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PASSPORT
=Outstanding Requirement(s) or
renewal of requirement(s) required
=Not Applicable
Outstanding Requirements Item #s: 9
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: Jun 23, 2021 Date of Step 1: Jun 23, 2021 Date: Sep 11, 2023 Date:
Result (pos/neg): neg Result: neg Result: neg Result:
Induration in mm: 0 Induration: 0 Induration: 0 Induration:
Date of Step 2: Jun 30, 2021 Date of Step 2: Jun 30, 2021
Result (pos/neg): neg Result: neg Date of TB Date of TB
Blood Test: Blood Test:
Induration in mm: 0 Induration: 0
Result Result
1 Step TB skin test 1 Step TB skin test
Date of Step 1: Date of Step 1: Dec 01, 2022
Result (pos/neg): Result: neg
Induration in mm: Induration: 0
2. MMR: MEASLES:
MMR Immunization #1: May 30, 2000 Date of Test Result (reactive/non-reactive)
2023-09-23 ***PASSPORT CONTINUED... *** Required Documentation for the Program Year 20:28
WIL DOCUMENT REQUIREMENTS
PASSPORT
=Outstanding Requirement(s) or
renewal of requirement(s) required
=Not Applicable
4. HEPATITIS B VACCINATION:
Hep B #1: Nov 15, 2011 Hep B #2: Jun 08, 2012 Hep B #3: Date of TITRE: May 26, 2021 Result(pos/neg): pos
Booster Dose: Repeat TITRE: Result(pos/neg): (if neg, 2nd series of immunization required)
6. POLIO:
1st Dose Date: Jun 16, 1999 2nd Dose Date: Oct 01, 1999 3rd Dose Date: Oct 23, 2000 4th Dose Date: Apr 23, 2003
7. RESPIRATOR FIT:
Date: May 26, 2022 Model: 3M 1870+ Expiry: May 26, 2024
8. COVID VACCINE:
2023-09-23 ***PASSPORT CONTINUED... *** Required Documentation for the Program Year 20:28
WIL DOCUMENT REQUIREMENTS
PASSPORT
=Outstanding Requirement(s) or
renewal of requirement(s) required
=Not Applicable
9. INFLUENZA VACCINE:
Date: Oct 27, 2021 Date: Nov 17, 2022 Date: Nov 17, 2022 Date:
Level: HCP or BLS Date: Jun 16, 2021 Date: Jan 10, 2023 Date: Jan 10, 2023 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.
Signature:
*** End of Document ***