Health Screening Recrd: Entry Level MIDWIFERY EDUCATION PROGRAM HEALTH SCREENING REQUIREMENTS (Rev. June 2017) 1. Hepatitis B: Primary vaccinatin series (3 vaccines 0, 1 and 6 mnths apart), plus serlgic prf f immunity (Anti- HBs 10 IU/L) 1 mnth after primary series cmplete. Vaccine series may be in prgress during MWF 150 entry year if tw vaccines are cmplete and vaccine #3 with serlgic testing fr immunity is cmplete in accrd with standard immunizatin schedule. Evidence f vaccine #3 with serlgic prf f immunity is due with submissin f placement requirements prir t entry t MWF 120. If n prf f immunity after cmpletin f tw primary series, student t verify awareness and educatin f nn-respnder status. 2. Measles, Mumps, Rubella & Varicella: Tw vaccinatins at least fur weeks apart after 12 mnths f age (ne Rubella vaccine is acceptable) - OR - serlgic prf f immunity (IgG antibdy). 3. Tuberculsis (TB): N previus psitive tuberculsis skin test (TST): Negative tw-step TST, plus additinal negative single TST if tw-step test mre than six mnths prir t deadline (February 1st), plus subsequent annual single TST, plus negative ne-step TST pst expsure if required. Psitive TST r IGRA serlgy: Negative chest x-ray subsequent t psitive test, plus n symptms f active TB disease, plus verificatin f assessment and educatin f psitive result, plus annual verificatin f n symptms f active TB disease. 4. Adult Pertussis: One dse f pertussis vaccine age 18 years r lder. 5. Tetanus, Diphtheria & Pli: Primary vaccinatin series (3 vaccines 0, 1 and 6 mnths apart), plus tetanus diphtheria bster in last 10 years if required. Vaccine series may be in prgress during MWF 150 entry year if tw vaccines are cmplete by deadline and vaccine #3 is cmplete in accrd with standard immunizatin schedule. Evidence f vaccine #3 is due with submissin f placement requirements prir t entry t MWF 120. 6. Influenza: Annual influenza immunizatin is nt required by the Midwifery Educatin Prgram (MEP), but may be required by the practice site where students are placed fr placements ccurring between Nvember and June. Student t prvide prf f immunizatin directly t placement site as required. GENERAL INSTRUCTIONS TO STUDENT a. Print pages 1-5 t be cmpleted by an apprpriate health care prvider (HCP) within their scpe f practice. Yur childhd immunizatin recrd will be helpful t yur HCP, if available. b. Cmplete the student declaratin n page 5 and any relevant appendices. c. Exemptins t health screening requirements are allwed fr dcumented medical reasns nly, in which case dcumentatin by a physician is required. d. Ensure all sectins f the frm, relevant appendices are cmplete and all required reprts as indicated are attached. e. Submit the frm by the deadline with all required supprting dcumentatin t the MEP in a cmplete package. f. Keep riginals f all dcuments in case they are required during yur clinical placement. Health screening dcuments submitted t the MEP are nt returned. g. Cmpletin f this Recrd is mandatry t participate in clinical activities. If placement requirements are incmplete by the deadline fr submissin, entry t clinical activities will be delayed. Placement dates may be extended r successful cmpletin f the curse may be cmprmised. h. All health screening dcumentatin must be cleared by MEP befre students may attend clinical activities. The Ryersn MEP health screening requirements are in accrd with the Ontari Hspital Assciatin (OHA) Cmmunicable Diseases Surveillance Prtcls, the Canadian Immunizatin Guide fr Health Care Wrkers, and the Cuncil f Ontari Faculties f Medicine. Persnal infrmatin prvided n this Recrd and supprting dcuments are prtected and are being cllected pursuant t the Freedm f Infrmatin and Prtectins f Privacy Act f Ontari (RSO 1990). This infrmatin will be held in strict cnfidence by the Midwifery Educatin Prgram and is nly disclsed as needed with the cnsent f the student. Fr any questins abut the cllectin, use r disclsure f this infrmatin by the Midwifery Educatin Prgram, please cntact the MEP ffice at (416) 979-5104. Midwifery Educatin Prgram Tel: (416) 979-5104 HSR_06_17 Trnt ON M5B 1G7 midwiferyplacements@ryersn.ca
