Advanced Care Paramedic. Advanced Diploma Program. Application Guide. www.jibc.ca. Canadian Medical Association (CMA) Accredited Program



Similar documents
Primary Care Paramedic. Certificate Program Canadian Medical Association (CMA) Accredited Program. Application Guide. jibc.ca

Diploma in Health Sciences (EMS) Application Guide

ADMISSION TO THE MASSAGE THERAPY PROGRAM 2016

Ghazvini Center for Healthcare Education 1528 Surgeons Drive Tallahassee, Florida phone

Summa Center for EMS EMT Program Website: Accreditation #324. Note that this course is limited to the first 20 applicants.

BLINN COLLEGE ASSOCIATE DEGREE NURSING PROGRAM GENERIC APPLICATION PACKET

BLINN COLLEGE ASSOCIATE DEGREE NURSING PROGRAM LVN-TRANSITION APPLICATION PACKET

Allan Hancock College 2016 Licensed Vocational Nursing Program Application Period: April 1 st June 30 th, 2015

ST. ANTHONY HOSPITAL* INSTITUTE OF EMERGENCY MEDICAL TRAINING

Medical Laboratory Technician

EMERGENCY MEDICAL TECHNICIAN PROGRAM FALL/WINTER SESSION

DIAGNOSTIC MEDICAL SONOGRAPHY *ACCREDITED DIPLOMA PROGRAM

RESPIRATORY THERAPY ASSOCIATE OF APPLIED SCIENCE APPLICATION FOR ADMISSION. Application Deadline MAY 1 ST

Collin College Division of Health Sciences and Emergency Services AAS in Surgical Technology Surgical Technology Program Admission Packet

TMCC NURSING PROGRAM APPLICATION FOR FALL ADMISSION

Bachelor of Nursing Non-Academic Admission Requirements

RADIOLOGIC TECHNOLOGY Uvalde Campus

RN OPTION APPLICATION

What you need to know. ADN / BSN Concurrent Enrollment Program (CEP) Working together to provide Associate and Baccalaureate Degrees in Nursing

Practical Nursing Program. Information Pack

Bachelor of Science in Nursing Programs Lower Mainland

School of Health Sciences and Professional Studies. Associate Degree Nursing Program. (Registered Nursing)

Student Records office Columbia Basin College 2600 North 20th Avenue Pasco, WA 99301

ParaMed Student Information Package Medical / Non-Medical Program Requirements

DISCOVERY COMMUNITY COLLEGE. CURRICULUM GUIDE Development Date: October 2012 Revision Dates: November 2013; May 2014; December 2014;

Surgical Technician Program Application

Selkirk College Bachelor of Science in Nursing (BSN) Program Application Information Letter

MEDICAL ASSISTANT PROGRAM Application and Information Packet HEALTH PROFESSIONS

Dear Applicant: Sincerely, Grant Wilson Surgical Technology Program Director Calhoun Community College

Collin College Division of Health Sciences AAS in Surgical Technology Surgical Technology Program Admission Packet

Health Sciences Programs (General Procedures)

Clinical/Field Pre-Placement Health Form

ParaMed Student Information Package- Introduction & Medical / Non-Medical Program Requirements

Oregon Coast Community College Medical Assistant Program Application Academic Year Deadline: December 4, 2015

San Jacinto College North Campus Medical Assisting

Nursing Assistant I Admission Requirements

BScN Scholar Practitioner Program

NEW NON-DEGREE PROGRAM PROPOSAL

Dear Applicant: PROGRAM.APP\PTA APPLICATION 8/14 (1)

EL CAMINO COMMUNITY COLLEGE FIRE & EMERGENCY TECHNOLOGY DEPARTMENT PARAMEDIC TRAINING Program Information

Lee College Student Application for Admission For Vocational Nursing (L.V.N.) Program

G E T I N. G E T O U T. G E T O N W I T H Y O U R L I F E.

PHARMACY TECHNICIAN PROGRAM APPLICATION INFORMATION LETTER

LPN to ADN Online Option Admission Information & Requirements. 2. Hold a current unrestricted LPN license in North Carolina (or compact state).

