Compulsory Compliance
Requirements
Information Booklet for all
Health Science and Medicine
Programs
2016
Page |2
Table of Contents
Section 1: Introduction to Compliance ................................................................................................ 4
1.1
Security checks & placement requirements ........................................................................... 5
1.2
Immunisations and vaccinations............................................................................................. 5
1.3
Are you pregnant? .................................................................................................................. 5
1.4
Compliance timelines .............................................................................................................. 5
1.5
Compliance Requirement Schedule for Health Sciences and Medicine Programs................. 6
1.6
Definitions ............................................................................................................................... 7
Section 2: Security Checks & Placement Requirements ..................................................................... 8
2.1
QLD working with children (Blue Card)................................................................................... 8
2.2
NSW working with children (WWCC) – Allied Health students only ...................................... 9
2.3
National Criminal Police Checks ............................................................................................ 10
2.3.1
Australians, Australian residents and International students: ..................................... 10
2.3.2
International students .................................................................................................. 11
2.4
First aid and CPR certificates................................................................................................. 11
2.5
Specific Placement Requirements ........................................................................................ 12
2.5.1
QLD Health – Medical program and other (non-allied health) programs..................... 12
2.5.2
QLD Health – Allied Health programs only ................................................................... 12
2.5.3
NSW Health – Tweed Hospital ...................................................................................... 14
2.5.4
NSW Health – All facilities ............................................................................................. 14
Section 3: Immunisations and Vaccinations...................................................................................... 16
3.1
Immunisation, testing and screening requirements ............................................................. 16
3.1.1.
Seasonal Influenza ........................................................................................................ 16
3.1.2
Tuberculosis (TB) ........................................................................................................... 16
3.1.3
Additional Vaccination Requirements .......................................................................... 17
3.2
Conscientious Objection ....................................................................................................... 17
3.3
Exposure Prone Procedures (EPP) ........................................................................................ 18
3.4
Hepatitis B Vaccine Non-Responders.................................................................................... 19
3.5
Vaccine reactions .................................................................................................................. 19
3.6
Additional guidelines to assist in completion of the immunisations and vaccinations ........ 20
3.7.
Compulsory compliance costs............................................................................................... 22
3.8
Website addresses ................................................................................................................ 23
3.8.1
Immunisations and vaccinations ................................................................................... 23
3.8.2
Working with children checks ....................................................................................... 23
Health Sciences and Medicine Compliance Requirements
@ 2016 Bond University
Page |3
3.8.3
National criminal police checks..................................................................................... 23
3.8.3
First aid & CPR qualifications ........................................................................................ 23
3.8.4
Queensland Health ....................................................................................................... 24
3.8.5
New South Wales Health .............................................................................................. 24
Section 4: PRINT ALL THE FORMS AFTER THIS PAGE ............................................................................ 25
SINGLE SIDED PRINTING PLEASE ........................................................................................................... 25
Compulsory Compliance meeting checklist ...................................................................................... 26
Permission to disclose additional information to NSW Health ........................................................ 27
HSM Immunisation and Health Record Form Information Summary ............................................. 28
ADDITIONAL FORMS Section 4 continued (Pages 1-7):
HSM Immunisation and Health Record Form: Sections I – VII
Vaccination Evidence Assessment (Hepatitis B)
Non-Responder to Hepatitis B Vaccine-Acknowledgement
Exposure Prone Procedures Declaration Form (EPP)
Health Sciences and Medicine Compliance Requirements
@ 2016 Bond University
Page |4
Section 1: Introduction to Compliance
Undertaking a Faculty of Health Sciences and Medicine (HSM) Program can be physically and
emotionally demanding. If you are aware that you are suffering from an illness, have conscientious
objections to vaccinations, a disability, a criminal conviction or any impairment that may make it
difficult to register to practice with your relevant registration board or to complete the requirements
of the Program, please seek guidance from the Office of Student Affairs prior to commencing your
Program.
As an HSM student, enrolled in a program with compulsory placements, you will be required to
attend a compulsory Compliance meeting. For most programs compulsory Compliance meetings
take place during Orientation Week (O Week) of your first semester. Although since compulsory
placements for some programs occur in the second year of the program the compulsory Compliance
meeting may take place outside of O Week. The compliance meeting is to ensure you have met the
requirements to be eligible to participate in the placements within your program. You will be
emailed a specific meeting time and location for your compulsory compliance requirements meeting.
