School of Pharmacy
Immunization Record Form - Supplemental
(Please refer to http://www.science.uwaterloo.ca/schools/pharmacy/undergrad/post_admission.html)
Student’s Name:
________
To Physician/Health Centre: Students are required to be immunized against the following diseases before they begin their first
direct patient care rotation. These requirements must be fulfilled in order to meet the requirements set forth by the School of
Pharmacy, University of Waterloo.
If a student develops symptoms of tuberculosis or is exposed to tuberculosis while enrolled in the Pharmacy program, he/she is
expected to obtain the necessary medical assessment, treatment and counselling recommended. The student must notify the
Associate Director, Practice-Based Education at the School of Pharmacy.
IMMUNIZATION
Measles,
Verification of immunity required:
Mumps
Please see attached School of Pharmacy Immunization Record Form
(verification of immunity must be within 12 months prior to the start of each rotation)
Rubella
Report attached:
Yes □
Polio
Hepatitis B
Influenza
(strongly encouraged)
Yes □
No □
If yes, date of vaccination:_______________________
Verification of Td immunity: (effective for 10 years)
Diphtheria/Tetanus/
Acellular Pertussis
(Tdap)
Verification of Tdap (Pertussis containing
vaccine) immunity
Date:_________________________
Please see attached School of Pharmacy
Immunization Record Form (verification of immunity
must be within 12 months prior to the start of each
rotation)
Name of Pertussis
vaccine:__________________________
Date
received:_________________________
Report attached: Yes □
Varicella
Diagnosis or verification of history by healthcare provider :
If yes, date: ____________________
Yes □
Healthcare provider signature:_____________________
If No: laboratory evidence of immunity (VZV antibody test required)
Titre:____________________ Date:____________________
Or provide a copy of report.
Yes □
Report attached:
Tuberculin Test
(TST = Tuberculin skin test)
If received a two-step TST more than
12 months from the start date of each
rotation
One-step TST required. Report attached: Yes □
If received a two-step TST within 12
months from the start date of each
rotation
No further TST is required
If TST is positive
Must have received chest x-ray within the past 12 months.
Report attached: Yes □
Please provide verification that test was completed within 12 months from start of
each rotation report attached: Yes □
If TST is negative or status is unknown Tuberculin test Date
Results (mm of Redness & Induration)
Test #1
Test #2
(if required)
Middle East Respiratory Syndrome
Coronavirus (MERs-CoV):
(if applicable)
Self-screen completed: Yes □
Date:___________________________
Ebola Virus Disease
(EVD):
(if applicable)
Self-screen completed: Yes □
Date:___________________________
Clinic/Health Centre Authorization: (name, address, and phone number of clinic/healthcare centre/hospital where form was
completed)
Signature of health care professional:
Date:
Printed name of health care professional:
Please submit completed forms, to the Administrative Coordinator, Experiential Learning at the School of Pharmacy by
September 15 prior to the start of rotations
STUDENTS WHO FAIL TO COMPLY WITH IMMUNIZATION AND DOCUMENTATION REQUIREMENTS WILL NOT BE PERMITTED TO
PARTICIPATE IN A NUMBER OF ACADEMIC COURSE REQUIREMENTS INCLUDING FOURTH YEAR ROTATIONS AND AS SUCH WILL
SUFFER AN ACADEMIC PENALTY