Arkansas State University Occupational Therapy Doctorate Program Admission Packet

Medical Radiography Technology Program. Information Session

Pharmacy Technician Program. Pharmacy Technician. Program Application Packet. Health Professions Division

ADN/BSN Concurrent Enrollment Program (CEP)

Medical Assisting Program Fall 2015 Admissions Packet

San Jacinto College North Campus Medical Assisting

DIAGNOSTIC MEDICAL SONOGRAPHY (probationary) Diploma Program

DENTAL ASSISTANT PROGRAM PROGRAM REQUIREMENT PACKET

Bachelor of Science in Nursing (BSN) Program Application

DENTAL ASSISTANT PROGRAM PROGRAM REQUIREMENT PACKET

Registered Nursing (RN) Program. Application Process Dear Registered Nursing Applicant:

NURSING ASSISTANT PROGRAM REGISTRATION PACKET AND INFORMATION

I. Provisions Applicable to All Allied Health Programs

CONTINUING NURSING STUDIES RE-ENTRY PROGRAM FOR REGISTERED NURSES

SURGICAL TECHNOLOGY PROGRAM APPLICATION

TVCC/OCNE NURSING PROGRAM APPLICATION PACKET DIRECTIONS

Overview. Certification

South Plains College Respiratory Care Fall 2015

COMPUTED TOMOGRAPHY CERTIFICATE PROGRAM

MATC PRACTICAL NURSING (PN) PROGRAM

THE PRE-REGISTRATION PROCESS AND DEPARTMENTAL CLEARANCE IS REQUIRED EACH TIME THAT YOU ATTEMPT TO REGISTER FOR NURSING 095 (NURSING ASSISTANT CLASS)

Program Coordinator: Andrea Ceron Phone #:

Health Information Management (HIM)

Practical Nursing Program. Information Pack

Department of Health Sciences. Degree in Nursing. (for Licensed Practical Nurses who wish to progress to An Associate of Applied Science RN degree)

Trinity Washington University School of Nursing and Health Professions Nursing Program Application Packet Checklist Spring Semester, 2013

Respiratory Care Program Information Packet

Practical Nursing Program Information for Applicants

Dear Prospective Student:

NURSING APPLICATION and INFORMATION GUIDE for Spring 2015 RE-ADMISSION

MASTER OF SCIENCE IN NURSING

BSN to DNP Application Packet

Clinical Medical Assistant Application

Pharmacy Technician. Program Application Packet. Northeast Texas Community College is an equal opportunity, affirmative action, ADA institution.

Campus Alberta Central, in partnership with Olds and Red Deer Colleges, is working with your community to offer this program locally.

CALIFORNIA STATE UNIVERSITY, STANISLAUS GRADUATE STUDY IN NURSING. Admission to CSU Stanislaus Graduate Program,

Ghazvini Center for Healthcare Education 1528 Surgeons Drive Tallahassee, Florida phone fax

COMPUTED TOMOGRAPHY CERTIFICATE PROGRAM

Upon completion of the Medical Assisting program, students will be eligible to take the national certification exam.

Researching and Choosing a School

MSU Bachelor of Science in Nursing Completion- (BSN-C) Program.

We offer two schedules for our RN Refresher program:

Transcription:

Advanced Care Paramedic Advanced Diploma Program Canadian Medical Association (CMA) Accredited Program Application Guide www.jibc.ca

Dear ACP Applicant, Thank you for your interest in the Advanced Care Paramedic (ACP) Advanced Diploma program. To respond to the continual growth and evolution of today s healthcare needs, JIBC has expanded and reinvigorated the ACP program. Our aim is to create leaders in healthcare professionals with a broad vision and understanding as well as an open mind to take on tomorrow s challenges. As a graduate from this accredited program, you will gain those lifelong skills as a trained Advanced Care Paramedic. This program provides an excellent opportunity for those planning to apply to BC Ambulance Service (BCAS) as all ambulance practicums take place on BCAS Advanced Life Support units with ACP Preceptors. This provides a valuable opportunity to learn and work within the BCAS targeted response model. Upon the completion of the Advanced Care Paramedic program, you will be a graduate from an accredited program and receive an Advanced Diploma in Advanced Care Paramedicine from the Justice Institute of British Columbia (JIBC). This will give you a nationally recognized professional credential and allow you to apply for licensure within British Columbia through the Emergency Medical Assistant Licensing Branch (EMA LB). The following package contains general information about the ACP program. It provides details of the prerequisites you need to submit with your application, lists the prerequisite courses you must have prior to the start of the program and describes the selection process. Once again, thank you for your interest in this challenging and rewarding program, we look forward to receiving your application. Sincerely, Rick Wong Program Manager, Advanced Care Paramedic Program JIBC Health Sciences Division Revised May 2015 Page 2

