Student Name: __________________________________________________
Students are required to:
CLINICAL PREPAREDNESS PERMIT
Last Name
First Name
1. Keep this permit up-to-date and current at all times.
2. Have an authorized health care provider sign-off and
provide the appropriate lab report(s) to support the
immunization record.
3. Present this permit and original documents for review each
term.
4. Present the stamped permit on the first day of the clinical
placement.
5. Make sure the permit is available to present if requested at the
clinical placement site.
IMPORTANT
College Student #
Birth Date (DD/MM/YY)
York University Student #
Program Intake Date
(DD/MM/YY)
Requirement
Contact Number(s): Cell/Home
Vulnerable Sector Police
Record Check
x
CPR- Level HCP
x
Seneca E-mail Address
It is the responsibility of the student to keep this form
and associated documents current for placement purposes.
The student will not enter clinical placement unless the permit
is completed and stamped. Missed clinical time may
jeopardise success in the course.
Upon
Entry
Standard First Aid
x
Worker Health and Safety
Awareness Certificate
x
Every
Year
Every 2
Years
Respirator Mask Fit Test
IMPORTANT:
MAKE A PHOTOCOPY OF THIS PERMIT AFTER
EACH UPDATE AND STORE IN A SAFE PLACE!
Base-line
Two-Step Mantoux Skin Test
x
One-Step Mantoux Skin Test
Immunizations & Titres
Flu Vaccination
Clinical Preparedness Permit – Seneca/York/Georgian
Revised June 2015
x
x
x
x
Page 1 of 9
Student Name: __________________________________________________
Non-Medical Requirements
Vulnerable Sector Screening (VSS) Police Record Checks (Required Annually)
Prior to having direct contact with patients and other vulnerable persons, community agencies
and hospitals require a satisfactory Vulnerable Sector Police Record Check. The police check
must be renewed every year. Please note that depending on the local police service used;
this process may take up to 12 weeks or more. Students are required to carry their police
reference check to the clinical area. A representative in the agency may ask to see that you
have a valid police reference check at any time.
Police Check Service
(Police Region)
Date of Issue
Applicants who apply for registration with the College of Nurses of Ontario (CNO) require a
Canadian Police Information Centre Criminal Record Synopsis as part of the registration
process. The CPIC check gives evidence that an applicant has met the requirement of
registration related to good character and suitability to practice. In the event that the applicant
has a criminal record, they will not be permitted to write the provincial exam and thus not
become a certified professional. If the applicant has a criminal record or obtains a criminal
record during undergraduate education it is highly recommended that a pardon be obtained.
VSS Police Record Checks are available through your local police service only. Toronto
Police and the OPP require a particular form/letter form the College. These forms/letters
are not available electronically. Please visit the Clinical Practicum Office in room GH1110
at King campus to request the form/letter. You must bring your Seneca OneCard to request
the application form/letter.
Students are required to complete the above
section, and keep supporting documentation with
this package at all times.
CPR at the Health Care Provider Level (CPR-HCP) and Standard First Aid
CPR at the Health Care Provider Level also known as Basic Cardiac Life Support (BCLS) at the
Health Care Provider Level is required yearly, regardless of the expiry date on the card.
Company
Course Level
Date of Issue
Standard First Aid is required upon entry into the program. It is the student’s responsibility to
ensure that the certificate is current throughout the program.
The following companies offer CPR/HCP training:
 Seneca College Continuing Education Program
 Canadian Red Cross
 Heart and Stroke Foundation of Canada
 St. John Ambulance
 Concise Health Solutions
Students are required to complete the above
section, and keep supporting documentation with
this package at all times.
Clinical Preparedness Permit – Seneca/York/Georgian
Revised June 2015
Page 2 of 9
Student Name: __________________________________________________
Ministry of Labour’s Worker Health and Safety Awareness Certification
This certification is available on the Ministry of Labour website via a free
eLearning module. Students must access the eLearning module from any
computer (home for instance), complete the training and print the certificate
of completion. It is crucial you print your own certificate at the time of
completion because the Ministry does not maintain a database. It is also
worth pointing out that you need to complete the module in a single sitting, it
is not possible to stop part way through and resume at a later time/date. The
website indicates that the module takes 45-60 minutes to complete.
Helpful hint: the module is a one-time requirement, with no expiration date
as of yet, so be sure to keep a copy for your records.
