PROGRAM: PRACTICAL NURSING Owen Sound Campus
Clinical Permit Document
This document is intended to be your record of all requirements (which may include but not limited to
immunizations, CPR & First Aid (FA) & vulnerable sector screen (VSS) / Police Checks & Mask Fit Testing
(MFT)) that you must complete to be eligible to attend clinical placement environments. Requirements
vary by program and from semester to semester – You are responsible to ensure that you meet all
requirements at the time required. If you do not complete your permit, you will not be eligible to attend
placements and will risk failing your clinical placement course. If you have questions about these
requirements, please contact your program coordinator.
Process
Immunizations: Present this document to your health care provider (HCP) and ask him/her to complete
as much of it as he/she can and to authorize any serological testing as required. Once you have
assembled all evidence required to meet the immunization requirements of your program, present this
evidence, signed by your HCP, to Synergy permit checkers at your appointment. Laboratory serological
evidence is the best proof of immunity though evidence that you have completed a full vaccination
series, as verified by your HCP, will be acceptable as well. Vaccinations or boosters are also
recommended if your last vaccination was over 10 years ago. If you are not immune, but have
completed full vaccinations series, please discuss this with the permit checkers and they will assist in
answering your questions. The role of the permit checking agents is to verify that your documentation is
complete and that it meets the requirements of your program.
Miscellaneous & TB Testing: These items include CPR & FA, MFT, VSS, and TB testing. Once you have
collected evidence that you have met all of these requirements, present this evidence at your permit
checking appointment. The role of the permit checker is to verify that your documentation is complete
and have met the requirements of your program.
CPR & FA and MFT: Once you complete the appropriate training and testing, you will receive a card
indicating that you have met the requirements. Please note that you must complete a CPR refresher
course after one year.
VSS: This screen is performed by your home police detachment. In some regions, this can take as long
as 12 weeks to process so please plan ahead. Request forms, to be taken to your home police
detachment, are available from Georgian College in most cases.
TB testing: A 2-step skin test (unless you have a recently documented test) must be completed prior to
your first clinical placement. If you have a positive response to the skin test, you are required to
complete a chest x-ray as well to meet the requirement.
Confirmation of Eligibility: Once all of your requirements have been verified by the Synergy permit
checkers, you will receive a stamped signed document stating that you are eligible to attend placement.
When you attend your clinical placement, please be prepared to show this document (and your
completed permit and all supporting documentation, if requested) to your clinical teacher or the agency.
It is strongly suggested that you keep the original Permit in a “safe place”, and take a photocopy to your
agency placement.
PROGRAM: PRACTICAL NURSING Owen Sound Campus
Year One Requirements
Name ______________________________________
SID ______________________
Immunizations: To be completed by week 7 of semester 1
MMR
Measles1
________________
______
Signature
Date
Acceptable Evidence: Serologic testing OR series of 2 doses of measles-containing vaccine
_______
Mumps2
Initial
Acceptable Evidence: Serologic testing OR series of 2 doses of mumps-containing vaccine
________
Rubella3
Initial
Acceptable Evidence: Serologic testing OR 1 dose of rubella-containing vaccine
________
Initial
Diphtheria / Pertussis / Tetanus (DTaP / TDaP)
Diphtheria4
________________
______
Signature
Date
Acceptable Evidence: 3 doses of diphtheria toxoid-containing vaccine
________
Pertussis5
Initial
Acceptable Evidence: 3 doses of pertussis toxoid-containing vaccine (primary series) OR single dose of “TDaP”
________
Tetanus6
Date
Initial
________
________
________________
Signature
_________
Date
Acceptable Evidence: 3 doses of tetanus toxoid-containing vaccine
________
Polio7
Acceptable Evidence: 4 doses of polio vaccine (primary) OR 3 doses of polio vaccine (IPV-containing)
Varicella8
Acceptable Evidence: Serological testing OR series of 2 doses
______________
________
Signature
Date
Hepatitis B9
Acceptable Evidence: serological testing OR two completed series of doses
______________
________
Signature
Date
Influenza10
Acceptable Evidence: One dose of vaccine
Repeat in about 1 year
________
Date
PROGRAM: PRACTICAL NURSING Owen Sound Campus
Miscellaneous Items: To be completed by week 7 of semester 1
CPR (HCP) & Standard First Aid
Acceptable Evidence: Signed Card from Certified Instructor.
