WIL DOCUMENT REQUIREMENTS

PASSPORT

First Name Caitlin Last Name Usher

Birth Date 1999-10-14 Program Respiratory Therapy Year 1
Academic Year 2022-2023 Fall 2022 Winter 2023 Spring 2023 =Requirements Complete

=Outstanding Requirement(s) or
renewal of requirement(s) required

=Not Applicable

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: Aug 30, 2022 Date of Step 1: Date: Date:
Result (pos/neg): neg Result: Result: Result:
Induration in mm: 0 Induration: Induration: Induration:
Date of Step 2: Sep 07, 2022 Date of Step 2:
Result (pos/neg): neg Result: Date of TB Date of TB
Blood Test: Blood Test:
Induration in mm: 0 Induration:
Result Result
1 Step TB skin test 1 Step TB skin test
Date of Step 1: Date of Step 1:
Result (pos/neg): Result:
Induration in mm: Induration:

Date of TB Blood Date of TB Blood Hx of positive test: Hx of positive test:

Test: Test: Chest X-ray (if required) Chest X-ray (if required)
Result (pos/neg): Result (pos/neg):
Date: Date:
Result: Result:
Hx of positive test:
Hx of positive test:
Chest X-ray (if required)
Chest X-ray (if required) Physician Statement Physician Statement
Date:
Date:
Result: Date: Date:
Result:
Clear of TB Clear of TB
Physician Statement signs/symptoms: signs/symptoms:
Physician Statement
Date:
Date:
Clear of TB signs/symptoms:
Clear of TB signs/symptoms:

2. MMR: MEASLES:

MMR Immunization #1: Nov 16, 2000 Date of Test Result (reactive/non-reactive)

Laboratory Evidence MUMPS:

of Immunity (Titre):
Date of Test Result (reactive/non-reactive)
MMR Immunization #2: Oct 23, 2003 RUBELLA:

Date of Test Result (reactive/non-reactive)

2022-10-24 ***PASSPORT CONTINUED... *** Required Documentation for the Program Year 13:35
 WIL DOCUMENT REQUIREMENTS
PASSPORT

First Name Caitlin Last Name Usher

Birth Date 1999-10-14 Program Respiratory Therapy Year 1
Academic Year 2022-2023 Fall 2022 Winter 2023 Spring 2023 =Requirements Complete

=Outstanding Requirement(s) or
renewal of requirement(s) required

=Not Applicable

*** Page 2 of 3, PASSPORT CONTINUED ***

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

Tetanus/Diptheria #1: Tdap: Oct 21, 2013 Tetanus: Expiry:
Tetanus/Diptheria #2: Tdap: Jun 30, 2022 Diptheria: Expiry:
Tetanus/Diptheria #3: Expiry: Jun 30, 2032 Pertussis:

4. HEPATITIS B VACCINATION:
Hep B #1: Sep 14, 2011 Hep B #2: Mar 28, 2012 Hep B #3: Aug 08, 2022 Date of TITRE: Jul 02, 2022 Result(pos/neg): neg
Booster Dose: Repeat TITRE: Sep 02, 2022 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)

Hep B requirement complete Document reviewed by Practicum Nurse Technologist

5. VARICELLA: One of the following is required:

* Laboratory Evidence of Immunity (Titre): Date of Titre: Jul 02, 2022 Result (pos/neg): pos
* Varicella Vaccine (2 doses required) 1st Dose Date: 2nd Dose Date:

6. POLIO:
1st Dose Date: Dec 16, 1999 2nd Dose Date: Feb 15, 2000 3rd Dose Date: Apr 17, 2000 4th Dose Date: Oct 23, 2003

7. RESPIRATOR FIT:

Date: Sep 12, 2022 Model: 3M 1870+ Expiry: Sep 12, 2024

Date: Model: Expiry:

Date: Model: Expiry:

8. COVID VACCINE:

1st Dose: May 20, 2021 Type: Pfizer-BioNTech/Comirnaty/BNT162B2/Tozinameran

2nd Dose: Jul 09, 2021 Type: Pfizer-BioNTech/Comirnaty/BNT162B2/Tozinameran

3rd Dose: Dec 23, 2021 Type: Pfizer-BioNTech/Comirnaty/BNT162B2/Tozinameran

4th Dose: Type:

Exemption: Expiry: TBD

2022-10-24 ***PASSPORT CONTINUED... *** Required Documentation for the Program Year 13:35
 WIL DOCUMENT REQUIREMENTS
PASSPORT

First Name Caitlin Last Name Usher

Birth Date 1999-10-14 Program Respiratory Therapy Year 1
Academic Year 2022-2023 Fall 2022 Winter 2023 Spring 2023 =Requirements Complete

=Outstanding Requirement(s) or
renewal of requirement(s) required

=Not Applicable

*** Page 3 of 3, PASSPORT CONTINUED ***

Year 1 Year 2 Year 3 Year 4

9. INFLUENZA VACCINE:
Date: Oct 20, 2022 Date: Date: Date:

10. CPR: Level: Level: Level:

Level: HCP or BLS Date: Jul 27, 2022 Date: Date: Date:

11. STANDARD FIRST AID:

Date: Jul 27, 2022 Date: Date: Date:

12. FOOD HANDLER CERTIFICATE:

Date: Date: Date: Date:

13. POLICE CHECK: Level: Level: Level:

Level: VSS Status: Clear Status: Status: Status:

Date: Jun 23, 2022 Date: Date: Date:

14. FETAL HEALTH

SURVEILLANCE:
Date: Date: Date: Date:

15. NEONATAL RESUSCITATION:

Date: Date: Date: Date:

Police Check Level: VSS=Vulnerable Sector Screening; CRJM=Criminal Record And Judicial Matters Check
Police Check Status: No CC=No criminal convictions; CC=Criminal convictions Student will have original police record check to accompany this document.

Name: Diana Bayne RN Title: WIL Nurse Technologist

Date: Oct 24, 2022

Signature:
*** End of Document ***

2022-10-24 Required Documentation for the Program Year 13:35