Students that are required to attend the compulsory Compliance meeting in O week will be expected
to have completed ALL requirements (or provide evidence of applications) and to provide the
relevant documentation at their scheduled Compliance meeting. Students unable to complete the
requirements and provide the appropriate documentation by O week will risk their ability to
undertake placements and progress in the Program. It is therefore imperative that you begin
working through these requirements as soon as possible as there is quite a lot to complete and
many may take some time to finalise.
This Information Booklet outlines the Compulsory Compliance Requirements necessary for Bond
University, New South Wales Health and Queensland Health. These include Blue Card and Australian
National Police Certificates, First Aid and CPR qualifications, specific placement requirements,
orientations, and detailed information regarding your immunisation and vaccination requirements.
Please read and understand this entire document and take time to complete the relevant sections
prior to your compliance meeting.
In Section 4 (page 26) there is a Compliance Meeting Checklist that should be used to ensure that
you have completed everything that is required and to ensure a smooth introduction into your
Program.
You will be required to have certain documents certified. Locations to have documentation certified
can be found on the following link https://www.qld.gov.au/law/legal-mediation-and-justice-of-thepeace/about-justice-of-the-peace/find-a-justice-of-the-peace/search-for-your-nearest-jp-or-cdec/
Please refer to the Bond University – Student Related University Policies for further guidelines.
Health Sciences and Medicine Compliance Requirements
@ 2016 Bond University
Page |5
1.1
Security checks & placement requirements
The information in Section 2 specifically relates to both Queensland Health (QLD Health) and New
South Wales Health (NSW Health) placement compulsory compliance requirements for placements
in health care settings. Please ensure that you are familiar with and understand the content.
HOWEVER please do not sign any of the documents/forms until your Compliance Meeting during O
Week (or when your Compliance meeting is arranged), as your signature needs to be witnessed.
1.2
Immunisations and vaccinations
The information in Sections 3 & 4 relate to immunisations and vaccinations. These forms will assist
you to gain compliance with regard to infectious disease screening and vaccination. The primary
form within this section is the ‘HSM Immunisation and Health Record Form' and this must be
completed by an impartial registered general practitioner or nurse (not a family member or relative).
You will be required to bring this form and certified copies of all other evidence / forms as outlined
in this booklet to your O Week Compliance Meeting (or when your Compliance meeting is arranged).
1.3
Are you pregnant?
Students who are pregnant will be required to provide a medical clearance certificate verifying the
ability to actively participate in all activities required to achieve the objectives of the students
Program. If a student becomes aware they are pregnant whilst enrolled a medical clearance must be
provided as soon as possible.
1.4
Compliance timelines
Students will be expected to have completed ALL requirements prior to O Week and to provide the
relevant documentation at their scheduled Compliance meeting in O Week (or when your
Compliance meeting is arranged).
The Faculty acknowledges there is a high volume of compliance documentation to complete and
there can be various circumstances hindering this process for a minority of students.
Therefore only in extenuating circumstances will students have until Week 5, Semester 1 to
complete any outstanding compliance requirements. Students failing to complete these
requirements or failing to respond to requests for documentation by this date may be ineligible to
attend placement. This may impact the student’s ability to participate in and complete required
placements therefore jeopardising progression in their program.
The Compulsory Compliance Requirements applies to specific courses offered by the Faculty of
Health Science and Medicine. Please refer to the table on the following page for a list.
If you have any questions, please contact:
HSM Compliance Officer
HSMCompliance@bond.edu.au
Health Sciences and Medicine Compliance Requirements
@ 2016 Bond University
+61 7 5595 1760
Page |6
1.5
Compliance Requirement Schedule for Health Sciences and Medicine Programs
PROGRAM
Blue Card
NSW Working
with children
First Aid/ CPR
Criminal Police
Check
Bachelor of Exercise & Sports Science
✓
✓
✓
Medical Program^
✓
✓
✓
Bachelor of Sports Management
✓
Doctor of Physiotherapy (Allied Health)
✓
✓
✓
Master of Nutrition & Dietetic Practice
(Allied Health)
✓
✓
Master of Sports Science
✓
Master of Sports Management
✓
Bachelor of Biomedical Science
NIL
Bachelor of Health Sciences
NIL
Master of Clinical Education
NIL
Master of Occupational Therapy (Allied Health)
✓
All research-based programs
NIL
QLD Health
Documentation
NSW Health
Documentation
Vaccinations
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
*International Students must also provide an Overseas Police Check from their home country in addition to an Australian Criminal Police Check.
