"Pre-employment Health Form for Employees/Providers/Volunteers in Child Care Centers" - Region of Waterloo, Ontario, Canada

This Ontario-specific "Pre-employment Health Form for Employees/Providers/Volunteers in Child Care Centers" is a document released by the Region of Waterloo Public Health and Emergency Services.

Download the fillable PDF by clicking the link below and use it according to the applicable legal guidelines.

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PRE-EMPLOYMENT HEALTH FORM FOR
EMPLOYEES / PROVIDERS / VOLUNTEERS
in Child Care Centers
This information will be kept on file at the child care setting or designated location. It will be used to maintain a cumulative record of
immunization status and to identify persons with health problems. This information may also be shared with Region of Waterloo Public
Health if an outbreak occurs.
Last Name:
First Name:
Home Address:
City:
Postal Code:
Home Phone (
) __ __ __ - __ __ __ __
Work Phone (
) __ __ __ - __ __ __ __ ext. _______
Child Care Centre:
Home Child Care
General Instructions:
a) Employees/providers are required to have up-to-date immunization, tuberculosis screening history and to
complete this form with information on infectious diseases and general health history as indicated.
b) Volunteers are required to complete this form to provide information regarding immunization, tuberculosis
screening history, infectious disease history and general health information. There is no requirement that
these be up-to-date, although it is highly recommended. Parent co-op volunteers are included in this
category. TB skin testing is not recommended for volunteers who expect to work less than 150 hours/year
(approximately one half day per week).
Please read and complete the following sections:
IMMUNIZATION HISTORY
DATE
It is very important that any persons working with children have up-to-date immunization.
(Year/Month/Day)
Tetanus Diphtheria Pertussis
(i.e., Adacel™) - funded for adults as a one time adult dose, safe
_____/_____/_____
any time after a tetanus vaccine; no need to wait 10 years
If Tetanus, Diphtheria, Pertussis was completed more then 10 year ago:
Tetanus Diphtheria –
_____/_____/_____
should receive a booster every ten year (after receiving tetanus, diphtheria,
pertussis.
st
Measles, Mumps, Rubella
(One dose after 1
birthday. Not required if born prior to 1970 or if
has lab-documented immunity to all three infections. Note: since Aug/11 a second dose of MMR is
_____/_____/_____
recommended for young adults (18-25 years) and persons who received the killed measles vaccine in
1967-1970.)
Polio
Yes
No
(Initial series given in childhood only - adult boosters are not required except in certain situations.)
Routine adult immunization is available free of charge from your physician if you require a booster.
Yes (series completed)
Hepatitis B
(Immunization against Hep B may be beneficial but is not a requirement. Vaccine may be purchased
through your family physician.)
No
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PRE-EMPLOYMENT HEALTH FORM FOR
EMPLOYEES / PROVIDERS / VOLUNTEERS
in Child Care Centers
This information will be kept on file at the child care setting or designated location. It will be used to maintain a cumulative record of
immunization status and to identify persons with health problems. This information may also be shared with Region of Waterloo Public
Health if an outbreak occurs.
Last Name:
First Name:
Home Address:
City:
Postal Code:
Home Phone (
) __ __ __ - __ __ __ __
Work Phone (
) __ __ __ - __ __ __ __ ext. _______
Child Care Centre:
Home Child Care
General Instructions:
a) Employees/providers are required to have up-to-date immunization, tuberculosis screening history and to
complete this form with information on infectious diseases and general health history as indicated.
b) Volunteers are required to complete this form to provide information regarding immunization, tuberculosis
screening history, infectious disease history and general health information. There is no requirement that
these be up-to-date, although it is highly recommended. Parent co-op volunteers are included in this
category. TB skin testing is not recommended for volunteers who expect to work less than 150 hours/year
(approximately one half day per week).
Please read and complete the following sections:
IMMUNIZATION HISTORY
DATE
It is very important that any persons working with children have up-to-date immunization.