Recertify CPR annually. Standard First Aid is good for 2 years.
Date __________
Two Step TB Test
Acceptable Evidence: This form signed and dated by Health Care Professional including readings for two tests, completed approximately 4
weeks apart OR normal X-ray following a positive skin reading.
Reading 1 _____________
Date _______________
Signature _______________________
Reading 2 _____________
Date _______________
Signature _______________________
Chest X-ray Reading ____
Date _______________
Signature _______________________
Complete a one-step test yearly
Mask Fit Testing
Acceptable Evidence: Signed Card from Certified Tester.
Retest in about 2 years
Mask Type _______________
Date ____________________
Police Check with Vulnerable Sector Screen
Acceptable Evidence: A negative report issued within 3 months of the start of placement, embossed by the police service that completed
the VSS.
Date __________
Note: Vulnerable Sector Screens can take up to 16 weeks to complete and are usually issued by the police service found closest to the
address on your Driver’s License
You must complete your next VSS prior to the start of year 2.
Notes: Immunizations and / or past infections must be verified by a Health Care Professional familiar
with your Health Record, unless otherwise noted. Serologic testing (titres) must show evidence that the
concentration of antibodies found in the blood exceeds a minimum concentration identified for that
vaccine to be considered immune. Serologic readings that are indeterminate will not be accepted as
evidence of immunity.
Hepatitis B – If you have had prior immunization for Hepatitis B, but serological testing comes back as
indeterminate or not immune, you will have to complete at least the first step in a 3 step series of
immunizations prior to start of clinical. If you are unsure if you have been immunized against Hepatitis B,
serological testing can be used to determine your level of immunity. If your blood levels do not indicate
that you are immune and you have no proof of prior immunization, you will need to complete a series of
immunizations and another round of serological testing. If you need to complete the entire series,
please speak to your program coordinator to find out what impact this will have on clinical availability.
Health Care Provider – please verify what you can and sign for each immunization or history of infection
listed above. For MMR and DPT, if you are verifying all three immunizations at once, you need only sign
the top line. Please date the document. Thank-you very much for supporting Georgian’s students!
PROGRAM: PRACTICAL NURSING Owen Sound Campus
Year Two Requirements
Immunizations: to be completed before beginning of year 2
Influenza
Acceptable Evidence: One dose of vaccine
Date ___________
Miscellaneous Items: to be completed before beginning of year 2
Criminal Record with Vulnerable Sector Screen
Acceptable Evidence: A negative report issued within 3 months of the start of placement, embossed by the police service that completed
the VSS.
Note: Vulnerable Sector Screens can take up to 16 weeks to complete and are usually issued by the police service found closest to the
address on your Driver’s License.
Date ___________
CPR (HCP) Recertification
Acceptable Evidence: Signed Card from Certified Instructor.
Date ___________
References:
Georgian College follows the recommendations set out in the Canadian Immunization Guide presented
on the Public Health Canada webpage. In particular, the recommendations for immunization schedules
and evidence of immunity for health care professionals is followed on this document. Your health care
provider is the best person to see to confirm your immunization status.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Measles - http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-meas-roug-eng.php#sched
Mumps - http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-mump-orei-eng.php#sched
Rubella - http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-rube-eng.php#sched
Diphtheria - http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-dip-eng.php#a5
Pertussis - http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-pert-coqu-eng.php#a5
Tetanus - http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-tet-eng.php#a5
Polio - http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-poli-eng.php#a5
Varicella - http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-vari-eng.php#a5
Hepatitis B - http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-hepb-eng.php#a5
Influenza - http://www.phac-aspc.gc.ca/publicat/cig-gci/p04-influenza-eng.php#vacadm
PROGRAM: PRACTICAL NURSING Owen Sound Campus