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					               Holland College Immunization Requirements
               ATLANTIC POLICE ACADEMY PROGRAMS
Students enrolling in the Correctional Officer, Basic Firefighting, Law & Security, Conservation
Enforcement and Police Science Cadet programs at the Atlantic Police Academy must receive
HEPATITIS B, MMR, and TETANUS immunizations as a requirement of the programs as well as for
personal health and safety. If you have previously received these immunizations, we require proof of
immunization from your Doctor or public health nurse. The following form must be completed by your
Doctor or public health official where any immunizations may have been administered.

IMPORTANT:        This form must be completed at least 60 days prior to the course start date and
                  faxed to (902) 629-4239 or mail it to the Admissions Office, 140 Weymouth Street,
                  Charlottetown, PE, C1A 4Z1.

                          Applicant Immunization Records

Applicant Name:                                           DOB:                           (dd/mm/yyyy)
Address:
Program:
Home Phone:                                         Cell Phone:



HEPATITIS B VACCINE

Has the applicant received a series of 3 Hepatitis B vaccines?     Yes          No
Date 1st dose:
      nd
Date 2 dose:
      rd
Date 3 dose:

HEPATITIS B ANTIBODY LEVEL
After the series is completed, the Hepatitis B Antibody level should be measured (blood work) to confirm
immunity. This must be done between 1 and 6 months following the Hepatitis series.

Hepatitis B Antibody level results:
Date tested:                                                      Result:   Immune     Not Immune
Name and Title of Health Care Professional completing form:
Telephone Number:
City/Town, Province:
Signature:


MMR – MEASLES, MUMPS, RUBELLA

If you were born after 1970 you should have had 2 doses of MMR provided you did not have all three
Diseases. If you haven’t had the diseases or the MMR vaccine, you must get this vaccine (will need at
least a month between doses).

Has the applicant been vaccinated against Measles, Mumps and Rubella?        Yes       No

Dates:
Measles (Rubeola):
Date 1st dose:
      nd
Date 2 dose:

Mumps:
Date 1st dose:
      nd
Date 2 dose:

Rubella (German Measles):
Date 1st dose:
      nd
Date 2 dose:




Continued on Page 2
Applicant Immunization Records
Page 2



DPTP – DIPTHERIA, PERTUSSIS (WHOOPING COUGH), TETANUS, POLIO
This is a primary series of 4. Please indicate dates and which vaccines were included in the primary
series.

Date 1:                                      Vaccines:
Date 2:                                      Vaccines:
Date 3:                                      Vaccines:
Date 4:                                      Vaccines:


If you are unable to locate your records, you will need to have this series repeated (3 doses over 8
months).

Polio vaccinations: If you have had polio vaccinations in addition to the above, please give those dates.

Date 1:
Date 2:
Date 3:


Booster Tetanus/Diptheria. You will require a booster if you haven’t had one in the last 10 years.

Date of booster:



Name and Title of Health Care Professional completing form:
Telephone Number:
City/Town, Province:
Signature:


CONSENT OF APPLICANT: I consent to the release of my immunization information to appropriate
personnel in order to meet requirements of admissions and clinical placement.




Student Signature:                                              Date:
Hepatitis B Immunization Form (March 2009)
Dated: March 23, 2009

				
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