Download Summer Early Exposures Visiting Students Application Package

Summer Early Exposures
Visiting Students
Application Package
The following documents must be submitted with your application at least 45 days in advance of the
exposures start date:
1.
2.
3.
4.
Completed Application Form (with Preceptor Signature or Email from Preceptor)
Completed CPSM Application (Attached)
Proof of N95 Mask Fitting (See attached information if you don’t have this)
Proof of Provincial Health Card (If are an international student and do not have a provincial
health card, the attached MISHIP application is required from you)
5. Proof of Malpractice/Liability Insurance - $5 million aggregate limit required (if you are studying
in Canada this is not required from you). See attached information if you need to purchase this.
Cost is approximately $700.
6. Completed Immunization Form (Attached)
Please send all to [email protected] or by mail to 260 Brodie Centre, 727 McDermot
Avenue, Winnipeg, MB, R3E 3P5
Summer Early Exposure Application
Visiting Students
PLEASE READ THE FOLLOWING CAREFULLY BEFORE YOU BEGIN:
Download this form to your computer before you start. Then save it and email it to [email protected] It will
work best to use Adobe Reader (free download) to complete this form.
College of Medicine
ALL sections on application form MUST be completed and be received two weeks in advance of exposure;
final application deadline is June 30th; Exposure MUST be pre-approved as per [Section D] and have fees paid
PRIOR to participation. You will receive an email when you are registered and fees are due.
In order to receive approval for this application, your preceptor must sign the form or alternatively, an email can be
received from your preceptor or his/her secretary/coordinator indicating that you are approved for this exposure. You
may forward the email or you may ask your preceptor to email directly to [email protected].
Section A - Student Information
Last Name
Middle Name
First Name
Street Address
Country
Birthdate
Phone Number
Citizenship
Home University
Uof M Student #
(if applicable)
Province/State
City
Postal
Gender
Student Email
Type of Exposure Select One...
Grad Class Year
BSc Med Split Between 2 Summers?
Select...
Section B - Preceptor Information
Email Address
Preceptor Name (Last, First)
Phone #
Section C - Exposure Information
Start Date
End Date
Specialty
# Days/Wk
# Days Assigned
Hospital/Site
(usually 5)
(usually 10)
(location)
*Must be a total of 80 hours (40 hours for BSc Med - Split Summer)
What are 3 Goals
for your
Exposure?
(i.e. What do you
hope to learn/
experience?)
Section D - Approval
By signing this form I hereby confirm these details are accurate. If my preceptor does not sign this form, I will forward an email from my
preceptor or ask my preceptor or his/her sectretary/coordinator to email [email protected] confirmation of the details found in
this application. I understand that in order to pass this exposure an evaluation must be completed and emailed to the Electives Office at the end of
this exposure.
Comments
Date
Preceptor's
Signature
Date
Student's
Signature
Adobe Reader works the best
to complete this form. Please
email it to
[email protected]
Thank you.
1000-1661 PORTAGE AVENUE WINNIPEG, MANITOBA R3J 3T7
TEL: (204) 774-4344 FAX: (204) 774-0750
E-MAIL: [email protected] [email protected]
EDUCATIONAL REGISTER APPLICATION
(Visiting/External Student)
In accordance with the Human Rights Act of
Manitoba, you may, but are no longer required
to include a photograph. However, if your
registration is accepted, you will be required to
supply a photograph and other identification to
establish that you are the person represented by
the documents, along with proof of any change
of name other than that upon which you seek to
be registered.
Name ……………………………...............................................................................................
Print in full, underline surname
If legal change of name, please indicate ...………………………...............................................
Present Mailing Address
..........…………………………............................................................
...............…………………...................................................................
E-Mail Address ……………………………………………………………………………….
Preferred method of communication: mailing address ……. e-mail address ……..
Date of Birth
Y:
M:
D:
CHECK ONE:
(Medical School and Year of Graduation)
((Medical School and Expected Year of Graduation)
(PA Program and Expected Year of Graduation)
(Medical School and Year of Graduation
MEDICAL IDENTIFICATION NUMBER FOR CANADA (MINC): CAMD - ___ ___ ___ ___ - ___ ___ ___ ___
(If you are a medical or external student and do not have a MINC number, CPSM will provide the following information to the
Medical Council of Canada to issue a number: name, DOB, sex, family name, given name, degree year, degree institution.)
Applicant – Complete Personal Information section on next page.
Note: This application is valid for six months only from date of receipt in the College offices. An update application will be required if your
registration is not issued within that period.
_____________________________________________________________________________________________________
OFFICE USE ONLY
TO BE COMPLETED BY THE UNIVERSITY OF MANITOBA, FACULTY OF MEDICINE UNDERGRADUATE/
POSTGRADUATE MEDICAL EDUCATION OFFICE/ OFFICE OF PHYSICIAN ASSISTANT STUDIES.
For Visiting Student:
This will confirm that the above named student is undertaking an elective in the Department of
______________________________________________ at _______________________________, under the supervision of Dr.
____________________________ for the period ___________________________ to ___________________________.
Signature _____________________________________________
For External Student:
This will confirm that the above named physician is registered as an external student while undertaking training in
____________________________________ for the period _______________________ to ______________________.
Signature:_________________________________________________
09/2015
PERSONAL INFORMATION
An applicant for registration must disclose the following information about himself or herself and his or her practice of
medicine or of any other profession.