PLEASE READ THIS DOCUMENT CAREFULLY GENERAL INFORMATION Welcome to the Paramedic Academy The Paramedic Academy at the JIBC Health Sciences Division is pleased to offer training in advanced paramedicine. The Advanced Care Paramedic (ACP) program is accredited by the Canadian Medical Association and exceeds the National Occupational Competency Profile (NOCP) requirements of the Paramedic Association of Canada (PAC). Advanced Care Paramedic Program The ACP program is an advanced diploma program providing the skills and knowledge required to practice as an Advanced Care Paramedic. Graduates of the ACP Diploma program will be clinically competent, advanced Paramedic Clinicians/Practitioners, who can function in an interdisciplinary environment and who have the communication skills, leadership ability, professionalism and critical judgment skills to contribute to the advancement of the profession of paramedicine. ACP graduates will be able to: Meet the ACP competencies and the entry to practice requirements of BCAS as an Advanced Care Paramedic. Demonstrate broader knowledge, skills and attitudes in areas such as use of advanced technology, pre hospital care, clinical decision making, current treatment methodologies and pharmacology. Work collaboratively in non traditional and inter professional environments (e.g. Industry, community based health care, and hospital environments etc.). Access other more traditional academic programs and institutions through credit transfer. Meet provincial and national employability standards. Graduates will be eligible for examination for licensure by the EMALB as Advanced Care Paramedics in B.C. The ACP program is a 20 month (3 terms) full time program. You will participate in online learning activities and facilitated discussions, guided independent study, classroom sessions, labs, practical workshops, and simulations. You will attend hospital practicums in a variety of settings and high acuity care facilities such as ER, ICU, CCU, & ORs. All ambulance practicums are on BCAS advanced Life Support units with ACP preceptors. Admission Requirements Admission to the Advanced Care Paramedic program is contingent on availability of seats, completion of all admission criteria, and applicant ranking as determined by a process of selective admission evaluation. Revised May 2015 Page 3

STEP 1 - APPLICATION FORM AND PREREQUISITE ASSESSMENT Applicants must submit the JIBC online program application form - www.jibc.ca/student-services/jibc-application-form All documents confirming the mandatory prerequisites are met must then be compiled and submitted in person, by mail or by fax to: Admissions Officer Student Services Centre Justice Institute of British Columbia 715 McBride Boulevard New Westminster, BC V3L 5T4 Fax Number: 604.528.5653 The onus is on each individual applying to the PCP Program to ensure that all required documentation is submitted. Mandatory Prerequisites: PCP Certificate with minimum of one year PCP work experience at time of application deadline Prerequisite courses: JIBC ENGL100 Academic Writing or equivalent (prerequisite English 12 'C') JIBC BIOL203 Human Anatomy & Physiology or equivalent (prerequisite Biology 11 'C+' and PCP CS200 or PARA100 Anatomy & Physiology) JIBC PATH214 Pathophysiology or equivalent (prerequisite Biology 11 'C+' and PCP CS200 or PARA100 Anatomy & Physiology) JIBC PHARM215 Principles of Pharmacology or equivalent (prerequisite Biology 11 'C+' and PCP CS200 or PARA100 Anatomy & Physiology) General Requirements: Detailed Resume Completed IV Insertion training Current BLS for Healthcare Provider certification Current immunizations Three written professional references Physically able to perform the required tasks of a paramedic self assessment Final Admission Requirements: Criminal record check for Children and Vulnerable Adults from the Ministry of Public Safety and Solicitor General (RCMP check NOT acceptable) Recommended Prerequisite: CPD101 Dysrhythmia Interpretation this is not required at time of application, however, we strongly recommend that all students complete this introductory course prior to commencing the ACP Program. For more information or to register please visit - www.jibc.ca/course/cpd101. Bonus points: Applicants who have met the mandatory prerequisites may be granted additional points in the selective entry process for the following: Completion of prerequisite courses Completion of JIBC Diploma in Health Sciences Emergency Medical Services (EMS) or an equivalent level of post-secondary education PCP experience/patient contacts Volunteer experience within last 2 years (one of your three reference letters should support this) Revised May 2015 Page 4

