University of Victoria School of Nursing

Post RN Diploma BSN Student
Personal Respirator Fit Testing & CPR Certification
Exemption Form

EF.201601

INSTRUCTIONS

Use this form to provide evidence in lieu of the University of Victoria School of Nursing practice requirements of personal respirator fit-test and/or CPR-C certification.
Failure to provide evidence of personal respirator fit-test and CPR-C certification prior to the commencement of a practice course will result in suspension of the student’s continued practice education.
Submit completed form to or fax to 250-721-6231 ATTN: Post RN Practice Team

STUDENT INFORMATION
First Name: / Last Name:
Student Number: V00 / UVic Email: / Practice Course: Select CourseNURS 351NURS 431NURS 495 / Term: Select TermSeptember 2016January 2017May 2017September 2017January 2018May 2018September 2018January 2019May 2019September 2019January 2020May 2020September 2020
Placement Agency: / Unit/Department:
UniverSIty of Victoria School of Nursing PRACTICE Requirements
Cardiopulmonary Resuscitation (CPR)
Post RN Diploma students must provide evidence of successful completion of basic life support level-C or higher prior to a practicum experience or provide an exemption form of this requirement signed by the placing agency contact. A student’s current CPR level-C certification, or an agency specific exemption form, must be on file in the School of Nursing for a student to remain registered in a practice course.
Choose one (1) of the following:
1)A CPR level-C certification is not required at the placement unit or organizational department
2)A CPR level-C certification requirement is already met at the placement unit or organizational department
3)Other:
Personal Respirator Fit Testing
Post RN Diploma students must be fit-tested before initial use of their personal respirators and annually thereafter while in the program, and must provide evidence of a personal respirator quantitative fit-test prior to a practicum experience or provide an exemption form of this requirement signed by the placing agency contact. A student’s current personal respirator fit testing certification, or an agency specific exemption form, must be on file in the School of Nursing for a student to remain registered in a practice course.
Choose one (1) of the following:
1)A personal respirator fit-test is not required at the placement unit or organizational department
2)A personal respirator fit-test certification requirement is already met at the placement unit or organizational department
3)Other:
To Be Completed By PLACING Agency Contact (Agency Supervisor/Manager/Practice Leader)
I certify that all information provided on this form is true and correct to the best of my knowledge and belief.
First Name: / Last Name:
Position Title: / Unit/Department:
Signature:
X / Date Signed (MM/DD/YYYY):

EF.201601