1.
ANY OF THE FOLLOWING ACTIONS BY A BODY WITH AUTHORITY TO REGULATE A PROFESSION:
(a)
HAVE YOU EVER BEEN THE SUBJECT OF A REVIEW OF YOUR CONDUCT, COMPETENCE, OR CAPACITY OR FITNESS
TO PRACTISE, WHETHER ARISING FROM A COMPLAINT OR OTHERWISE?
No ...... Yes ...... Give Particulars ………………………………….……............................................................................. .......................
(b)
ARE YOU CURRENTLY THE SUBJECT OF AN INVESTIGATION OR OTHER PROCEEDING IN RELATION TO YOUR
CONDUCT, COMPETENCE, OR CAPACITY OR FITNESS TO PRACTISE?
No ...... Yes ...... Give Particulars ………………………………….……....................................................................... .............................
(c)
HAVE YOU EVER BEEN THE SUBJECT OF A FINDING OF PROFESSIONAL MISCONDUCT, CONDUCT UNBECOMING,
INCOMPETENCE, OR AN INCAPACITY OR LACK OF FITNESS TO PRACTISE?
No ...... Yes ...... Give Particulars ………………………………….……....................................................................... .............................
(d)
HAVE YOU EVER BEEN DENIED AN APPLICATION FOR LICENSURE, REGISTRATION, PERMIT OR ANY OTHER
AUTHORIZATION TO PRACTISE?
No ...... Yes ...... Give Particulars ………………………………….……....................................................................... .............................
(e)
HAVE YOU EVER BEEN THE SUBJECT OF A SUSPENSION OF, RESTRICTION ON, OR REVOCATION OF LICENSURE,
REGISTRATION, PERMIT OR ANY OTHER AUTHORITY TO PRACTISE?
No ...... Yes ...... Give Particulars ………………………………….……....................................................................................................
2.
WITHIN THE LAST THREE YEARS, HAVE YOU BEEN THE SUBJECT OF ANY REVIEW OF YOUR CONDUCT,
COMPETENCE, OR CAPACITY OR FITNESS TO PRACTISE, WHETHER ARISING FROM A COMPLAINT OR OTHERWISE, BY
AN ENTITY OTHER THAN A BODY WITH AUTHORITY TO REGULATE A PROFESSION?
No ...... Yes ...... Give Particulars ………………………………….……....................................................................... .............................
3.
HAVE YOU EVER BEEN, OR ARE YOU NOW, THE SUBJECT OF ANY RESTRICTION, TERMINATION OR
SUSPENSION OF YOUR ABILITY TO WORK IN ANY PROFESSION OR OCCUPATION, OR IN ANY SETTING?
No ...... Yes ...... Give Particulars ………………………………….……................................................................ ....................................
4. (a)
DO YOU CURRENTLY SUFFER FROM OR ARE YOU CURRENTLY BEING TREATED FOR ANY PHYSICAL OR
MENTAL CONDITION OR ADDICTION WHICH HAS THE POTENTIAL TO COMPROMISE THE ABILITY TO DELIVER SAFE
MEDICAL CARE?
No ...... Yes ...... Give Particulars ………………………………….……............................................................................. .......................
(b)
HAVE YOU EVER PREVIOUSLY SUFFERED FROM OR BEEN TREATED FOR A PHYSICAL OR MENTAL CONDITION OR
ADDICTION WHICH HAD THE POTENTIAL TO COMPROMISE THE ABILITY TO DELIVER SAFE MEDICAL CARE AT THAT
TIME?
No ...... Yes ...... Give Particulars ………………………………….……....................................................................... .............................
5.
CRIMINAL OFFENCES (CPSM INTERPRETS THE TERM “CRIMINAL” TO INCLUDE A CHARGE UNDER ANY OF THE
FOLLOWING: THE CRIMINAL CODE OF CANADA, NARCOTIC OR CONTROLLED SUBSTANCES LEGISLATION, INCOME TAX
ACT, EXCISE TAX ACT, ANY INDICTABLE OFFENCE; ANY SIMILAR OFFENCE IN ANY JURISDICTION OTHER THAN CANADA).
FOR EVERY YES ANSWER, PROVIDE A DETAILED EXPLANATION AND PROVIDE A COPY OF RELEVANT DOCUMENTS
INCLUDING A COPY OF THE PARDON DOCUMENT IF YOU HAVE BEEN GRANTED A PARDON FOR ANY CONVICTION.
(a)
HAVE YOU EVER PLEADED GUILTY TO OR BEEN FOUND GUILTY OF ANY CRIMINAL OFFENCE(S)?
No ...... Yes ...... Give Particulars ………………………………….……....................................................................... .............................
(b)
ARE THERE ANY CHARGES NOW PENDING AGAINST YOU FOR ANY CRIMINAL OFFENCE(S)?
No ...... Yes ...... Give Particulars ………………………………….……....................................................................... .............................
(c)
HAVE YOU EVER PLEADED “NO CONTEST” OR MADE ANY OTHER SIMILAR PLEA TO ANY CRIMINAL CHARGE?
No ...... Yes ...... Give Particulars ………………………………….……....................................................................... .............................
09/2015
(d)
HAVE YOU EVER BEEN CHARGED OR ARRESTED FOR ANY CRIMINAL OFFENCE(S)?
No ...... Yes ...... Give Particulars ………………………………….……....................................................................................................