Here is more information on each prerequisite to help you prepare your application. If you have any questions on any of these requirements please contact us at acp@jibc.ca PCP Certificate Applicants must have a PCP License to practice in any province or territory of Canada with a minimum of one year s PCP experience at the time of the application deadline. Once accepted to the program, graduates of non-accredited PCP programs may need to complete a PCP NOCP sign off session in order to comply with CMA accreditation requirements. If so these students may incur an additional cost. Please provide a copy of your PCP License and a copy of your PCP Certificate if not from a JIBC program. Prerequisite courses In addition to being prerequisites for the ACP program, these courses may be applied towards the JIBC Diploma in Health Sciences Emergency Medical Services (EMS). Course outlines and schedules can be found on the Diploma in Health Sciences (EMS) webpage www.jibc.ca/emsdiploma or contact emsdiploma@jibc.ca for further information. You do not need to enroll in the diploma as these courses are available on a standalone basis. We recommend that you have completed or be registered for a minimum of two prerequisite courses at time of application. All four courses must be completed by the start of the ACP Program. If you have taken or are registered in JIBC courses no transcript is required. If you have taken equivalent courses please provide transcripts or proof of registration. If you wish to have a course reviewed for equivalency please contact us at acp@jibc.ca. Detailed Resume Your detailed resume should include the following: Education: List all post secondary education including your PCP certification and prerequisite courses or your plan for completion. Work Experience: Please detail your experience working as a PCP including length of service, locations and approximate number of calls in the previous year. Volunteer experience if applicable IV Insertion Training PCP License endorsement or training certification. Please provide a copy of your PCP License showing your IV endorsement or a copy of certification. BLS for Healthcare Providers (HCP) Certificate This certificate is required for clinical placement. Please provide a copy of current certification. Please visit our website for more information on courses and updates offered by the JIBC. www.jibc.ca/course/cpd220 Immunizations A current record of immunizations consistent with the requirements of practice agencies is required. These include: Tetanus, Diphtheria, Pertussis Vaccine (within the last 10 years) Polio Vaccine Measles, Mumps, Rubella Vaccine Hepatitis B Vaccine Varicella Vaccine Influenza (seasonal) Tuberculosis (TB) In addition, once admitted to the program, you will be required to provide a negative TB skin test or chest x-ray (within 6 months of your first hospital placement). Please print off the Immunization Checklist Form at the end of this document and take this to your Doctor or Public Health Nurse to review and complete. Revised May 2015 Page 5

Three Written References Applicants must submit three professional reference letters. To obtain a bonus point for volunteer experience one of these should be a letter of support from the organization. Physically able to perform the required tasks of a paramedic Throughout the program, during classroom simulations and while on practice education shifts, you will be performing the physical tasks of a paramedic. To work safely and effectively you will require a healthy level of: aerobic fitness (e.g., climbing stairs with equipment when elevator not accessible) muscular endurance (e.g., performing prolonged CPR on a patient) muscular strength (e.g., lifting and carrying patients) flexibility (e.g., treating patients on the floor or in difficult to reach situations) A high proportion of job-related injuries to paramedics occur when lifting patients. Physical fitness is critical to maintaining the wellness of paramedics, and fitness must be incorporated into the overall philosophy of the ACP program and the paramedic profession. While physical fitness involves the physical capability of an individual to perform different tasks, emotional fitness involves psychological factors and the ability to deal with stress. To tolerate the physical and psychological stress associated with pre-hospital care work, you will require a high level of physical and emotional fitness. Applicants should self-assess and monitor their physical ability for the program. No documentation is required. Criminal Record Check New process In accordance with the BC Criminal Records Review Act all students are required to undergo a criminal record search for people working with children and vulnerable adults through the Criminal Record Review Program completed by the Ministry of Public Safety and Solicitor General. If a relevant record exists the individual will not be able to participate in clinical practice placements and therefore will not be considered for the program. Relevant offences and more information are available on the BC Ministry s website: www.pssg.gov.bc.ca/criminal-records-review/index.htm. Please note that RCMP Criminal Record Checks are no longer acceptable. Details of how to complete the new Criminal Record Check process will be provided at the time an applicant is offered admission to the program. Notes: International students should email international@jibc.ca for detailed information regarding admission procedures and criteria and an International Student Admissions Package. The application fee for the ACP Program is $75.00. Once we have received your online program application form, our Admissions Officer will contact you for payment. Payment may be made by cheque, money order, Visa, MasterCard, cash or debit card. Cheques must be made payable to Justice Institute of British Columbia. The application fee is nonrefundable and your program application will not be considered until the application fee is paid. Any costs associated with the application and selection process are the sole responsibility of the applicant. The Paramedic Academy will not reimburse applicants for any expenses. Revised May 2015 Page 6

