School of Medicine, Fremantle
Immunisation Pack for Commencing Medical Students
Part A: Due in Week 2, Semester 1
Part B: DUE Week 6, Semester 1
Please take the following forms to your Doctor or
immunisation clinic to be completed. Please read each
form carefully, and follow the instructions given.
The University has an agreement with Travel Health
Fremantle to bulk bill students & they have on site all
required vaccinations.
These forms must be completed by a doctor or a
Registered Nurse working in a Health Care Facility
Please note that all items on the checklist need to be
completed – incomplete packs will not be accepted.
Should you have any questions, please contact the
School on (08) 9433 0228
Part A
Tuberculosis
Due: Week 2, Semester 1
Students – please present this form for completion by the testing facility.
Important! TB tests can interact with live vaccinations, it is important to complete your tuberculin
testing BEFORE having any vaccinations for measles, mumps, rubella and varicella.
Testing is available at Travel Health Fremantle, 85 South Street, Fremantle, WA 6160, Ph: (08) 9336
6630, reception@travelhealthfremantle.com.au.
Student Name
Student ID No.:
Tuberculin Test
Quantiferon Gold
Date of test
Result
(please circle)
Follow up Required
Positive
Negative
Yes
No
Doctor/Registered Nurse Name
Signature
Health Care Agency
This form must be signed by a Doctor or Registered Nurse
NOTE: If you have worked outside of Australia in a health care facility in the past 12 months, please
advise your health care provider.
Travel Health Fremantle will manage Quantiferon Gold positive tests in liaison with the Perth Chest
Clinic.
Due: Students must return this form completed by Week 2 of Semester 1
Submit: to the Clinical Placements Team – in Week 2 of Semester 1
Part B
Measles, Mumps, Rubella
Due: Week 6 of Semester 1
Students – please present this form for completion by the testing facility.
Important! You need to provide proof of 2 MMR vaccinations. If you are unable to provide this
evidence, then you will be required to provide serological evidence of immunity or receive 2 doses
of MMR 4 weeks apart. The completed 2 dose course are due in Week 6.
Students with an equivocal serology result require one booster of MMR
Student Name:
MMR x 2 doses
sighted
Student ID No.:
Yes
2 Vaccination Dates:
#1 Date:
No
#2 Date:
or
Serology Testing
Measles
Mumps
Rubella
Date of serology test
Immune status result
Vaccines Required
Immune/not
Immune/not
Immune/not immune/equivocal
immune/equivocal Immune/equivocal
yes/no
yes/no
yes/no
#1 Date:
#2 Date:
Dates MMR x 2 given
Doctor/Registered
Nurse Name
Signature
Health Care Agency
This form must be signed by a Doctor or Registered Nurse
Submit: to School of Medicine Reception
Part B
Varicella (Chicken Pox)
Due: Week 6 of Semester 1
Students – please present this form for completion by the testing facility.
Important! If you do not have record of vaccination dose(s) you are required to provide serological
evidence of immunity or receive 2 doses of varicella 4 weeks apart. The completed course of 2
doses are due in week 6.
*Note: Serological testing is usually negative after vaccination and therefore not recommended.
Serology will be positive after previous infection.
Student Name:
Student ID No.:
2 Vaccination Dates
Varicella x 2 doses
sighted
Yes
No
#1 Date
#2 Date
or
(if required – see above note*)
Serology Testing
Varicella
Date of test
Immune status result
Immune/not immune
Vaccines Required
Yes/No
Dates Varicella x 2 given
#1 Date:
Doctor/Registered Nurse
Name
Signature
Health Care Agency
This form must be signed by a Doctor or Registered Nurse
Submit: to School of Medicine Reception
#2 Date:
Part B
Diphtheria, Tetanus, Pertussis (Whooping Cough)
Due: Week 6 of Semester 1
Students – please present this form for completion by the testing facility.
Student Name:
Record of Adult DTP Given
Student ID No.:
Date of Booster (within 10 years):
Doctor/Registered Nurse Name
Signature
Health Care Agency
This form must be signed by a Doctor or Registered Nurse
Submit: to School of Medicine Reception
Part B
Hepatitis A
Due: first dose due by Week 6 of Semester 1
Students – please present this form for completion by the testing facility.
In order for you to attend your first clinical practicum, you must provide evidence of
commencement of the first dose.
Second dose is given at 6 months from the first dose and this evidence is to be submitted
Student Name:
Hepatitis A
vaccination x 2 doses sighted
Student ID No.:
2 Vaccination Dates
#1 Date :
Yes / No
#2 Date:
or Serology testing
Hepatitis A
Date of test
Immune status result
Immune / Not immune
Doctor/Registered Nurse
Name
Signature
Health Care Agency
This form must be signed by a Doctor or Registered Nurse
Submit: to School of Medicine Reception
Part B
Hepatitis B
Due: First dose due by Week 6 of Semester 1
Students – please present this form for completion by the testing facility.
You are required to provide evidence of commencing the vaccination course followed by evidence
of immunity through a blood test.
Student Name:
Student ID No.:
Vaccination Dates:
#1 Date:
Hep B vaccination course
sighted
Signature:
#2 Date:
Yes / No
Signature:
#3 Date:
Signature:
Serology Testing
Hepatitis B
Date of test
Immune status result
Immune / Not immune Titre_____________
HBsAg: Positive / Negative
Doctor/Registered Nurse
Name
Signature
Health Care Agency
This form must be signed by a Doctor or Registered Nurse
Submit: to School of Medicine Reception
Adapted with permission by School of Nursing
Authorised: S Bowen
Reviewed: L Abbott
Date: October 2014
Bachelor of Medicine / Bachelor of Surgery
Student Declaration Form Infectious Diseases Policy
Student Name:
Student ID:
I declare that I have read, understood and agree to comply with the School of
Medicine, Fremantle’s Infection Diseases Policy for the duration of the Bachelor of
Medicine / Bachelor of Surgery course.
I understand my responsibilities to protect myself as an individual and my
responsibility to protect patients from the hazards of blood borne and other infectious
diseases.
I have undertaken immunity and immunisation requirements required by the School
of Medicine, Fremantle for enrolling students and submitted the completed and
signed Immunisation Pack for Commencing Medical Students.
I am aware of my infectious status for blood borne disease.
I agree that if I test positive for a blood borne virus such as Hepatitis B, Hepatitis C
or HIV that I will exclude myself from exposure prone procedures and that I will seek
counselling from the Dean of Medicine, Fremantle about the implications for clinical
practice and future career options.
Signature:
Date: