Health Questionnaire The information collected in this document is solely for the purpose of obtaining that which is required under the Ambulance Act of Ontario and is a condition of employment for all employers participating in the Centralized Paramedic Competency Recruitment Testing. It will only be used by the EMS employers to which you apply and will not be released to other agencies.
THIS AREA FOR APPLICANT COMPLETION Name: Sex: Male Female Date of Birth YYYY / MM / DD Address: City: Province Postal Code Telephone Number: ( ) Alternate Number ( ) Email: Applicant s Certificate and Release of Information I certify that the foregoing information is to the best of my knowledge correct and I agree to this report and any future report derived from this information being given only to the EMS employers participating in the CPCRT. The fee for the completion of this form is the sole responsibility of the applicant and not the responsibility of the CPCRT or participating EMS employers. MONTH DAY Applicant s Signature:,, 2011 Page 2 of 5
Applicant Name: IMMUNIZATION RECORD: 1. Tuberculin Skin Test Negative or Unknown Reaction: 2 step Test required prior to employment (within 3 months of hire date). Must be completed before MMR vaccine (or any live attenuated vaccine) is given or 30 days after receiving a live attenuated vaccine. If step 1 is negative (0-9 mm. induration at 48-72 hours), do Step 2 in 7-21 days. If either step 1 or 2 is positive (10 mm. Or more in duration @ 48-72 hours) evaluate as Known Positive Reaction below. STEP 1 STEP 2 Date of Test Dates Read Induration (mm.) + - Known Positive Reaction: Date of TB Test: Size (mm): Evaluation: 1. Physical examination/symptom enquiry regarding evidence of active disease 2. Chest X-ray: Date: Result: (copy of x-ray report within 1 year) 3. INH Prophylaxis: No Yes Dosage Duration 2. Chicken Pox (Varicella): Record confirmed date of illness, date of vaccination or date immunization was confirmed by lab report. 3. Tetanus: (every 10 years) 4. Diphtheria: (every 10 years) 5. Polio: (Full Primary Series is required) series was completed OR of last booster 6. Measles, Mumps, and Rubella: Record date of vaccination or date immunization was confirmed by lab report. Measles Mumps Rubella Page 3 of 5
Applicant Name: 7. Pertussis: Date: 8. Hepatitis B Vaccine: Date 1 st Date 2 nd Date 3 rd If booster received date: 9. Influenza: _ (Must be current year) If immunizations not complete, an explanation is required: How long has this person been your patient? Family Physician or Certified Specialist in Based on today s examination, there are no medical or physical reasons that would prevent this person from safely fulfilling the duties of a paramedic (see attached Physical Demands Analysis) Physicians Name Physicians Address Physicians Signature *Yellow Immunization cards will not be accepted as proof of immunization Page 4 of 5
HEALTH STATUS REPORT Communicable Diseases This report is being requested to comply with the conditions of Ambulance Services Communicable Disease Standards Oct 2002, which states each paramedic within the service is to be free from all communicable diseases as listed below. This form is to be completed by your general practitioner. Taken from Ministry of Health and Long Term Care Emergency Services Branch, Ambulance Services Communicable Disease Standards Table 1 Part B April 2000 (Revised October 2002) This is to certify that to the best of my knowledge (Patient s full name) IS FREE FROM the following communicable diseases listed below. Acquired Immunodeficiency Syndrome (AIDS) Amebiasis Anthrax Botulism Brucellosis Campylobacter enteritis Chancroid Chicken Pox (Varicella) Chlamydia trachomatis infections Cholera Cytomegalovirus Infection (Congenital) Diphtheria Encephalitis (Primary Viral) Food Poisoning, all causes Gastroenteritis Giardiasis Gonorrhea Group A Streptococcal Disease (Invasive) Haemophilus Influenza B Disease (Invasive) Hemmorrhagic Fevers including Ebola virus disease, Marburg Virus Disease, and other Viral Causes Viral Hepatitis including Hepatitis A, B, C and D (Delta Hepatitis) Influenza Lassa Fever Legionellosis Leprosy Listeriosis Lyme Disease NOT Measles Meningitis, acute, i. bacterial ii. viral iii. other Meningococcal disease, invasive Malaria Mumps Opthalmia Neonatorum Parathyphoid Fever Pertussis (Whooping Cough) Plague Poliomyelitis (Acute) Psittacosis / Ornithosis Q Fever Rabies Rubella Rubella (Congenital Syndrome) Salmonellosis Shigellosis Syphilis Trichinosis Tuberculosis Tularemia Typhoid Fever Verotoxin producing E. Coli Infections Yellow Fever Yersiniosis NOT NOTES (if applicable) Family Physician or Certified Specialist in Physician s Name: Physician s Signature: Physician s Address: Page 5 of 5