Clinical Preparedness Permit must be completed & approved to attend clinical placement; without attending clinical, students cannot progress in the program.
Reason for Current Immunization Requirements
CLINICAL PREPAREDNESS PERMIT
Ontario legislation specifies certain surveillance requirements for those entering into a practice
setting. The Nursing Program policy was developed in accordance with the Public Hospitals Act
and is based on the Canadian Immunization Guide 7th Edition, and Canadian TB Standards;
therefore, specified immunization information must be submitted. Consultation was provided by
Public Health, Hospital Occupations & Health, and LTC facilities of Grey/Bruce.
The process is necessary to ensure that those working within health care or other facilities are
free from or protected against communicable and infectious diseases.
___________________________________________________________________
Last Name
First Name
The completion of this information is NOT optional; it is required information to confirm the
student’s practicum placement.
___________________________________________________________________
College Student #
College Email Address
___________________________________________________________________
Contact Number(s): Cell/Home
IMPORTANT
THE STUDENT WILL NOT ENTER CLINICAL PLACEMENT
UNLESS THE PERMIT IS COMPLETED AND STAMPED.
Privacy
Georgian College is compliant with the Freedom of Information and Protection of Privacy Act
(FIPPA), and endeavors to protect your personal information in accordance with this law. The
personal information requested on this form is collected under the legal authority of the Ontario
Colleges of Applied Arts and Technology Act, 2002 and in accordance with Sections 38(2) and
41(1) of FIPPA. The information provided will not be used for any purposes other than clinical
placements.
For further information about the information requested on this form or the purpose for which it
will be used, please contact Program Coordinator, 519-376-0840 ext 2081; for more information
about FIPPA, please contact the Access and Privacy Office at 705-728-1968, extension 5770 or
AccessPrivacy@GeorgianCollege.ca
Due Date:
Authorization for Placement
Signature &Stamp
Semester 1& 2 students: Monday of Week 3
Date:
Semester 3,4,&5 students: First day of Semester



Police Check, CPR, Mask Fit, WHMIS, & Health Record
must be completed
Shaded areas on pages 3&4 must be completed and
signed by your health care provider, nurse or doctor.
Please take this form with you to your medical appointment.
It is the responsibility of the student to keep this form
and associated documents for placement purposes.
Please Note: If you have a criminal record or obtain a criminal record during the nursing program,
you will be required to obtain a pardon. Without a Pardon, you will be denied clinical access, and
therefore will not be permitted to proceed in the program until a pardon is obtained.
Clinical Preparedness Permit – Georgian, Practical Nursing
Revised Oct 2014
Year 1
Year 2
Semester 5
Please ensure that all data and information is up-to-date for licensing exam
and future employer.
Clinical Preparedness Permit must be completed & approved to attend clinical placement; without attending clinical, students cannot progress in the program.
1.
Vulnerable Sector Police Record Checks (Required Annually)
Police Check Service
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 service used this process may take up to
12 weeks or more, so be sure to apply early. Your first placement will be in Long Term Care and
your Police Check must be current and within 6mos of placement. Please see the guidelines
below in red.
Students are required to carry their police check result to the clinical area. A representative in the
agency may ask to see that you have a valid Police Check result at any time.
If the applicant has a criminal record or obtains a criminal record during
the nursing program, she/he will be required to obtain a pardon. Without a
Pardon, the student will be denied clinical access, and therefore will not be
permitted to proceed in the program until a pardon is obtained.
Date Issued
1
2
Praxis
Police Record Checks are available through your local police service only.
Please see your Program Coordinator for additional information.
*If you are accepted for the program in Jan 2015, your Police Check must
be done no earlier than Sept 2nd, 2014
*If you are accepted for the program in Sept 2015, your Police Check must
be done no earlier than May 2nd, 2015
2.
Basic Cardiac Life Support and First Aid (BCLS) for Health Care Providers
(HCP) (CPR must be the HCP level)
BCLS and Standard First Aid for Health Care Providers (Level HCP) is required upon entry into the
program. The School of Nursing requires a minimum re-certificate every year for the CPR
regardless of the expiry date on the card. It is the student’s responsibility to ensure that the
certificate is current throughout the program.

There are various organizations that offer both First Aid and CPR
Clinical Preparedness Permit – Georgian, Practical Nursing
Revised Oct 2014
Company
1
2
Praxis
Course Level
Date of Issue
Clinical Preparedness Permit must be completed & approved to attend clinical placement; without attending clinical, students cannot progress in the program.
3.
Respirator Mask Fit Testing ( Completed every two years)
.
N95 Mask Type
Size
Date issued
Respirator Mask Fit Testing is arranged by the School of Nursing. A scheduled date and time for
testing will be provided to you during the first two weeks of school. If you miss your scheduled
appointment, it will be your responsibility to obtain a Mask Fit test at your own expense.
4.
WorkSmart WHMIS – Health & Safety Training
To attend practicum, you must complete an online in-service dealing with the basic understanding of
the principles of workplace safety. You will be provided with directions and an access code to
complete this mandatory requirement. Upon completion of this in-service, you will print off the
certificate of completion as evidence of completion. Without this record, you will not be permitted to
proceed to clinical. Access training at www.WorkSmartCampus.ca , register where indicated
and enter the campus ID: MEVT2747. A 70% score is required. If that score is not obtained,
please contact the Program Assistant to reset.
5. Mental Health First Aid Certificate
To attend practicum in semester 3, you must complete a 2 day in class course and obtain your
Mental Health First Aid Certificate, prior to first day of classes in semester 3.
If you are accepted into the program for Jan 2015, you will need to complete and produce
proof of this course for Jan 2016.