(e)
HAS A COURT EVER ISSUED A RESTRAINING ORDER AGAINST YOU?
No ...... Yes ...... Give Particulars ………………………………….……............................................................................. .......................
6.
CIVIL LITIGATION HISTORY (NOTE: For Questions 6(a), (b), (c) and (d), report only matters related to your practice of medicine
or your professional activities or involving a patient.)
(a)
HAVE YOU EVER BEEN THE DEFENDANT IN A LAWSUIT?
No ...... Yes ...... If yes, Give Particulars (include the date, name of court jurisdiction, court file number if known)
………………………………….……............................................................................. .....................................................................................
(b)
HAVE YOU SETTLED ANY LAWSUITS PRIOR TO A COURT TRIAL? (NOTE: A settlement means an agreement to resolve a
lawsuit related to your practice of medicine or your professional activities or involving a patient either before or during a court trial.)
No ...... Yes ...... If yes, Give Particulars (include the date, name of court jurisdiction, court file number if known)
………………………………….……............................................................................. .....................................................................................
(c)
ARE YOU THE DEFENDANT IN A LAWSUIT WHICH IS CURRENTLY OUTSTANDING?
No ...... Yes ...... If yes, Give Particulars (include the date, name of court jurisdiction, court file number if known)
………………………………….……............................................................................. .....................................................................................
(d)
HAS A COURT EVER MADE A FINDING AGAINST YOU ARISING FROM ANY LEGAL ACTION, CLAIM OR OTHER
PROCEEDING THAT WAS IN ANY WAY RELATED TO YOUR PRACTICE OF MEDICINE OR YOUR PROFESSIONAL
ACTIVITIES? (NOTE: A finding means any judgment or decision made against you by a court in relation to any lawsuit related to your practice
of medicine or your professional activities or involving a patient and includes any finding in which you were found by the court to be liable for the
actions of others (e.g. employee) in a lawsuit involving a patient. )
No ...... Yes ...... If yes, Give Particulars (include the date, name of court jurisdiction, court file number if known)
………………………………….……............................................................................. .....................................................................................
7.
ARE YOU AUTHORIZED TO PRACTISE MEDICINE IN ANY OTHER JURISDICTION?
No ...... Yes ...... Give Particulars ………………………………….……....................................................................... .............................
WARNINGS: THE MANITOBA MEDICAL ACT STATES THAT WHERE ANY PERSON PROCURES HIS REGISTRATION, OR
CAUSES IT TO BE PROCURED, BY MEANS OF ANY FALSE OR FRAUDULENT REPRESENTATION, EITHER ORALLY OR
IN WRITING, THAT PERSON'S REGISTRATION WILL BE CANCELLED.
DECLARATION
1.
The information contained in this application is true to the best of my knowledge, information and belief.
2.
I authorize the College of Physicians and Surgeons of Manitoba (the College), to make inquiries, written or verbal, of any
licensing authority which has licensed or refused to license me, and/or of any of my previous employers, current employers,
associates, partners, university(s) where I have trained or held an appointment either as a member of the faculty or research, or
references, and I authorize any such authority or person to release to the College verbally and/or in writing as the College may
request, such information as the College in its sole discretion may require relating to my application for registration.
3.
I will keep the Registrar informed immediately of any change of office address while practising in Manitoba.
4.
I also hereby authorize the Undergraduate/Postgraduate Medical Education Office/Office of Physician Assistant Studies to
release to the College any information with respect to any change in my status with the Undergraduate/Postgraduate Office/Office of
Physician Assistant Studies.
.......................…………...................
Date
……………………........................................................................................
Signature
09/2015
AUTHORIZATION FOR PAYMENT
Educational Register – Visiting / External Student
Visa ______
Amount Authorized:
MasterCard _______
American Express _____ Cheque____
_____ $50 registration fee
_____ $25 licence fee
_____ $75 TOTAL FEE
Applicants Name ___________________________________________________________
Name on card (please print) _____________________________________________
Credit card number ______/______/______/_______ Expiry date ___/___ (mm/yy)
Credit Card Authorization signature _______________________________________
If paying by cheque, please affix cheque here.
CREDIT CARD INFORMATION WILL NOT BE ACCEPTED VIA EMAIL. PLEASE FAX
OR MAIL YOUR INFORMATION TO OUR OFFICE.
SHOULD YOU EMAIL THIS FORM, IT WILL NOT BE PROCESSED.
to 204.774.0750
You can also pay by phone by calling 204. 774. 4344
Visiting Medical Student Immune Status Record
University of Manitoba
Student name: _________________________________________________
Date of birth: ____________________________
Current university: _____________________________________________
Expected year of graduation: _____________
For instructions, please refer to pages 3 to 5.
1. Tetanus,
diphtheria,
pertussis
2. Polio
Has a primary immunization series of tetanus
and diphtheria been given? (Must be three or
more doses)
¨ Yes ¨ No
Has a primary immunization series of polio
been given? (Must be three or more doses)
¨ Yes ¨ No
3. Measles
4. Mumps
5. Rubella
Last dose of tetanus/diphtheria
vaccine (must be within 10 years):
One dose of tetanus/diphtheria/
acellular pertussis (Tdap) vaccine:
Date: _____________________
Date: _____________________
Vaccine: __________________
Vaccine: __________________
Last dose of polio vaccine:
Date: _____________________
Vaccine: __________________
¨ Measles vaccine: Two doses required
¨ Measles titre (IgG): Vaccination is generally preferred
over serology, but either is acceptable.
