Checklist to assist students in completing and submitting their required clinical placement documents.

Checklist to assist students in completing and submitting their required clinical placement documents.

This letter is to be used when applying for Criminal Records Check with Vulnerable Sector Check.  It is a pdf fillable form and you must enter the date and your name once you have downloaded this form.

If you are unable to obtain a "Criminal Records Check with Vulnerable Sector Screening" due to age restriction, you must complete this form and submit with clinical document package to Synergy.  If you become of age during your 1st year you must provide a "CRC with VSS" at that time.

Your 2 Step TB Skin test should be recorded on this form.  Form is to be fully completed by the Healthcare Provider Only.  When clinic uses their own stationary they must provide the same information:  Dated Administered:, Date Read:, Result: (for both tests), along with Administered by:  (name printed plus signature) and name of clinic with full address (stamp with information allowed). Skin Tests provided on immunization records not accepted.  A 2 Step TB Skin test requires 4 visits to the healthcare provider to have the test completed.

This form should be used for 1 step TB Skin tests and is to be fully completed by the Health Care Provider ONLY.  Your Health Care Provider can use their own stationary but it must show:  Date administered;, Date read;, and Result;, along with Administered by: (name printed with signature), and name of clinic with full address (stamp with all info accepted).

This declaration form can be used by any student in the BScN or MN and NP programs who has previously had a positive TB skin test.