If you are accepted into the program for Sept 2015, you will need to complete and produce
proof of this course for Sept 2016.
Please watch for posting on Blackboard for courses in Grey Bruce offered in the summer and
fall of 2016.
Clinical Preparedness Permit – Georgian, Practical Nursing
Revised Oct 2014
Georgian College WorkSmart
WHMIS training
Completed & Certificate provided
Mental Health First Aid Certificate
Completed & Certificate provided
Clinical Preparedness Permit must be completed & approved to attend clinical placement; without attending clinical, students cannot progress in the program.
HEALTH CARE RECORD
Take this form to your health care provider to be
completed before Jan 2015 or Sept 2015
Copies of lab results for specified diseases
must be presented with this Permit.
Date Read
1. TUBERCULOSIS
Documentation of 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.
Students who have had a previously documented positive Mantoux test should not
receive further Mantoux testing.
a)
If a student has a previously documented positive Mantoux Two-Step screening
and has received investigation – a copy of chest x-ray report from this year and a
note must be provided indicating that the “student is free from signs and
symptoms of active tuberculosis” and must be included in this package.
b) A chest x-ray every 2 years is required for positive Mantoux test.
For any student that tests positive for the first time:
a) Include results of the positive Mantoux screening (mm of duration).
b) A chest x-ray is required and the report must be enclosed in this package.
c) The responsibility for follow-up lies with the physician as per OHA/OMA
Communicable Disease Surveillance Protocols.
Mantoux
Skin Test
Date Given
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
Chest x-ray – Date & Result:
________________________________________
Health Care Provider Signature: ______________________________
2. INFLUENZA VACINATION( Flu Shot) –available Fall season
In Grey-Bruce counties, the Influenza vaccination is mandatory for students to attend
clinical placements. An agency representative will ask for proof of vaccination. Agencies
do deny student access if proof of vaccination is not provided. A Doctor’s Note will be
required, if student cannot receive vaccination and a formal request to agency will need to
occur. Speak with Program Coordinator immediately.
Clinical Preparedness Permit – Georgian, Practical Nursing
Revised Oct 2014
Influenza Vaccine
Date Received
Health Care Provider Signature
1st year
__________
__________________________
2nd year
__________
__________________________
Praxis
__________
__________________________
Clinical Preparedness Permit must be completed & approved to attend clinical placement; without attending clinical, students cannot progress in the program.
3. Tetanus/Diphtheria (TD)/ Pertussis
A Tetanus/Diphtheria booster within the last 10 years is required.
One dose of Adacel is recommended if booster has not been administered within last 10 years. There
is a cost associated with receiving Adacel (approx. $35 per adult).
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.
Date of last tetanus:_______________________________________
Date of Last boster:_______________________________________
Optional Adacel:__________________________________________
NB: If immunization is required have Tetanus / Diptheria and Pertussis
Health Care Provider Signature: ________________________________
Students must obtain lab results (titres), to verify immunity to: Chicken Pox and Hepatitis B. If you are unable to show proof of 2 vaccinations of MMR,
lab results to show immunity are required.
Lab Reports – please attach
4. MMR (Measles, Mumps, Rubella)
You will need to show proof of vaccination for 2 doses, with the 1st dose given on or after
your 1st year of age and the second dose given at least 4 weeks after OR laboratory
evidence of immunity (titres). If you do not have documentation of 2 doses of
vaccination, you will need to show proof of immunity with blood work (titres). These tests
can take a minimum of 10-14 days or longer for results.
Rubella:
Mumps:
Measles:
Immune
 Yes  No
 Yes  No
 Yes  No
 Indeterminate
 Indeterminate
 Indeterminate
If blood work not completed:
Born in Canada before 1970 (DOB):______________________________
Date MMR vaccine dose 1 given:__________________ Dose 2:______________
Health Care Provider Signature: ________________________________
5. Varicella (Chicken Pox)
Lab Reports – please attach
Immune
 Yes  No
Laboratory evidence of immunity results must be provided.
If you have had Chicken Pox and show no immunity with your blood work, you must then
complete a series of 2 needles 1 month a part and show proof of vaccination.
 Indeterminate
If blood work not completed:
Has had varicella (chicken pox)
 Yes
 No
Date Varicella Vaccine dose 1: ________________ Dose 2: _________________
Health Care Provider Signature: ______________________________
Clinical Preparedness Permit – Georgian, Practical Nursing
Revised Oct 2014
Clinical Preparedness Permit must be completed & approved to attend clinical placement; without attending clinical, students cannot progress in the program.
6. Hepatitis B
Students are required to provide evidence of immunity to Hep B for clinical placement.
If you have never received Hep B immunization, you must complete the series of two
vaccinations (required prior to placement) and then have blood drawn x 1 month post
2nd vaccination date to show immunity. Lab results MUST be provided
OR
If you have previously received the two Hep B vaccinations, (ie in grade school), you now
require a “challenge” dose, and then have blood drawn x 1 month post vaccination date to
show immunity. Lab results MUST be provided
Mandatory Lab Reports
Immune
Hepatitis B:
 Yes
 No
 Indeterminate
If blood work not completed:
1st Vaccination Date:
___________________________________
2nd Vaccination Date:
(within 1 month of 1st)
___________________________________
Post Vaccination Lab Tests should be done 1 – 6 months, ideally at
week 6 after the last vaccination; otherwise will not necessarily show
immunity.
3rd Vaccination Date:
(6 months after 1st)
___________________________________
7. Polio
Date Primary Series Completed: ______________________________________
OR
Date of Last Booster (if required) ______________________________________
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.
Clinical Preparedness Permit – Georgian, Practical Nursing
Revised Oct 2014
Health Care Provider Signature: _________________________________
Health Care Provider Signature: __________________________________