Cds Form - Niagara College
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1
2OFFICE USE ONLY
CL _____ GC exp. ______________ COMP _____
CL _____ GC exp. ______________ COMP _____
H
S
EALTH
ERVICES
CL _____ GC exp. ______________ COMP _____
CL _____ GC exp. ______________ COMP _____
CDS F
ORM
C
D
S
OMMUNICABLE
ISEASE
URVEILLANCE
Name:
Student Number:__________________________
Program:
Program Start Date:_______/________
month
year
Address:
City:_______________________________
Province:
Postal Code:
Date of Birth:_______/_______________/_____________
day
month
year
Home Phone:___________________________
The Communicable Disease Protocols require that hospitals and community placements must have documented proof of
immunization and/or history of specific communicable disease for all persons. Please provide actual dates for requested
immunizations listed below. This form will be reviewed by Niagara College’s Health Services and an e-mail will be sent your
student account confirming your health requirements are met for your student placement.
Students will be denied placement without this clearance from Niagara College Health Services.
The information given below is true to the best of my knowledge and I authorize the release of this information to any
Niagara College placement.
Signature:____________________________________
Date:___________________
**ATTACH COPIES OF YOUR VACCINATION RECORDS and LAB REPORTS**
Section 2 – REQUIRED
1. TUBERCULOSIS:
Documentation of a two-step tuberculin skin test is required regardless of BCG vaccination.
An initial tuberculin skin test is given, and must be read between 48 and 72 hours after the skin test is given. If this test is
0-9mm of induration, a second test is given in the opposite arm at least one week and no more than four weeks after the
first, and must be read between 48 and 72 hours later. If it has been more than 12 months since the two-step TB test, a
one-step TB skin test is also required, and dates of the previous two step are required.
NOTE: If the student has previously tested Positive (10mm or greater) please enter the following:
Date of Positive test: _______________ Result:____mm induration Physician’s signature: ____________________
TUBERCULIN SKIN TESTING: TWO STEP MUST BE COMPLETED/ RESULTS MUST BE RECORDED IN mm INDURATION.
NOTE: Dental Hygiene; PN; OTA/PTA; Paramedic; Recreational Therapy students must update annually during program
Step 1. Date Given: _________________ Given By: ______________
DD/MM/YYYY
Date Read: __________________ Read By: ______________ Result:______mm induration
DD/MM/YYYY
Step 2. Date Given:__________________ Given By:______________
DD/MM/YYYY
*Persons who are tuberculin positive (10mm or greater) must have a chest x-ray completed
Date Read: __________________ Read By:_______________ Result:______mm induration
DD/MM/YYYY
If it has been more than 12 months since the two-step TB test (recorded above), A ONE-STEP TB UPDATE TEST IS ALSO REQUIRED.
Date Given:__________________ Given By:______________
Update
DD/MM/YYYY
Date Read: __________________ Read By: ______________ Result:______mm induration
DD/MM/YYYY
*Persons who are tuberculin positive (10mm or greater) must have a chest x-ray completed
Please provide copy of chest x-ray report with this form
Date of Chest X-ray: _____________________________ Result: _____________________________________
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