University of Toronto Mississauga Immunization Record Form

University of Toronto Mississauga | Immunization Record Form

The information you provide is confidential. It is intended for use by UTM Health Services Staff only to ensure that you meet the health requirements for your placement. This information will not be released to anyone outside of UTM Health Services without your permission.

Please complete this form with your Doctor’s assistance, sign and return the form in a sealed envelope to UTM Health Services on or before the first day of classes. NOTE: You will not be allowed to work in your placement until all Immunization requirements have been met. These requirements are based on recommendations established by the Ontario Hospitals Act and the Ontario Chief Medical Officer of Health.

IMPORTANT: Keep a copy of this form in the event it is required for your placement.

Student Name: / Student Number:
Full Address:
Family Physician Name: / Phone:
Full Address:
Special Needs (e.g. Mobility/Physical Difficulty, Health Concerns, etc.):
Known Allergies (list and indicate if any of your allergies are life threatening):
Drugs: / Life Threatening: YES NO
Food: / Life Threatening: YES NO
Bee Sting: / Life Threatening: YES NO
Other: / Life Threatening: YES NO
Medication (list each drug by name, including drugs for birth control, diabetes, epilepsy, blood pressure, etc.):
General Remarks:
Tdp (Tetanus, Diphtheria, Polio – Primary Series) / YES NO
Tdp (Tetanus, Diphtheria, Polio Booster Injection) – every 10 years / Date of Last Booster:
MMR (Measles, Mumps, Rubella Vaccine, 1980 or later) / Date:
Two Step Tuberuclin Skin Test required within the past 12 months
NOTE: SEE A PHYSICIAN FOR THIS TESTING / #1 Date:
Result:
Second step: 1-3 weeks after step #1 / #2 Date:
Result:
Please note: If T.B. test is positive, evidence of a negative chest X-Ray is required within 9 months
Chest X-Ray (within 9 months) / Date:
Result:
Chicken Pox: /
YES NO
If NO, Varicella titre necessary / Date:
Result:
Hepatitis B vaccine is NOT COMPULSORY but is highly recommended. Hepatitis B vaccine may be arranged with UTM Health Services at a special student rate.
Hepatitis B Vaccine / #1 Date:
#2 Date:
#3 Date:
Hepatitis B Titre (post vaccine) / Date:
Result:

I ______understand that it is my responsibility to inform UTM Health Services Personnel of any communicable disease, special need or medical condition which may place me at risk or pose a risk to others in my placement setting.

Intern Print Name:
/ Intern Signature:
Date:
Physician’s Name: / Physician’s Signature:
Date:

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