Date: _____________________
Date: ______________________
Date: _____________________
Result: _____________________
¨ Mumps vaccine: Two doses required
¨ Mumps titre (IgG): Vaccination is generally preferred
over serology, but either is acceptable.
Date: _____________________
Date: ______________________
Date: _____________________
Result: _____________________
¨ Rubella vaccine: One dose required
¨ Rubella titre (IgG): Vaccination is generally preferred
over serology, but either is acceptable.
Date: _____________________
Date: ______________________
Result: _____________________
6. Varicella
7. Hepatitis B
¨ Varicella vaccine:
¨ Varicella titre (IgG):
Date: _____________________
Date: ______________________
Date: _____________________
Result: _____________________
Hepatitis B vaccine:
Hepatitis A+B vaccine:
Serology:
Date: _____________
Date: _____________
Date of anti-HBs: _____________
Date: _____________
Date: _____________
Result: _____________
Date: _____________
Date: _____________
Date: _____________
Date: _____________
The above is a complete
The above is a complete
¨2 ¨3 ¨4 dose series.
¨2 ¨3 ¨4 dose series.
If indicated:
Date of repeat anti-HBs: _____________
Result: _____________
Additional notes on hepatitis B status:
University of Manitoba
Page 1 of 5
February 2014
Student name: _________________________________________________
8. Tuberculosis
Date of birth: ______________________________
Past TB history:
Are any of the following present? Past history of active TB disease, latent tuberculosis infection (LTBI),
positive TST or positive IGRA.
¨ Yes ¨ No
If yes, please provide details of any follow-up measures taken, or attach documentation.
BCG vaccine: A new or repeat BCG is not recommended.
Given: ¨ Yes ¨ No ¨ Unsure
Approximate date/age: ______________
Scar present?: ¨ Yes ¨ No ¨ Unsure
Site: ____________________________
Tuberculin Skin Test (TST): Only indicated for those without contraindications. Document a two-step TST, and
the most recent TST.
Date given: ____________
Date read: ____________
Result: _______ mm
Interpretation: _____________
Date given: ____________
Date read: ____________
Result: _______ mm
Interpretation: _____________
Date given: ____________
Date read: ____________
Result: _______ mm
Interpretation: _____________
Chest X-ray: Not required routinely. If indicated, please attach report.
Interferon gamma release assay (IGRA): Will be accepted in lieu of a TST.
9. Influenza
Date: ____________
Result: ____________
Date: ____________
Result: ____________
Influenza immunization for current influenza season (2013-2014):
Date: _________________________
10. Additional
notes on
Immune Status
Record:
Please document any additional relevant information.
The physician or nurse signing below indicates that the information listed on this form
is an accurate account of the student’s immune status as of the date shown.
Name of physician/nurse:
________________________
Signature:
________________________
Date:
________________________
Contact information (telephone, address) or stamp:
This personal health information is being collected by the University of Manitoba under the authority of the University of Manitoba Act. It will be used to
document your immune status in order to determine your ability to participate in patient-related activities in your current program of study. It is protected
by the Protection of Privacy provisions of the Freedom of Information and Protection of Privacy Act (FIPPA). If you have any questions about the
collection of your information, contact the FIPPA/PHIA Coordinator’s Office: (204) 474-8339, University of Manitoba Archives and Special Collections,
331 Dafoe Library, Winnipeg MB R3T 2N2.
University of Manitoba
Page 2 of 5
February 2014
Instructions for Completing the
Visiting Medical Student Immune Status Record
University of Manitoba
The following provides healthcare providers information on immunizations and tests that are required for undergraduate medical
students applying to the University of Manitoba, Faculty of Medicine for a medical elective. The University of Manitoba follows
recommendations found in the Canadian Immunization Guide, Evergreen Edition (available at: http://www.phacaspc.gc.ca/publicat/cig-gci/index-eng.php) and the Canadian Tuberculosis Standards, 7th edition, 2013 (available at:
http://www.respiratoryguidelines.ca/tb-standards-2013).
An immunization form from another university, or other health records can be attached without completing the Visiting
Medical Student Immune Status Record. However, all attached documentation must be completed and signed by a physician
or nurse; student documentation is not acceptable. Records should indicate the name of the student, name of the vaccine or
test, type of vaccine given or test, and the name and designation of the nurse or physician documenting the immunization or
test. If records are not in English a certified English translation should accompany the records.
For questions about immunization and testing requirements please contact the Immune Status Program Coordinator, 204-4801305, fax 204-480-1333, [email protected]. For all other inquiries please contact the Undergraduate Medical
Education (UGME) Electives Administrator, tel. 204-789-3820, [email protected].
Contraindications to Immunizations
Polio
A student with a severe allergy to a vaccine or tuberculin
should submit documentation from an allergy specialist
indicating that the item is contraindicated for the student.
Indicate if a primary series (in childhood or as an adult) of
polio has been given. If doubt exists regarding whether a
primary series has been given a primary series should be
offered (refer to the Canadian Immunization Guide for
additional details).