Instructions to access the eLearning module are to the right.
Respirator Mask Fit Testing (Completed Every Two Years)
It is your responsibility to arrange and obtain a respirator mask fit at your
own expense.
Date of Issue
Students are required to complete the above section, and keep
supporting documentation with this package at all times.
To access the eLearning module
1. Use a computer with audio and a printer (you are welcome
to use a computer in the King computer lab. The people at
the service desk can provide you with headphones)
2. Visit this website:
http://www.labour.gov.on.ca/english/hs/training/workers.php
3. Click the link titled “Access the eLearning Module”
4. Complete the eLearning module
5. Print your certificate of completion
6. Keep your printed certificate of completion with your CPP
and bring it to clinical on your first day
Please indicate your N95 size, type and date of testing
N95 Type
Size
Date of Issue
Students are required to be fit tested for an N95 respirator prior to their 1st
clinical placement and at least every two years thereafter.
Please note that if you lose/gain a significant amount of facial weight or
experience changes in your facial shape, i.e. trauma or surgery, fit-testing
should be repeated earlier.
Clinical Preparedness Permit – Seneca/York/Georgian
Revised June 2015
Students are required to complete the above section, and keep
supporting documentation with this package at all times.
Page 3 of 9
Student Name: __________________________________________________
Medical Requirements (To be completed by Health Care Provider)
Tuberculosis Screening
TUBERCULOSIS
Is an infectious disease spread through air by coughing, sneezing or spitting.
Classic symptoms are a chronic cough with blood-tinged sputum, fever, night
sweats and weight loss.
Please indicate any living, travel or work history in which you may have been at
risk for tuberculosis _______________________________________________
_______________________________________________________________
1. A Base-line Two Step Mantoux skin test is required for all new students.
Students who have received a BCG vaccination are not exempt from
Mantoux testing.
2. Mantoux testing should be completed within 4-6 weeks from administration
of live vaccine including oral polio, MMR, yellow fever, polio and cholera.
3. Students who have had a previously documented positive Mantoux test
should not receive further Mantoux testing.
If a student has a previously documented positive Mantoux Two-Step screening
and has received investigation, the student must include the following in this
package:
a) A chest x-ray report every 2 years, and;
b) A yearly note from their doctor indicating that the “student is free from
signs and symptoms of active tuberculosis”
The responsibility for follow-up lies with the physician as per OHA/OMA
Communicable Disease Surveillance Protocols.
Mandatory Lab Reports (To be completed by Health Care
Provider)
Mantoux
Skin Test
Date Given
Date Read
48 – 72 h
from testing
Induration
(mm)
BASELINE 2
STEP
Step 1
Step 2
(7 – 28 Days
After Step 1)
Step 1
Required Annually
Step 1
Required Annually
Step 1
Required Annually
Step 1
Required Annually
Step 1
Required Annually
Chest x-ray – Date & Result:
Chest x-ray – Date & Result:
4. A student who had a two-step in the past 12 months and tested
negative must complete a one-step annually.
Health Care Provider Signature:
A ONE-STEP MANTOUX SKIN TEST IS REQUIRED ANNUALLY.
Clinical Preparedness Permit – Seneca/York/Georgian
Revised June 2015
Page 4 of 9
Student Name: __________________________________________________
MMR (Measles, Mumps, Rubella)
If a student is born in Canada prior to 1970, immunity to
measles, mumps and rubella can be assumed.
Born in Canada before 1970 (DOB):
OR
If a student is born after 1970 they must provide:


Record the dates vaccinated for two MMR doses
MMR Vaccine Date Given (Dose 1):
OR
MMR Vaccine Date Given (Dose 2):
Lab results (titres) which show immunity to measles,
mumps and rubella
OR
Additional immunization can be discussed with your health care
provider.
Lab Reports
Immune
Measles:
 Yes
 No
 Indeterminate
Mumps:
 Yes
 No
 Indeterminate
Rubella:
 Yes
 No
 Indeterminate
Health Care Provider Signature:
Polio
If immunization required, 3 doses are recommended: the first 2, 4 to 8
weeks apart and the third dose should be 6 to 12 months later. The
first one immediately, the second one, one month after the first and
the third one 6 to 12 months later.
