Directions For Completing Medical Requirement Forms Page 5
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8Name: _____________________ DOB: _____________ Health Card # __________________
Immunization/Communicable Disease Record:
Section A
Hepatitis B Series or TwinRix
st
nd
rd
1
dose date __________ 2
dose date: __________ 3
dose date _______
2 step TST* Date administered #1 _____________ Reading ______ Date: _____________Initial _______
Date administered #2 _____________ Reading ______ Date: _____________Initial _______
* TST is not required for students who have had BCG vaccine or previously positive TST
** If there is a record of previous negative TST in the past 12 months, only a one-step TST is required
It is recommended the student have current immunization against the following:
Tetanus and Diphtheria – Date: ______________(Strongly recommended to repeat q 10 years)
Pertusis
Date: ______________(Strongly recommend to be repeated with Td to age 24)
Polio
Date: ______________
Meningitis
Date: ______________ (Highly recommended for ages 19 and younger)
Varicella
Date: ______________ History of chicken pox or shingles/ _____________
MMR Vaccinations
Fill this section only if Student returned after
Measles Date #1 __________ Date #2 _____________
MMR Titers:
Mumps Date #1 __________ Date #2 _____________
Rubella Date #1 __________ Date #2 _____________
Date#1 _________ Initial: ______
If incomplete series then refer to section B.
Date #2_________ Initial: ______
The above recommendations are based on Ontario Guidelines for Immunization. If you do not feel it is
necessary or advisable at this time to administer one or any of the vaccines listed above, please note the
reason(s) for this:
Section B
This area to be competed by Physician/Nurse Practitioner
If CHN indicates no recent MMR or Hepatitis evidence of immunization received, then MMR and Hepatitis B
titer is recommended.
Date ordered: MMR
__________________ Date ordered: Hepatitis __________________
If student shows no evidence of immunity. The Student must be informed to call the CHN and rebook for the
vaccines. These vaccines are a requirement for entering clinical. The date administered must then be
recorded by the CHN/Public Health Nurse in Section A, (shaded area).
Section C
Must be signed by Doctor or NP
I certify that as of this date, the student is free of any symptoms of active illness or any reportable
communicable disease.
Signature: _________________________________________ Date: __________________________
Section D If completed by a Community Health Nurse Sign, designation and date:
Signature:_________________________________________ Date: __________________________
Medical Form
Page 5
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