Students who are pregnant should not receive certain
immunizations (e.g., live vaccines); some vaccinations
(e.g., influenza) and tuberculin skin tests are safe in
pregnancy (refer to the Canadian Immunization Guide for
additional details). If a vaccine is contraindicated due to
pregnancy please submit documentation of this from a
physician or nurse
Students with Special Immunization
Requirements
Some students may have compromised immune systems
due to the use of immune-suppressing medications,
certain infections (e.g., human immunodeficiency virus
[HIV]
infection),
or
genetic
disorders.
Special
immunization or serological testing requirements may be
recommended for these students, different from those
listed in this document; in such situations consultation
with an infectious diseases expert is recommended.
Tetanus, Diphtheria, Pertussis
Indicate if a primary series (in childhood or as an adult) of
tetanus and diphtheria has been given. If any doubt exists
regarding whether a primary series has been given a
primary series should be offered (refer to the Canadian
Immunization Guide for additional details).
Document the last dose of an immunization containing
polio. A booster dose of polio is not required.
Measles, Mumps, and Rubella
Routine pre- or post-immunization serology is not
recommended to determine an individual’s measles,
mumps, or rubella immune status. Generally the preferred
approach is to review an individual’s previous
immunization records, and then offer any missing
immunizations,
without
ever
checking
serology.
Furthermore, the presence of antibodies does not
necessarily indicate immunity, and the absence of
antibodies does not necessary indicate susceptibility.
However, if a student submits records of positive
measles, mumps, and/or rubella antibody (IgG), this will
be considered acceptable proof of immunity. A history of
disease with measles, mumps, and/or rubella is not
considered proof of immunity unless accompanied by
laboratory confirmation.
The following are required for proof of immunity:
Measles:
1.
Document the last dose of an immunization containing
tetanus and diphtheria. The last dose of a tetanus and
diphtheria immunization must be within the past ten years.
One dose of tetanus/diphtheria/acellular pertussis (Tdap)
is required and must have been given in adolescence or
adulthood. A dose of Tdap is required regardless of
whether or not previous immunizations containing
pertussis were given in childhood, or whether the
individual ever had pertussis disease (whooping cough).
University of Manitoba
Two doses of measles-containing vaccine, a
month or more apart, with the first dose given on
or after the first birthday;
OR
2.
Serology for measles antibody (IgG)
Mumps:
1.
Page 3 of 5
Two doses of mumps-containing vaccine, a
month or more apart, with the first dose given on
or after the first birthday;
February 2014
OR
2.
Serology for mumps antibody (IgG)
Rubella:
1.
One dose of rubella-containing vaccine, given on
or after the first birthday;
OR
2.
Serology for rubella antibody (IgG)
Varicella
One of the following two items is required for proof of
varicella immunity:
1.
Positive serology for varicella (IgG);
OR
2.
Two doses of varicella-containing vaccine, six or
more weeks apart, with the first dose given on or
after the first birthday (if the doses are four or
more weeks apart but less than six weeks apart
indicate which brand of varicella vaccine was
used).
Post-immunization
varicella
serology
is
NOT
recommended, so long as documentation of the
immunization series is available. If varicella serology (IgG)
is tested after a properly documented immunization series
and is negative, the result most likely represents a false
negative and should be ignored.
For all ages receiving a varicella immunization series
TWO doses are required at least six weeks apart, starting
on or after the first birthday (if the doses are four or more
weeks apart but less than six weeks apart indicate which
brand of vaccine was chosen; some manufacturers
require doses to be given a minimum of four weeks apart,
others require a minimum of six weeks).
If a student previously received only one dose of varicella
vaccine, current guidelines recommend two doses for all
ages; a second dose should therefore be given.
For students with a history of chickenpox infection or
herpes zoster (shingles) serology for varicella antibodies
(IgG) should still be obtained.
For adults with an absent history of disease generally
varicella antibodies (IgG) should be tested before varicella
vaccine is offered, as the majority of such individuals will
already be immune due to an infection that was not
recognized as such at the time.
Hepatitis B
Students generally fall into one of the following four
categories:
1. Completion of a full hepatitis B or combined
hepatitis A+B series and post-immunization
serology: Document the immunization series. For
hepatitis B vaccine and combined hepatitis A+B
vaccine there are complete two-dose, three-dose,
and four-dose immunization series that are all
acceptable; each depends on the type of vaccine
used, the spacing between doses, and (in some
University of Manitoba
cases) the age of the vaccine recipient. A common
series for adults is the three dose series, with doses
given at time zero, one month, and six months.
Serology (antibody to hepatitis B surface antigen, or
anti-HBs) should be checked ideally one to two
months after completion of the series to ensure
immunity (positive anti-HBs, or a level that is ≥ 10
mIU/mL). If antibody levels are negative the student
should be provided one or more additional doses of
vaccine and repeat serology should be obtained
(refer to the Canadian Immunization Guide for
additional details). Repeat testing should include a
test for chronic hepatitis B infection, which can be a
cause of negative anti-HBs.
2. Immunity due to natural infection. Some students
will already be immune to hepatitis B due to natural
infection. Such students will have positive anti-HBs,
and may have detectable antibody to hepatitis B
core antigen (anti-HBc), which is not produced by
immunization. Students in this category do not
require hepatitis B immunizations. Testing for
immunity prior to starting a hepatitis B immunization
series should be considered for students who
originate from hepatitis B endemic countries.
3. Vaccine non-responder. Some students fail to
show protective levels of anti-HBs despite two
complete hepatitis B immunization series. Chronic
hepatitis B infection should be ruled out. Such
students should be counseled on the need for
passive immunization after potential exposure to
hepatitis B.
