SCHEDULE “A”

FORM OF LEARNER ACKNOWLEDGEMENT TO BE DELIVERED TO THE HOSPITAL BY THE

INSTITUTION FOR EACH PARTICIPATING LEARNER

TO: Markham Stouffville Hospital

NAME: ____________________________
(Name of Attendee)

In consideration of the opportunity to gain placement experience at the Hospital, I agree to

comply with and be bound by the following terms and conditions:

1. I shall provide specific goals and objectives that I seek to accomplish during my placement.

2. I consent to ______________________ providing the Hospital with such information and

(Academic Institution)
personal health information about me as the Hospital may require to confirm my eligibility
and suitability to participate in this opportunity. I further consent to the release to the
Hospital of the results of any criminal records check conducted about me.

3. I shall become familiar with and will observe the philosophy, objectives, rules, regulations,
policies and procedures of the Hospital during my placement at the Hospital.

4. I shall comply with such obligations or requirements as may be imposed upon me by the
Regulated Health Professions Act, 1991 or by my professional College, as applicable.

5. If I am in a non-clinical placement, I shall not have clinical contact with Hospital patients and
I shall not access or attempt to access personal health information.

6. I shall carry comprehensive personal health insurance that shall apply throughout the term
of my placement at the Hospital.

7. I shall comply with health procedures as the Hospital may require during my placement.

8. I represent and warrant that I have fulfilled all of the requirements as set out in Exhibit I
attached hereto. In the event that Exhibit I is revised at any time during my placement, I
agree that I shall take all steps as may be necessary to fulfill the new requirements.

9. I understand that I am responsible for obtaining, at my sole expense, such uniforms as may
be required by the Hospital, all board and lodging, transportation and all other expenses.

10. I understand and agree that I will follow the instructions or direction of the supervising
Preceptor who will be responsible for my education and experience during my placement.

11. I shall review and sign the Hospital’s form of Privacy and Confidentiality agreement and
agree to comply with the Hospital’s Privacy Statement.

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DATED at __________________________ this ______ day of ______________, 20__

____________________________________ _____________________________
Witness Signature: Learner Signature:

____________________________________ _____________________________
Witness Name (Print): Learner Student Number:

EXHIBIT I
List of Occupational Health & Safety Requirements for Learners
Prior to Starting Placement

1. Respirator/Mask Fit Test*

2. Basic Cardiac Life Support Certification (BCLS)*

* Items 1 and 2 are required for Learners who will be involved in patient care including
Nursing, Occupational Therapy, Radiological Technology, Nuclear Medicine, Pharmacy,
Magnetic Resonance Imaging, Physiotherapy, Respiratory Therapy & Radiation Therapy
placements.

In order to comply with the Communicable Disease Surveillance Protocols for Ontario
Hospitals, the following must be completed and signed acknowledgement by a physician
or delegated health professional.

3. Tuberculin Skin Testing:

• a) two-step TST OR b) two negative TST results in past (<12 months apart) OR c) one
negative TST within last 12 months. One chest x-ray required if TB skin test becomes
positive (>10 mm induration).
4. Measles:
• Lab evidence of immunity (serum measles IgG) OR documentation of 2 doses of live
measles vaccine (e.g. MMR) on or after first birthday
5. Rubella:
• Born before 1957, OR Lab evidence of immunity (serum rubella IgG) OR
documentation of immunization with live rubella vaccine (e.g MMR) on or after 1st
birthday
6. Mumps:
• Lab evidence of immunity (serum mumps IgG) OR documentation of 2 doses of
mumps vaccine (or trivalent measles-mumps-rubella (MMR) vaccine) on or after first
birthday

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7. Varicella:
• Lab evidence of immunity (serum VZV IgG), OR history of disease (chicken pox or
shingles) OR Varicella vaccine (2 doses required)

8. Hepatitis B:
• Lab evidence of immunity (anti-Hbs), Vaccination not mandatory but highly
recommended for staff who may have exposure to blood & body fluids
9. Tetanus/Diptheria/Pertussis:
• Not mandatory but Adacel vaccine (one time in adulthood) is recommended to protect
against pertussis
10. Influenza:
• Not mandatory but highly recommended. In an outbreak, non-immunized learners
will not be able to continue placement until 14 days after obtaining immunization
(unless documented medical contraindication) OR earlier if they take appropriate
antiviral prophylaxis.

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