STEP 2 - CANDIDATE ASSESSMENT Candidates who have met all requirements in Step 1 will be required to complete two assessment elements: Medical Knowledge Test - online Panel Interview Candidates will be provided with access to a Candidate Assessment online campus which will contain practice quizzes for the online medical knowledge test and information on the interview process. Medical Knowledge Test This 90 minute on-line test will assess a candidate's level of knowledge relative to the Primary Care Paramedic needed for entering the ACP program. Candidates do not need to come to campus to take the test. The online test is accessed through the online campus. The test is based on the JIBC PCP final comprehensive exam and is referenced to the Essentials of Paramedic Care Canadian Edition by Bryan E. Bledsoe, Richard A. Cherry and Robert S. Porter. Panel Interview Selected candidates will be invited to attend an on-site interview session at the campus indicated as their preferred location for the program. The panel interviewers will ask behavioural and case study questions that focus on the selection criteria that have been identified as relating to success in the ACP program: learning motivation, work standards, communication, initiative, interpersonal skill, planning and organization, and stress tolerance. SELECTION PROCESS RESULTS The results from each component will be compiled to produce an overall candidate score. This score is then used to create a rank ordering of candidates. ACP program seats are filled by working from the top of the rank order list down. Successful candidates will be contacted and offered a seat in an available class conditional on completion of final admission requirements (Criminal Record Check and Immunizations). Unsuccessful candidates will be notified by email and invited to forward their application to the next intake only without an additional application fee. For any future intakes candidates must submit a new application and application fee. Revised May 2015 Page 7

TUITION, FEES AND OTHER PROGRAM COSTS Fees (Non-refundable) Application Fee... $75.00 Deposit after successful pre-screening... $500.00 Program Fees Total Tuition (including deposit)... $14,906.16 Additional Fees JIBC Learner Services Fee (LSF)... $283.50 Textbooks (Approximately)... $1,100.00 Uniform, Equipment (Approximately)... $ 500.00 Note: All fees are subject to change without prior notice. The application fee for the ACP program is $75.00. Payment may be made by cheque, money order, Visa, MasterCard, cash or debit card, and must accompany your registration. Cheques must be made payable to the Justice Institute of British Columbia. The application fee is non-refundable your application will not be processed until the application fee is paid. Any costs associated with the application and selection process are the sole responsibility of the applicant. JIBC will not reimburse applicants for any expenses. Program Tuition The tuition fee includes hospital and ambulance practicum components but does not include the costs for course material, textbooks, uniforms, equipment, transportation, living expenses or any additional fees associated with applying to the program. The $500.00 non-refundable and non-transferable deposit must be paid within five working days of acceptance into the program. This deposit will be credited towards your tuition fees. A second installment of $6,124.49 is due six weeks prior to the start of the program. Payment Schedule: Term 1 Term 2 Term 3 Deposit $500.00 Tuition $6,124.49 Learner Services Fee $121.50 Tuition $4,969.44 Learner Services Fee $97.20 Tuition $3,312.23 Learner Services Fee $64.80 Fees quoted are for Canadian citizens/permanent residents only; international applicants please contact international@jibc.ca for further details. JIBC Learner Services Fee The Learner services fee is used to enhance student services that benefit students at all JIBC locations. These include library services, technology improvements and student support services. Refunds The application fee and program deposit are non-refundable and non-transferable in any circumstances. Students who withdraw a minimum of 6 weeks prior to Term I will be refunded 100% tuition & LSF minus deposit Students who withdraw from 6 weeks prior to 2 weeks into Term I will be refunded 50% tuition & LSF minus deposit After the first two weeks in any term there is no refund of tuition paid for that term There will be an administrative fee of $50.00. For more information, please contact the Registration Office at 604.528.5590 or toll free 1.877.528.5591. Revised May 2015 Page 8