4. Chronic hepatitis B infection: Students with
chronic hepatitis B infection typically have positive
hepatitis B surface antigen (HBsAg), and may also
have positive hepatitis B “e” antigen (HBeAg). Such
students should be referred to a specialist in viral
hepatology for assessment.
In some situations a student with chronic hepatitis B
infection may be positive for both anti-HBs and HBsAg;
i.e., the presence of anti-HBs does not necessarily mean
that HBsAg will be negative. However, routine testing for
HBsAg is not required by the University of Manitoba.
Hepatitis vaccination can be given as either hepatitis B
alone, or as combined hepatitis A and B vaccine.
However, if some combination of hepatitis A, hepatitis B,
and combined hepatitis A+B vaccines are given, caution
must be taken to ensure a full hepatitis A and a full
hepatitis B series are given. Combined hepatitis A+B
vaccine contains half the hepatitis A antigen compared to
plain hepatitis A vaccine (refer to the Canadian
Immunization Guide for additional details).
Please document in the section “Additional notes on
hepatitis B status” any additional details regarding a
student’s hepatitis B status, particularly students falling
into categories 2, 3, or 4 above.
Tuberculosis (TB)
All students should submit documentation of testing for
latent
tuberculosis
infection
(LTBI)
unless
a
contraindication exists. Contraindications include:
Page 4 of 5
February 2014
A past history of active TB disease
A previously positive tuberculin skin test (TST or
Mantoux)
Treatment for active TB disease or LTBI
Severe allergy to tuberculin or any of its
components
X-ray report can be submitted, and a repeat chest X-ray is
not required. If a previous X-ray report is not available the
X-ray should be repeated. Generally repeat X-rays are
only required if a specific medical indication exists (e.g., a
student now has symptoms consistent with active TB
disease; an individual is considering undergoing treatment
for LTBI).
If any of these contraindications exist please submit
documentation of follow-up measures taken (e.g.,
physician
or
nurse
documentation
summarizing
treatment).
A chest X-ray is not a substitute for a TST; if a student
requires a TST, a normal chest X-ray does not rule out
the presence of LTBI.
-
Readings: All TSTs must be read by a trained healthcare
worker 48-72 hours after administration and recorded in
millimeters of induration; please do not record TSTs as
only “positive” or “negative”. Self-reading of TSTs is not
acceptable.
Two-step TST: Students without contraindications should
have a two-step TST documented. A two-step TST
generally only needs to be done once; all subsequent
TSTs can be one-step. A two-step TST consists of a
single TST being administered and read, and then
(assuming the first TST was negative), a repeat TST
being administered ideally 7 to 28 days (up to one year)
after the first TST was administered.
Recent TST: Students without contraindications must
also have a recent TST (done when the student entered
Medicine, or later); this does not necessarily need to be
current within the past 12 months. Repeat TSTs (e.g.,
annual TSTs) are generally not required unless the
student experiences a high-risk exposure (e.g., confirmed
significant exposure to an individual with infectious TB
disease).
Positive TST: If a positive TST has been documented
this should be indicated. For healthcare workers a positive
TST is usually defined as one ≥ 10 mm induration,
although the tester must be aware of situations where a
TST <10 mm may be considered positive (for further
details including recommended management please refer
to the Canadian Tuberculosis Standards, 7th edition,
2013).
Bacillus Calmette–Guérin (BCG) vaccine: Document
whether a BCG immunization has been given. A new or
repeat BCG immunization is not required or
recommended. The BCG vaccine is not considered a
contraindication to TST testing. Although a BCG
immunization sometimes makes it more likely to have a
false-positive TST, many individuals who have had a BCG
will have a negative TST. It is possible to have received a
BCG and still be infected with Mycobacterium
tuberculosis.
Interferon Gamma Release Assay (IGRA) Tests: While
Canadian guidelines discourage use of an IGRA blood
test for those who will be undergoing serial testing for
LTBI, for the purpose of the elective applications an IGRA
test result will be accepted in lieu of a TST.
Chest X-rays: Chest X-rays are not required routinely for
students. A chest X-ray should be obtained only for
individuals who have had a positive TST, or a diagnosis of
active TB disease. In most situations the previous chest
University of Manitoba
Examples:
The
following
examples
requirements for common TB situations:
illustrate
Example 1: A student had a two-step TST
documented in first year Medicine, and has had no
known significant exposures to TB since then. The
student does not require a repeat TST. The student
should submit documentation of the two-step TST.
Example 2: A student had a two-step TST
documented five years before entering Medicine, but
has not had a repeat TST. This student should have
a single TST performed now, and submit
documentation of the two-step TST and the recent
TST.
Example 3: A student had a positive 17 mm TST
that was documented previously. The student should
submit documentation of the positive TST, the chest
X-ray that was taken after the positive TST was
discovered, and documentation of any follow-up
measures taken. The student does not require a
repeat chest X-ray unless a specific medical
indication exists.
Example 4: A student has had a BCG vaccination,
and has a normal chest X-ray, but no previous TSTs,
and no contraindications. The student requires a
two-step TST.
Example 5: A student was treated for active
respiratory TB disease. No new TSTs should be
performed. The student should submit physician
documentation of the TB diagnosis and any followup measures (e.g., medications taken, whether
treatment was completed, most recent chest X-ray
and final sputum if applicable).