Health Screening Recrd: Entry Level Health Care Prvider Infrmatin Health Care Prvider (1) Name: Prfessin: Initials: Address: Email: Signature: Phne: Date: Health Care Prvider (2) Name: Prfessin: Initials: Address: Email: Signature: Phne: Date: Health Care Prvider (3) Name: Prfessin: Initials: Address: Email: Signature: Phne: Date: Exceptins and Cntraindicatins t Vaccinatin and Testing Requirements Is the student unable t meet any f the requirements listed in this dcument due t a medical cnditin? N, a medical cnditin is nt present that prevents the student frm meeting vaccinatin r testing requirements Yes, a medical cnditin is present that prevents the student frm meeting vaccinatin r testing requirements Please prvide details belw - OR - Relevant infrmatin attached Details: The student must als cmplete and attach Appendix A: Exceptins and Cntraindicatins t Vaccinatin and Testing Requirements Self Declaratin Frm. Midwifery Educatin Prgram Tel: (416) 979-5104 1 Trnt ON M5B 1G7 midwiferyplacements@ryersn.ca
Health Screening Recrd: Entry Level Hepatitis B Dcument Hepatitis B vaccinatins, recrd serlgic testing fr antibdies t HBsAg (anti-hbs) fr evidence f immunity and attach labratry reprts fr anti-hbs. 1. Vaccinatin series (D nt vaccinate if the student is Hepatitis B surface antigen psitive) Dcument a three dse primary vaccinatin series. If starting a new primary series, a three-dse schedule (0, 1, 6 mnths) is recmmended ver a rapid fur-dse schedule. (Nte that Recmbivax administratin at ages 11-14 requires nly a tw-dse schedule.) If a primary vaccinatin series is in prgress, vaccine 1 and 2 must be administered and dcumented and the student must cmplete and attach Appendix B: Cmpletin f Primary Vaccinatin Series. Vaccine 1: Vaccine 2: Vaccine 3: Vaccine 4 (if required): Vaccine 5 (if required): Vaccine 6 (if required): Date Vaccine name (if knwn) HCP initials 2. Serlgy (attach reprts) Dcument serlgic testing fr immunity (anti-hbs) ne r mre mnths after primary vaccinatin series is cmplete and attach labratry reprt. Immune: anti-hbs 10 IU/L Nn-immune: anti-hbs < 10 IU/L. If mre than six mnths since cmpletin f primary series, give ne bster dse and repeat anti- HBs ne mnth later. If repeat anti-hbs is nt immune, give tw additinal dses f the vaccine five mnths apart and repeat anti-hbs ne mnth later. If between ne and six mnths since primary series cmplete, give secnd primary vaccinatin series (0, 1, 6 mnths) and repeat anti-hbs ne mnth later. Nn-respnder: If anti-hbs < 10 IU/L after tw primary series, the student is cnsidered t be a vaccine nn-respnder and shuld cmplete Appendix C: Hepatitis B Vaccine Nn-Respnders Self-Declaratin Frm. anti-hbs Test date Labratry result Interpretatin (immune r nn-immune) HCP initials Midwifery Educatin Prgram Tel: (416) 979-5104 2 Trnt ON M5B 1G7 midwiferyplacements@ryersn.ca
Health Screening Recrd: Entry Level Measles, Mumps, Rubella and Varicella Dcument ne f the fllwing fr evidence f immunity fr each infectius disease: 1. Tw dses f live vaccine given 28 days r mre apart, with the first dse after 12 mnths f age. One dse f live vaccine is acceptable fr rubella - OR - 2. Psitive serlgy fr IgG antibdies (recrds t be attached) - OR - 3. Labratry evidence f infectin (recrds t be attached) Nte that tuberculin skin tests must be given befre r at least fur weeks after live vaccines (MMR, Varicella). 1. Vaccinatins If a primary vaccinatin series is in prgress, vaccine 1 and 2 must be administered and dcumented and the student must cmplete and attach Appendix B: Cmpletin f Primary Vaccinatin Series. Measles: Mumps: Rubella: Varicella Date vaccine 1 Date vaccine 2 HCP initials - OR - 2. Serlgy (attach reprts) The preferred apprach fr students with n recrd f measles, mumps r rubella is t immunize withut testing fr immunity. Fr students with n recrd f varicella vaccinatins, the preferred apprach is t test fr varicella serlgy. Pst-vaccinatin serlgy shuld nt be dne fllwing vaccinatin requirements in #1 abve. Labratry reprts must be attached fr serlgic prf f immunity. Measles: Mumps: Rubella: Varicella Test date Lab result Interpretatin (immune r nn-immune) HCP initials - OR - 3. Labratry Evidence f Infectin (attach reprts) Labratry evidence f infectin (e.g. islatin f virus, detectin f dexyribnucleic acid r ribnucleic acid r sercnversin) t measles, mumps, rubella r varicella meets the requirement fr evidence f immunity. Labratry reprts must be attached fr labratry evidence f immunity. Name f test Test date Labratry results HCP initials Midwifery Educatin Prgram Tel: (416) 979-5104 3 Trnt ON M5B 1G7 midwiferyplacements@ryersn.ca
