Algoma EMS
Verification of Immunity & Communicable Disease Status

1. Attached to this form is sufficient proof of my current immunity to each of the diseases listed in Part ‘A’ below. (Sufficient proof is any combination of a copy of immunization records, a copy of titre results and/or a note signed by a physician or physician’s delegate clearly indicating a) your immunity and b) which disease(s) the note pertains to.
   
   
   
2. I, _________________________________________, verify that, to the best of my knowledge, I am not acutely symptomatic of any of the communicable diseases listed in Part ‘B’.

Candidate’s Signature _______________________________________

Date ____________________

Part ‘A’ – Presence of Immunity

Part ‘B’ – Table of Communicable Diseases