Example 6: A student has a 6 mm TST; the student
has a medical condition that severely compromises
the immune system (e.g., HIV). The TST is
considered positive. No further TSTs should be
performed.
The
student
should
submit
documentation of the TST and a chest X-ray.
Influenza
All students must submit documentation of a seasonal
influenza immunization for the current influenza season
(e.g., 2013-2014 vaccine). Vaccine can be given
throughout influenza season, right up until the date the
vaccine expires. If a student applies for an elective and
that season’s influenza vaccine is not yet available, the
student should submit documentation of the influenza
vaccine as soon as vaccine becomes available.
Page 5 of 5
February 2014
N95 Mask Fitting:
If you cannot complete the N95 at your current location please make arrangements to complete the
N95 when you arrive in Canada. You can make an appointment at Levitt Safety:
Levitt-Safety Winnipeg
100 Plymouth St.
Winnipeg, MB R2X 2V7
P: (204) 633-7228
Toll Free: (888) 453-8488
F: (204) 633-1268
E-mail: [email protected]
http://www.levitt-safety.com/
When you have made the appointment, please email me the date/time so I can add it to your file. We
must receive proof of your fitting prior to the start of your elective. Please note that this must be done
and handed into to the Electives Administrator before you can begin your elective.
Malpractice/Liability Insurance - $5 Million Aggregate Limit Required
If your University does not provide coverage, I would recommend contacting one of the following
individuals:
1. Richard W. Pater, CAIB
Commercial Insurance Marketer
Team Insurance Brokers Inc.
Unit 6-2605 Main Street (Rivergrove Shopping Centre)
Winnipeg, MB R2V 4W3
B. 204.334.4373
F. 204.338.9129
E. [email protected]
www.teamib.com
2. Arnold Cariaga
Account Associate
HUB International HKMB Limited
595 Bay St., Suite 900
Toronto ON M5G 2E3
Tel: 416-597-0555 ext 353
Fax: 416-597-2313
Email: [email protected]
Application for MISHIP Inpatriate Coverage
(Manitoba International Student Health Insurance Plan)
Please print in ink
POLICY NO. 100009313
NAME OF UNIVERSITY, COLLEGE OR SCHOOL: ____________________________________________
PARTICIPANT INFORMATION
LAST NAME
FIRST NAME AND MIDDLE INITIALS
GENDER

STREET ADDRESS IN CANADA
CITY
Male
DATE OF BIRTH (DD/MMM/YYYY)

Female
PROV
POSTAL CODE
MANITOBA
EMAIL ADDRESS
HOME TELEPHONE NO.
(
DATE OF ARRIVAL IN CANADA
(DD/MMM/YYYY)
DATE EDUCATIONAL PROGRAM OR
WORK ASSIGNMENT BEGINS (DD/MMM/YYYY)
)
CELL PHONE NO.
-
(
DATE EDUCATIONAL PROGRAM OR
WORK ASSIGNMENT WILL END (DD/MMM/YYYY)
)
-
COVERAGE IS REQUIRED
STARTING ON (DD/MMM/YYYY)
ARE YOU CURRENTLY ELIGIBLE FOR MANITOBA HEALTH INSURANCE?
IS YOUR SPOUSE CURRENTLY ELIGIBLE FOR MANITOBA HEALTH INSURANCE?


No

Yes (If YES, you are not eligible for the MISHIP Inpatriate coverage)
No

Yes (If YES, they are not eligible for the MISHIP Inpatriate coverage)
ARE YOU ELIGIBLE FOR OTHER HEALTH INSURANCE?
HAVE YOU BEEN COVERED BY THIS MISHIP PLAN BEFORE?


No

Yes (If YES, please provide name of other plan)
____________________________________________________________________
No

Yes (If YES, please provide your Mbr/EE ID)
Mbr/EE ID |____|____|____|____|____|____|____|____|____|
COVERAGE SELECTION (Select One Only)
Term (in months)
 SINGLE COVERAGE
______________
 COUPLE COVERAGE * (Complete Dependent Information below)
Premium Payable
 FAMILY COVERAGE * (Complete Dependent Information below)
$ ____________
* Participants with an eligible Spouse and/or Children accompanying them to Manitoba must apply for Family Coverage immediately. If your eligible
Spouse and/or Children are joining you later, please refer to the Rate Chart on Page 2 for instructions on calculating the appropriate premium.
(See Chart on Reverse for
Term & Rate Information)
PREMIUM PAYMENT OPTIONS (Select One Only)
 CHEQUE – Please make cheque payable to Industrial Alliance.
 CREDIT CARD PAYMENT – I authorize Industrial Alliance to charge the credit card indicated below with the required premium.
Cardholder Name |___________________________________|
 VISA or  MasterCard
Credit Card # |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Expiry Date |__|__|__| / |__|__|__|__| (mmm/yyyy)
LIST THE NAMES OF ALL DEPENDENTS TO BE INSURED
(If more space is required please attach separate list)
LAST NAME
FIRST NAME
RELATIONSHIP TO PARTICIPANT
DATE OF BIRTH
(DD/MMM/YYYY)
 Spouse OR
 Common-Law Spouse
 Son
 Daughter
 Son
 Daughter
GENDER
DATE OF ARRIVAL IN
CANADA (DD/MMM/YYYY)
 Male
 Female
 Male
 Female
 Male
 Female
AUTHORIZATION
I acknowledge that I have read the Notice on Privacy and Confidentiality on the back of this page concerning privacy practices and consent to the collection, use and disclosure of
my and/or my dependent’s personal information for the purposes specified.
