Title:
Staff Immunisation Form
Title No:
F601.06
Prepared by:
PB
PB Chief Operating
Officer
Approved by:
Page 1 of 2
Edition:
Date:
2
12/12/2012
1. STAFF HEALTH EMPLOYMENT FORM
This Form should be completed by all clinical and non-clinical staff on or
before commencement of employment.
Name:
Date Commenced Employment:
Allergies (e.g. Latex, antibiotics, neomycin, egg, yeast or other vaccine components) YES/NO:
If Yes, please provide details:
HISTORY OF VACCINE PREVENTABLE DISEASES
This information will be entered on a database and it kept strictly confidential.
Please indicate whether you have had, or have been immunized against any of the following diseases:
Disease History
(Please circle correct answer)
Disease
Hepatitis B
Immunisation History
(Please circle correct answer)
History of
Disease
Yes/No
Number of
Vaccination Doses








Hepatitis A



Diphtheria /
Tetanus




1 dose
2 doses
3 doses*
Not received
Unsure
1 dose
2 doses
Twinrix A & B
Combined
o 1 does
o 2 doses
o 3 doses
Not received
Unsure
Adult diphtheria/
tetanus vaccine
(ADT) as child.
Booster < 10 yrs
Booster > 10 yrs
Not received
Unsure
Serological
Evidence if
Known
Immunisation
Recommendations for
HCWs
Initial course only**
N/A
Comment/
Vaccination
Required
Yes/No
Serology
Result:
HCW working in
paediatrics, ICU and
emergency depts. With
high populations of
indigenous children.
Initial or combined A &
B course.
Date Given:
Initial Course which
includes primary course
of 3 injections & 2
booster doses.
Date Given:
Title:
Staff Immunisation Form
Title No:
F601.06
Prepared by:
PB
PB Chief Operating
Officer
Approved by:
Page 2 of 2
Edition:
Date:
2
12/12/2012
HISTORY OF VACCINE PREVENTABLE DISEASES (cont)
Disease History
(Please circle correct answer)
Disease
History of
Disease
Yes/No
Poliomyelitis
Measles
Measles/
Mumps/
Rubella
Mumps
Rubella
Influenza
Pertussis
(Whooping
Cough)
Immunisation History
(Please circle correct answer)
Number of
Vaccination Doses
 Oral sabin as
child
 Booster dose as
adult
 Not received
 Unsure
 Rumbella
vaccine
 Measles only
 MMR vaccine
o 1 does
o 2 doses
o 3 doses
 Not received
 Unsure
 Mantoux test –
Year of mantoux
test:
 BCG vaccine
 Never tested
 Unsure
 DTP – Primary
course
o 1 does
o 2 doses
o 3 doses
o Booster dose
o Not received
o Unsure
 Varicella vaccine
o 1 does
o 2 doses
o Not received
o Unsure
Serological
Evidence if
Known
N/A
 Negative (No
reaction)
 Positive
>10mm
 Yes – visible
scar
 No – no visible
scar.
N/A
Immunisation
Recommendations for
HCWs
Comment/
Vaccination
Required
Yes/No
Primary Course
Booster at 10 years
Date Given:
One prior dose or
documented infection
Date Given:
Mantoux test on
employment. Chest
xray for staff with
previous conversion >
15mm
Date Given:
To received 1 dose of
adult pertussis
containing vaccine
unless have received
diphtheria/ tetanus
vaccine within
previous 5 years
Date Given:
Varilrix or Varivax x 2
doses recommended in
Date Given:
Varicella Zoster
non-immune health
(Chicken Pox)
care workers. Serology
Serology
required if no history
Result:
of disease.
rd
*Post vaccine serological testing 4 weeks after 3 does of hepatitis B is recommended for health care workers.
**There is good evidence that a complete primary course of Hepatitis B provides long lasting protection in
immunocompetent individuals.
Reference: National Health & Medical Research Council, 2003. The Australian Immunisation Handbook, 8th Edition.
(Please return completed Form to within ten days of commencing employment)