WIL DOCUMENT REQUIREMENTS

PASSPORT

First Name Rachel Last Name Pawa

Birth Date 1999-04-15 Program Respiratory Therapy Year 3
Academic Year 2023-2024 Fall 2023 Winter 2024 Spring 2024 =Requirements Complete

=Outstanding Requirement(s) or
renewal of requirement(s) required

=Not Applicable
Outstanding Requirements Item #s: 9

Year 1 Year 2 Year 3 Year 4

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

Date of TB Blood Date of TB Blood Hx of positive test: Hx of positive test:

Test: Test: Chest X-ray (if required) Chest X-ray (if required)
Result (pos/neg): Result (pos/neg):
Date: Date:
Result: Result:
Hx of positive test:
Hx of positive test:
Chest X-ray (if required)
Chest X-ray (if required) Physician Statement Physician Statement
Date:
Date:
Result: Date: Date:
Result:
Clear of TB Clear of TB
Physician Statement signs/symptoms: signs/symptoms:
Physician Statement
Date:
Date:
Clear of TB signs/symptoms:
Clear of TB signs/symptoms:

2. MMR: MEASLES:

MMR Immunization #1: May 30, 2000 Date of Test Result (reactive/non-reactive)

Laboratory Evidence MUMPS:

of Immunity (Titre):
Date of Test Result (reactive/non-reactive)
MMR Immunization #2: Apr 23, 2003 RUBELLA:

Date of Test Result (reactive/non-reactive)

2023-09-23 ***PASSPORT CONTINUED... *** Required Documentation for the Program Year 20:28
 WIL DOCUMENT REQUIREMENTS
PASSPORT

First Name Rachel Last Name Pawa

Birth Date 1999-04-15 Program Respiratory Therapy Year 3
Academic Year 2023-2024 Fall 2023 Winter 2024 Spring 2024 =Requirements Complete

=Outstanding Requirement(s) or
renewal of requirement(s) required

=Not Applicable

*** Page 2 of 3, PASSPORT CONTINUED ***

3. TETANUS/DIPTHERIA/PERTUSSIS: Date of last immunization:

Tetanus/Diptheria #1: Tdap: Aug 12, 2013 Tetanus: Expiry:
Tetanus/Diptheria #2: Tdap: Sep 08, 2021 Diptheria: Expiry:
Tetanus/Diptheria #3: Expiry: Sep 08, 2031 Pertussis:

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)

Hep B #1: Hep B #2: Hep B #3: Date of TITRE: Result(pos/neg):

Booster Dose: Repeat TITRE: Result(pos/neg):

Hep B Non-Responder (as per Physician and/or 2 immunization series completed)

Hep B requirement complete Document reviewed by Practicum Nurse Technologist

5. VARICELLA: One of the following is required:

* Laboratory Evidence of Immunity (Titre): Date of Titre: May 26, 2021 Result (pos/neg): pos
* Varicella Vaccine (2 doses required) 1st Dose Date: Jun 16, 1999 2nd Dose Date:

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

Date: Model: Expiry:

Date: Model: Expiry:

8. COVID VACCINE:

1st Dose: May 07, 2021 Type: Pfizer-BioNTech/Comirnaty/BNT162B2/Tozinameran

2nd Dose: Aug 06, 2021 Type: Pfizer-BioNTech/Comirnaty/BNT162B2/Tozinameran
3rd Dose: Type:
4th Dose: Type:
Booster: Type:
Booster: Type:
Exemption: Expiry: TBD

2023-09-23 ***PASSPORT CONTINUED... *** Required Documentation for the Program Year 20:28
 WIL DOCUMENT REQUIREMENTS
PASSPORT

First Name Rachel Last Name Pawa

Birth Date 1999-04-15 Program Respiratory Therapy Year 3
Academic Year 2023-2024 Fall 2023 Winter 2024 Spring 2024 =Requirements Complete

=Outstanding Requirement(s) or
renewal of requirement(s) required

=Not Applicable

*** Page 3 of 3, PASSPORT CONTINUED ***

Year 1 Year 2 Year 3 Year 4

9. INFLUENZA VACCINE:
Date: Oct 27, 2021 Date: Nov 17, 2022 Date: Nov 17, 2022 Date:

10. CPR: Level: HCP or BLS Level: HCP or BLS Level:

Level: HCP or BLS Date: Jun 16, 2021 Date: Jan 10, 2023 Date: Jan 10, 2023 Date:

11. STANDARD FIRST AID:

Date: Jun 16, 2021 Date: Jun 16, 2021 Date: Jun 16, 2021 Date:

12. FOOD HANDLER CERTIFICATE:

Date: Date: Date: Date:

13. POLICE CHECK: Level: VSS Level: VSS Level:

Level: VSS Status: Clear Status: Clear Status: Clear Status:

Date: May 28, 2021 Date: Jun 13, 2022 Date: Feb 15, 2023 Date:

14. FETAL HEALTH

SURVEILLANCE:
Date: Date: Date: Date:

15. NEONATAL RESUSCITATION:

Date: Date: Date: Mar 04, 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.

Name: Diana Bayne RN Title: WIL Nurse Technologist

Date: Sep 23, 2023

Signature:
*** End of Document ***

2023-09-23 Required Documentation for the Program Year 20:28