Health Screening Recrd: Entry Level Tuberculsis (TB) 1. Past TB Histry D any f the fllwing apply t the student? Yes Yes N Dcumented psitive tuberculin skin test (TST) (recrd result in #2 belw), psitive blistering TST reactin (attach recrd), and/r psitive interfern gamma release assay (IGRA) test (attach reprt). N Previus diagnsis and/r treatment fr TB disease r TB infectin. If Yes applies t the student n either f these tw questins, the student must cmplete and attach Appendix C: Tuberculsis Awareness and Signs and Symptms Self-Declaratin Frm. These students shuld nt have a repeat TST; skip t #4 belw. 2. Tuberculin Skin Tests (TSTs) If N applies t the student t bth questins in #1 abve, dcument a tw-step TST given at any time in the past (tw separate tests, ideally 7-28 days apart but may be up t 12 mnths apart.). In additin, if the negative tw-step TST was cmpleted befre February 1st in current calendar year, additinal single TST is required. TSTs must be given befre r at least fur weeks after live vaccines (MMR, Varicella). Previus Bacillus Calmette-Guérin (BCG) vaccinatin and pregnancy are nt cntraindicatins t tuberculin skin testing. Step 1: Step 2: Additinal TST if required Date TST Date read mm Induratin HCP initials 3. Recent TB Expsure Has the student had any f the fllwing since admissin t midwifery schl? Yes N Significant expsure t an individual diagnsed with infectius TB disease. Yes N Previus diagnsis and/r treatment fr TB disease r TB infectin. If Yes applies t the student n either f these tw questins, the student must cmplete and attach Appendix D: Tuberculsis Awareness and Signs and Symptms Self-Declaratin Frm. These students shuld nt have a repeat TST; skip t #4 belw. 4. Chest X-ray (attach reprt) If the student has a psitive TST (dcumented in #2 abve) r any ther psitive TB histry, the student must submit a chest X-ray reprt. The chest X-ray must be perfrmed subsequent t the psitive TST r psitive TB histry. The HCP must als cnfirm that n signs r symptms f active disease are present. If any abnrmalities n the chest X-ray reprt r physical exam are nted, dcumentatin frm the physician explaining the findings is required. Chest X-ray date Chest X-ray result HCP assessment HCP initials Nrmal Abnrmal Nrmal Abnrmal Midwifery Educatin Prgram Tel: (416) 979-5104 4 Trnt ON M5B 1G7 midwiferyplacements@ryersn.ca
Health Screening Recrd: Entry Level Pertussis Dcument a ne-time acellular pertussis cntaining vaccinatin (Tdap r Tdap-IPV) given at age 18 years r lder. The type f vaccine must be knwn. If this infrmatin is n lnger available, repeat the vaccinatin. Date Type f vaccine used Age received HCP initials Tetanus, Diphtheria and Pli Dcument the last three tetanus, diphtheria and pli cntaining vaccinatins (minimum ne mnth between first tw dses f a series and minimum six mnths between last tw dses). Last tetanus/diphtheria vaccinatin must be within the past 10 years. If a primary vaccinatin series is in prgress, vaccine 1 and 2 must be administered and dcumented and the student must cmplete and attach Appendix B: Cmpletin f Primary Vaccinatin Series. Vaccine 1: Vaccine 2: Vaccine 3: Date Td Date Pli HCP initials Seasnal Influenza Vaccine The MEP recmmends a seasnal influenza vaccine by December 1 fr placements ccurring between Nvember and June. This is nt mandatry unless required by a clinical practice setting where the student is placed. If an influenza utbreak ccurs in the assigned practice setting, the placement will be interrupted fr students withut current vaccinatin. Placement dates may be delayed r extended and successful cmpletin f the curse culd be cmprmised. Student Declaratin My signature belw indicates the fllwing: I understand that the persnal health infrmatin prvided in this frm will be kept cnfidential and will be used by the MEP fr purpses f participatin in clinical activities t ensure I meet the health standards f the prgram and clinical settings. I understand that I am respnsible fr any csts assciated with health screening requirements. I understand that additinal health screening may be required in clinical settings where I am placed and that I will be respnsible t prvide dcumentatin directly t the placement site. Last name: First name: Date f birth: Ryersn ID: Signature: Date: Midwifery Educatin Prgram Tel: (416) 979-5104 5 Trnt ON M5B 1G7 midwiferyplacements@ryersn.ca