Date Primary Series Completed:
OR
Date of Last Booster (if required):
Health Care Provider Signature:
Clinical Preparedness Permit – Seneca/York/Georgian
Revised June 2015
Page 5 of 9
Student Name: __________________________________________________
Varicella (Chicken Pox)
If a student has had varicella (chicken pox) they will have natural
immunity.
 Yes
Has had varicella (chicken pox):
 No
OR
OR
Record dates vaccinated for Varicella (2 doses for adults)
OR
Varicella Vaccine Date Given (Dose 1):
Varicella Vaccine Date Given (Dose 2):
If there is no known history of having varicella and no documentation
of vaccination, titre lab results are required.
OR
Lab Reports
Immune:
 Yes
 No
 Indeterminate
Health Care Provider Signature:
Tetanus/Diphtheria (TD)/ Pertussis
Date of Last Tetanus:
A Tetanus/Diphtheria booster within the last 10 years is required.
Date Primary Series Completed:
One dose of Adacel is recommended if booster has not been
administered within last 10 years. There is a cost associated with
receiving Adacel.
If previously unimmunized, 3 doses are recommended. The first one
immediately, the second one, one month after the first and the third
one 6 to 12 months later.
If immunization is required have Tetanus/Diphtheria and Pertussis.
Clinical Preparedness Permit – Seneca/York/Georgian
Revised June 2015
Date of Booster:
Optional: Adacel (1 dose)
Date given:
Health Care Provider Signature:
Page 6 of 9
Student Name: __________________________________________________
Hepatitis B
A lab test (titre) is required if there is a history of previous
immunization and the immune status is unknown. If the vaccine has
not been given, or if the vaccine dates are not known, the lab results
must be included with this Permit.
Once you have completed the vaccination series, a titre is
required. The titre is done at least 1-6 months after your 3rd
vaccination or final vaccine.
Students may enter clinical placements as long as they have had their
2nd Hep. B vaccine.
For non-responders, additional doses, up to another complete series
of three, can be done, with testing for response after each dose.
Persons who fail to respond to three additional doses of vaccine are
unlikely to benefit from further immunization.
Mandatory Lab Reports
 Yes
Immune:
 No
 Indeterminate
1st Vaccination Date:
2nd Vaccination Date:
(within 1 month of 1st)
3rd Vaccination Date:
(6 months after 1st)
Health Care Provider Signature:
After having received the series of Hepatitis vaccine and having post
vaccination blood work I still do not show immunity.
Signature___________________ Date:________________________
Influenza Vaccination (Flu Shot)
ANNUAL IMMUNIZATION VACCINE ONLY AVAILABLE DURING
FLU SEASON (OCTOBER/NOVEMBER).
Students who have not received the vaccination will be removed from
clinical placement as most of our placement partners may require that
students receive influenza immunization and show proof especially if
there is an outbreak. In the event of an outbreak at your
placement, any student without the vaccination may be denied
access to the facility thereby jeopardizing successful completion
of the clinical course.
Clinical Preparedness Permit – Seneca/York/Georgian
Revised June 2015
Year
Date Received
Health Care Provider
Signature
1st Year
2nd Year
3rd Year
4th Year
Page 7 of 9
Student Name: __________________________________________________
TO BE COMPLETED BY HEALTH CARE PROVIDER (HCP)
Name:
Name:
(please print)
(please print)
Address:
Address:
Official
HCP
Stamp:
Official
HCP
Stamp:
Telephone:
Telephone:
Signature:
Signature:
Date:
Date:
Clinical Preparedness Permit – Seneca/York/Georgian
Revised June 2015
Page 8 of 9
Student Name: __________________________________________________
This page is for the Practicum “verification” stamp. This means that the appropriate staff person/agency has verified that the
required clinical documents and information is current and clear and up to date as per clinical requirements.
Proceed to:
Proceed to:
Proceed to:
Proceed to:
Approved by:
Approved by:
Approved by:
Approved by:
Date:
Date:
Date:
Date:
Verification of Clearance
Verification of Clearance
Verification of Clearance
Verification of Clearance
Proceed to:
Proceed to:
Proceed to:
Proceed to:
Approved by:
Approved by:
Approved by:
Approved by:
Date:
Date:
Date:
Date:
Verification of Clearance
Verification of Clearance
Verification of Clearance
Verification of Clearance
Clinical Preparedness Permit – Seneca/York/Georgian
Revised June 2015
Page 9 of 9