Check Level: VSS=Vulnerable Sector Screening; CRC=Criminal Record Check

Police Check Status: No CC=No criminal convictions; CC=Criminal convictions Student will have original police record check to accompany this document.

Name: Janet Parrott-Sobczuk, RN Title: Practicum Nurse Technologist

Signature: Date: Apr 07, 2017

*** End of Document *** Status: Complete

2017-04-07 Required Documentation for the Program Year 19:50