Health Screening Recrd: Entry Level Appendix A: Exceptins and Cntraindicatins t Vaccinatins and Testing Self Declaratin Frm Appendix A applies nly t students wh are unable t meet any f the requirements listed in the Health Screening Recrd due t a medical cnditin dcumented by their physician n page 1 f this recrd. Only these students are required t cmplete and submit this appendix with the Health Screening Recrd. My signature belw indicates the fllwing: I acknwledge that I may be inadequately prtected against the fllwing infectius disease(s): I acknwledge that in the event f a pssible expsure that passive immunizatin r chemprphylaxis may be ffered t me fr the infectius disease(s) listed abve where apprpriate. I acknwledge that in the event f an utbreak f the infectius disease(s) listed abve that I may be withdrawn frm clinical activities fr the duratin f the utbreak. I acknwledge that my placement may be delayed r extended if I am withdrawn frm clinical activities. I acknwledge that I may be required t take additinal precautins t prevent transmissin, such as wearing a surgical mask. Student name Signature Date Midwifery Educatin Prgram Tel: (416) 979-5104 6 Trnt ON M5B 1G7 midwiferyplacements@ryersn.ca
Health Screening Recrd: Entry Level Appendix B: Cmpletin f Primary Vaccinatin Series Appendix B nly applies t students whse primary vaccinatin series fr tetanus and diphtheria and/r hepatitis B is in prgress. Only these students are required t cmplete and submit this appendix with the Health Screening Recrd. Tw f the three vaccines in a primary series must be administered by the deadline and the third vaccine must be administered accrding t the standard vaccinatin schedule. The third vaccine must be dcumented by the student s health care prvided n the Placement Requirements Recrd: Returning Students by the deadline fr the entry year t MWF 120 Nrmal Childbearing. Students requiring dse 3 fr Hepatitis must als prvide evidence f immunity by serlgic testing fr anti-hbs. My signature belw indicates the fllwing: I acknwledge that I may be inadequately prtected against the fllwing infectius disease(s): I acknwledge I am required t cmplete dse #3 f the primary vaccinatin series in accrd with the standard vaccinatin schedule. I acknwledge that I am required t dcument dse #3 fr the primary series in prgress n the Placement Requirements Recrd: Returning Students by the deadline fr the entry year t MWF 120 Nrmal Childbearing, in additin t serlgic testing fr anti-hbs where relevant. I acknwledge that in the event f a pssible expsure that passive immunizatin r chemprphylaxis may be ffered t me fr the infectius disease(s) listed abve where apprpriate. I acknwledge that in the event f an utbreak f the infectius disease(s) listed abve that I may be withdrawn frm clinical activities fr the duratin f the utbreak. I acknwledge that my placement may be delayed r extended if I am withdrawn frm clinical activities. Student name Signature Date Midwifery Educatin Prgram Tel: (416) 979-5104 7 Trnt ON M5B 1G7 midwiferyplacements@ryersn.ca
Health Screening Recrd: Entry Level Appendix C: Hepatitis B Vaccine Nn-Respnders Self Declaratin Frm Appendix C nly applies t students wh have received tw primary vaccinatin series fr hepatitis B and pst-vaccinatin serlgy des nt demnstrate immunity (anti-hbs < 10 IU/L). Only these students are required t cmplete and submit this appendix with the Health Screening Recrd. It is imprtant that students ensure that each vaccinatin was dcumented, all dses were administered with apprpriate spacing (0, 1, 6 mnths) and pst-vaccinatin serlgy was cnducted between 28 days and six mnths after the final dse f the series. N further pre-expsure hepatitis B vaccinatins r serlgy testing are required fllwing tw primary vaccinatin series. My signature belw indicates the fllwing: I acknwledge there is n labratry evidence that I am immune t hepatitis B. I acknwledge that in the event f a pssible expsure t hepatitis B (e.g. percutaneus injury r mucsal splash) that passive immunizatin with hepatitis B immune glbulin may be required. Student name Signature Date Midwifery Educatin Prgram Tel: (416) 979-5104 8 Trnt ON M5B 1G7 midwiferyplacements@ryersn.ca
Health Screening Recrd: Entry Level Appendix D: Tuberculsis Awareness and Signs and Symptms Self Declaratin Frm Appendix D applies nly t students wh have ne r mre f the fllwing: Psitive tuberculin skin test Psitive interfern gamma release assay bld test Previus diagnsis and/r treatment fr tuberculsis (TB) disease Previus diagnsis and/r treatment fr TB infectin Significant expsure t infectius TB disease Only these students are required t cmplete and submit this appendix with the Health Screening Recrd. My signature belw indicates the fllwing: I have received medical assessment and educatin fr a psitive result r histry related t tuberculsis I will reprt any symptms f pssible TB disease t my health care prvider, including: persistent cugh lasting three r mre weeks bldy sputum shrtness f breath chest pain night sweats fever chills unexplained weight lss Student name Signature Date Midwifery Educatin Prgram Tel: (416) 979-5104 9 Trnt ON M5B 1G7 midwiferyplacements@ryersn.ca