Uniform Students are expected to be in JIBC uniform starting the first day of class. JIBC uniform includes a white shirt with JIBC ACP arm patches and a JIBC paramedic jacket with JIBC ACP arm patches. All uniform items are available at the JIBC store. Scrubs Navy blue ER scrubs are required for clinical practice education placements and are available through the JIBC Store. One JIBC ACP patch is required for placement on the left breast pocket. Travel Regional cohorts: Students in regional cohorts (i.e. Victoria and Kelowna) are required to attend approximately 5 weeks of classes at the New Westminster campus, over the course of the 20-month program, for face-to-face sessions with specialist faculty. Practice Education: There are no guarantees that students will be placed in their home communities for practicum shifts. Practicum sites are determined by the availability of sites and ability to provide an appropriate volume and variety of patient contacts for students to meet program practicum and clinical competencies. Students must be prepared to accept the financial cost of travel and living expenses associated with attendance at the placement sessions. Ambulance stations and hospitals may not be located on routes that are accessible by public transportation. Students are responsible for making the appropriate arrangements to ensure their ability to attend placement sessions at the assigned sites. Exam Retest Fees When a student does not demonstrate that they have met an acceptable standard in a program exam component, they may be provided an opportunity to retest. An Examination Fee of $150 will be charged for each practical exam retest and Capstone exam retest and $75 for each OSCE retest. There is no charge for a written exam retest. Only one retest per each exam component is allowed. Program Policy and Procedures For full details of JIBC and ACP program policies and procedures such as academic progression, evaluations and grading please visit the ACP Program Webpage www.jibc.ca/acp Financial Assistance A number of options are available for supplemental funding and loans. Many students apply for and receive the EMA Education Fund Award, Canada Student loans, bursaries, EI and special scholarships. We encourage all students to apply for the EMA Education Fund Award. www.jibc.ca/student-services/financial-aid-awards/awards-bursariesscholarships/emergency-medical-assistant-education-fund-award For more information please visit www.jibc.ca/studentservices/financial_assistance.htm or contact the Financial Aid & Student Awards Advisor at financialaid@jibc.ca or 604.528.5762 (toll free 1.877.528.5591). Administration Fees NSF Cheques: A $30.00 service fee applies to all cheques returned NSF. Transfers and withdrawals are subject to an administrative fee. WorkSafe BC Coverage The JIBC provides WorkSafe BC coverage to students while participating in the hospital and ambulance practicum. This coverage does not extend to any other components of the program. Revised May 2015 Page 9

Health Sciences Division Immunization Checklist Student Name (print): Date of Birth: LASTNAME FIRSTNAME INITIAL YYYY/MM/DD The following Immunizations, based on The Practice Education Guidelines for BC set out by the BC Academic Health Council, are required by healthcare students in BC doing practice education placements. TO COMPLETE THIS FORM 1. Check with your family physician or local public health unit for childhood immunization records 2. Take immunization records and this form to your Doctor or Public Health Nurse to review and complete 3. Note: Your Doctor may require you to have serology testing and results of this can take up to 28 days to be processed 4. Submit this form to JIBC when it is complete. Incomplete forms will be returned to the student. REQUIRED IMMUNIZATIONS DIPHTHERIA, PERTUSSIS, TETANUS DPT Primary Series Yes No Dates: Diphtheria and Tetanus booster within 10 years Yes No Date: POLIO Primary Series Yes No Dates: Dates to be in YYYY / MM / DD format Booster within 10 years Yes No Date: MEASLES, MUMPS AND RUBELLA (MMR) HEPATITIS B VARICELLA (CHICKEN POX) INFLUENZA Initial Dose Yes No Date: Secondary Dose Yes No Date: Primary Series Yes No Dates: Serology: Immune Not immune Date: History of Disease > 12 months of age Yes No Date: OR Varicella Titer: Results: Positive Negative Date: If susceptible, Varicella Vaccine (2 doses) Dose #1 Dose #2 Date: Date: Flu Vaccine (November - March only) Yes No Date: TB SKIN TEST: You will be required to have a TB skin test, and provide proof, within six (6) months of your first clinical placement. Further details will follow. I certify that this information is accurate and up-to-date. Student Signature Date: Physician s Stamp Name of Health Care Provider reviewing this document (print) Signature of the Health Care Provider Date: 285 20_PEDU_HSD_Immunization_Checklist_2015 06 11