I confirm that I am not eligible for coverage under the Manitoba Provincial Health Insurance Plan. I confirm that the information provided above is true and that any
misrepresentation on this application regarding age, gender or eligibility may cause my coverage to be void.
I understand that the coverage contains limitations and exclusions.
I understand that coverage will not take effect until my properly completed application has been approved by Industrial Alliance and the premium has been paid.
Please sign
X ________________________________________________________
Date
_________________________
Signature of Participant * or Adult Responsible for Participant (Must always sign)
* If the Participant is a minor, then the application must be reviewed and signed by a person who has responsibility for the Participant while in Canada. If you are signing on
behalf of the Participant, please complete the information below.
Name of Adult Responsible for Participant (Please print clearly)
Day Phone Number
___________________________________________________________________
(______)_______________________
Form 4650/A (SEP/2012)
Page 1 of 2
Application for MISHIP Inpatriate Coverage
ELIGIBILITY
To be eligible for coverage you must be a non-Canadian Participant or a non-Canadian member of the academic community under 70 years of age studying or working for a
participating Educational Institution in the province of Manitoba.
A non-Canadian Spouse, under 70 years of age, or non-Canadian Dependent Children, under 25 years of age, of an eligible Participant are also eligible for coverage.
RATE CHART
Participants – Please note that you must enrol under the Manitoba Health Insurance Plan as soon as you are eligible to apply.
TERM OF
COVERAGE *
1 month
2 months
3 months
4 months
5 months
6 months
7 months
8 months
9 months
10 months
11 months
12 months
SINGLE RATE
PER PARTICIPANT
$ 65.00
110.00
135.00
200.00
240.00
270.00
320.00
370.00
420.00
470.00
520.00
570.00
COUPLE RATE
PER PARTICIPANT
$ 130.00
220.00
270.00
400.00
480.00
540.00
640.00
740.00
840.00
940.00
1,040.00
1,140.00
FAMILY RATE
PER PARTICIPANT
$ 175.00
300.00
350.00
500.00
600.00
700.00
850.00
1,000.00
1,150.00
1,300.00
1,450.00
1,600.00
* Note that premiums can not be adjusted or pro-rated. Each partial month of coverage must be rounded up to a full month. For example, if your Term of Coverage is for 3 weeks
only, then you must pay the premium for 1 month of coverage. If your Term of Coverage is from January 15 to June 15, then you must pay the premium for 6 months of coverage.
If you arrive in Canada before your Spouse and/or Dependent Children arrive, you should pay the Single Rate premium for the term you are alone and then pay for the Couple or
Family Rate for the time they will be in Canada. For example, if your Term of Coverage is for 6 months but your family arrives one month later, you should pay for 1 month at the
Single Rate ($65.00) and then 5 months at the Family Rate ($600.00) for a total of $665.00. If you need assistance in determining the correct premium payable, please do not
hesitate to contact one of our Customer Service Administrators at 1-800-266-5667.
Changes: Please notify us immediately if there is any change to your status and/or the status of your dependents.
Extension of coverage: If you need to extend your coverage, your request for an extension and your payment must be submitted before your current coverage expires.
UNDERWRITTEN BY
Please send your completed application together with your payment to:
Special Markets Solutions
Industrial Alliance Insurance and Financial Services Inc.
2165 Broadway W, PO Box 5900
Vancouver, BC V6B 5H6
Toll Free Fax: 1-888-553-5433 (Credit Card payments only)
For inquiries, call us Toll Free at 1-800-266-5667 or by email at [email protected]
PLEASE READ CAREFULLY
NOTICE ON PRIVACY AND CONFIDENTIALITY
The specific and detailed information requested pursuant to this application from you and which may be subsequently requested by us, from time to time, is
required to process your application, and process any claim for benefits made by you. To protect the confidentiality of such personal information, access to
your information is restricted to any person you authorize or as authorized by law as well as those Industrial Alliance Insurance and Financial Services Inc.
employees, its reinsurers, third party administrators, mandataries, agents or brokers of Industrial Alliance, plan sponsors and any agents or brokers of such
sponsors or other market intermediaries who are responsible for (a) sponsoring a plan for you, (b) marketing and administration of products or services, (c)
assessment of risk (underwriting) and (d) investigation of claims. Your file will be kept in Industrial Alliance’s offices.
You are entitled to review your personal information contained in our files, subject to certain limited exceptions established by law, and if
necessary, to have it rectified by sending a written request to us at: 2165 West Broadway, P.O. Box 5900, Vancouver, BC, V6B 5H6, Attention:
Manager, Administration, Special Markets Solutions.
Corrections will be noted in the file. If a requested correction is in dispute, we nonetheless note your requested correction in the file. Further information on
our privacy practices can be found at our website www.inalco.com or alternatively, contact us at 1-800-266-5667 and request that a copy be faxed or mailed
to you.
FOR OFFICE USE ONLY
Educational Institution #:
Date Application Received:
__________________________
Date Application Processed: __________________________
Date Fulfillment Sent:
__________________________
Processed by:
Sent by:
__________________________
Form 4650/A (SEP/2012)
____________
__________________________
Page 2 of 2