Confirmation of

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					                               Algoma EMS
         Verification of Immunity & Communicable Disease Status
1.       Attached to this form is sufficient proof of my current immunity to each of the diseases listed in
         Part ‘A’ below. (Sufficient proof is any combination of a copy of immunization records, a copy
         of titre results and/or a note signed by a physician or physician’s delegate clearly indicating a)
         your immunity and b) which disease(s) the note pertains to.
2.       I, _________________________________________, verify that, to the best of my knowledge,
         I am not acutely symptomatic of any of the communicable diseases listed in Part ‘B’.


Candidate’s Signature               _______________________________________________


                            Date    ________________________________________________


Part ‘A’ – Presence of Immunity
        Tetanus                                                 Rubella
        Diphtheria                                              Hepatitis ‘B’
        Polio                                                   Varicella Zoster
        Measles                                                  (Chicken pox)
        Mumps                                                   Influenza (current year)


Part ‘B’ – Table of Communicable Diseases
        Acquired Immunodefieciency Syndrome                     Leprosy
         (AIDS)                                                  Listeriosis
        Amebiasis                                               Malaria
        Anthrax                                                 Measles
        Botulism                                                Viral Meningitis
        Campylobacter enteritis                                 Meningococcal Meningitis
        Chicken pox (Varicella)                                 Mumps
        Cholera                                                 Opthalmia Neonatorum
        Cytomegalovirus Infection (Congenital)                  Parathyphoid Fever
        Diphtheria                                              Pertussis (Whooping Cough)
        Encephalitis (Primary Viral)                            Plague
        Gastrointesteritis                                      Poliomyelitis (Acute)
        Giardiasis                                              Psittacosis/Ornithosis
        Group A Streptococcal Disease                           Q fever
         (Invasive)                                              Rabies
        Haemophilus Influenza B Disease                         Rubella
         (Invasive)                                              Rubella (Congenital Syndrome)
        Hemorrhagic Fevers including Ebola                      Salmonellosis
         Virus Disease, Marburg Virus Disease,                   Shigellosis
         and other Viral Causes                                  Tuberculosis
        Viral Hepatitis including Hepatitis A, B                Tularemia
         and C                                                   Typhoid fever
        Influenza                                               Verotoxin producing E. Coli Infections
        Lassa fever                                             Yellow Fever
        Legionellosis                                           Yersiniosis

				
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