(Year/Month/Day)
Tetanus Diphtheria Pertussis
(i.e., Adacel™) - funded for adults as a one time adult dose, safe
_____/_____/_____
any time after a tetanus vaccine; no need to wait 10 years
If Tetanus, Diphtheria, Pertussis was completed more then 10 year ago:
Tetanus Diphtheria –
_____/_____/_____
should receive a booster every ten year (after receiving tetanus, diphtheria,
pertussis.
st
Measles, Mumps, Rubella
(One dose after 1
birthday. Not required if born prior to 1970 or if
has lab-documented immunity to all three infections. Note: since Aug/11 a second dose of MMR is
_____/_____/_____
recommended for young adults (18-25 years) and persons who received the killed measles vaccine in
1967-1970.)
Polio
Yes
No
(Initial series given in childhood only - adult boosters are not required except in certain situations.)
Routine adult immunization is available free of charge from your physician if you require a booster.
Yes (series completed)
Hepatitis B
(Immunization against Hep B may be beneficial but is not a requirement. Vaccine may be purchased
through your family physician.)
No
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P
age 2
TUBERCULOSIS (TB) SCREENING HISTORY
Please complete the following screening tool:
Have you come to Canada in the past 5 years from one or more of the following regions?  Yes  No
Asia (including Middle Eastern Countries)
Africa
Central and South America
Eastern Europe
Have you spent more than 3 consecutive months in one or more of the following regions in the last 5 years?  Yes  No
Asia (including Middle Eastern Countries)
Africa
Central and South America
Eastern Europe
Do you have any of the medical conditions listed below?  Yes  No
Kidney Problems
HIV/AIDS
Diabetes
Silicosis
Cancer
Do you take immune suppressing medications?  Yes  No
Have you been exposed to someone with tuberculosis in the past?  Yes  No
If you answered YES to any of the above questions TB Skin Testing is required.
Complete testing section below.
If you are unsure how to answer any of the above questions, please contact your family physician or call Region of
Waterloo Public Health at (519) 575-4400.
A one step (not two step) TB skin test is required for those child care providers
Result (in
Date of test
and employees who have answered YES to any of the above TB screening
mm)
questions.
The testing should be completed within six months prior to commencing employment and is strongly
recommended for volunteers who expect to work more than 150 hours/year (one half day per week).
______/____/____
Note: Employees working at multiple sites or changing employment in the child care sector within
Waterloo Region only require one TB skin test ever; therefore the 6 month requirement would apply
only to the first job.
Chest X-ray
______/____/____
If needed due to a positive skin test reaction as recommended by the health care practitioner at the
time of testing. A repeat chest x-ray is not required within six months of hire.
TB skin test may be obtained through your family physician (will charge a fee as advised by the College of
Physicians and Surgeons), a local walk-in clinic (fees vary) or can be arranged by calling Region of Waterloo
Public Health at 519-575-4400 (fee will also be charged).
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INFECTIOUS DISEASE HISTORY
Immune
Working with children may expose persons to a variety of infectious diseases. It
NO
UNKNOWN
(history of disease or
is helpful for a person to know if he/she is immune to certain childhood diseases
immunity from vaccine)
for his/her own protection (as some infections produce more severe symptoms in
adults or are a concern to a fetus if a person is pregnant).
Chickenpox
If you are unsure, a blood test can be done to determine immunity. A chickenpox
vaccine is now available at your family physician, or contact Region of Waterloo
Public Health for more information at 519-575-4400
Rubella (German Measles)
All women of childbearing age should know if they are immune to rubella prior to a
pregnancy. A blood test will determine immunity; a routine test during pregnancy.
Please consult with your physician if you wish to determine your immunity to these infections.
GENERAL HEALTH
YES
NO
I am presently in good health.
Any limitations to participation?
Comments:
Signature of Employee / Provider / Volunteer:
Date:
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