Confirmation of Immunizations & Criminal Record Check

Students/Employees: Please have your educational institution/healthcare employer complete this form to confirm that you meet Capital Health’s placement requirements.

This form will confirm that the student/employee has provided proof of all the required immunizations outlined in Capital District Health Authority’s Pre-Placement Immunization policy (CH 15-026) dated June 2008 and that s/he does not have tuberculosis as evidenced from a negative Two-step TST or chest X-ray.

This form will also confirm that the student/employee had a criminal records check (and a vulnerable sector search, if required based on their educational program), completed on the stated date, which is on file at the educational institution/healthcare employer and that either no criminal convictions were discovered, or a criminal conviction was discovered and the details of the conviction are outlined in this form.

Required fields that must be filled in are indicated with an *.

Educational Institution/Healthcare Employer Information

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Student/Employee Information

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The employee is licensed to practice in Nova Scotia.

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The student/employee has provided proof that s/he has obtained all of the immunizations listed in Capital District Health Authority’s Pre-Placement Immunization policy (CH 15-026) dated June 2008 and that s/he does not have tuberculosis as evidenced from a negative Two-step TST or chest X-ray.  

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A criminal records check is on file at the educational/health care institution.  

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A vulnerable sector search is on file at the educational/health care institution.  

 

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