^ The Medical Program is comprised of two sequential degrees – the Bachelor of Medical Studies (BMedSt) and the Doctor of Medicine (MD). All students selected for entry into the Medical Program will have
to complete both the BMedSt and MD to be eligible for registration as a medical practitioner in any state or territory in Australia or New Zealand.
Both degrees are awarded at the completion of Year 5.
Please contact HSM Compliance at HSMCompliance@bond.edu.au if you require any clarification or assistance with any of your compliance requirements.
Health Sciences and Medicine Compliance Requirements
@ 2016 Bond University
Page |7
1.6
Definitions
Compliance
Regulatory compliance
Certified Copy
Program
Facility
Placement
Red Text
Blue underlined text
FHSM
HSM
QLD
NSW
Means conformity to a rule such as a specification, policy, standard
or law.
Describes the goal that corporations or public agencies aspire to
achieve in their efforts to ensure that personnel are aware of and
take steps to comply with relevant laws and regulations.
A certified copy is a photocopy of a primary document, with an
endorsement to confirm that it is a true copy of the primary
document.
(Note: Original documentation, photocopies and ID must be taken to
a Justice of the Peace, doctor or other notary professional. They will
sight your original documents and stamp/sign your photocopies
stating they are true to the original document. NOTE: Family
members CANNOT certify documentation.)
Means the tertiary degree Program a student is enrolled at the
University.
Means a health or human service facility including; a public health
facility, public sector hospital or department, a private healthcare
facility, community based health service or other facility or service
run by a Health Service District or organisation or a Bond University
teaching clinic where placements are undertaken.
Refers to a practical educational experience, a required component
of a course or degree Program, in a health or human services facility
that may be on campus or off campus. It is also known as
professional practice, work-placement, work experience, workintegrated learning placement, fieldwork, practicum, internship,
clinical experience, clinical placement or practical work.
(Note: Placements maybe outside of the Brisbane metropolitan /
Gold Coast area including Northern New South Wales and (by
negotiation) in other States or overseas. Excursions are not
considered to be Placements.)
Red text refers to forms.
Links to external resources for you to read, complete etc.
Faculty of Health Sciences & Medicine
Health Sciences & Medicine
Queensland
New South Wales
Page |8
Section 2: Security Checks & Placement Requirements
2.1
QLD working with children (Blue Card)
As part of your Program you may be required to undertake placements which involve working with
children or young people, therefore you must comply with the Queensland state legislative
requirements (Child Protection Act 1999 and Commission for Children and Young People and Child
Guardian Act 2000). In accordance with these Acts students are required to obtain a Queensland
Blue Card. This check is designed to determine whether a person is suitable to work with children.
Please note the following:





Obtaining a Blue Card is free;
The Blue Card is valid for three years.
You may be asked to present your Blue Card to facility staff on the first day of your
placement.
You should keep your Blue Card on you at all times while attending placement.
It is an offence to provide false or misleading information or documents.
Application forms are available from Blue Card Services via the link
http://www.bluecard.qld.gov.au/ .
The HSM Compliance Officer will collect your completed application form for submission on your
behalf prior to commencement of your Program or during your O Week Compliance meeting.
The Commission for Children and Young People and Child Guardian determines suitability of an
applicant following lodgment of the application by Bond University. The result will either be a
positive or negative notice about the suitability of the applicant.
A positive notice: issued to the applicant and to the University, which will remain on the student’s
records. If any changes occur to a student’s criminal record, notification must be made to the HSM
Compliance Officer immediately.
A negative notice: if deemed by Blue Card Services that an applicant is unsuitable, this remains valid
indefinitely unless cancelled by Blue Card Services. For privacy reasons the University will only be
advised that the applicant is unsuitable, and reasons for unsuitability will not be revealed to the
University.
Students receiving a negative notice may be prevented from undertaking specific program
placement requirements, which may impact the ability to satisfactorily complete required
placements and continue in the program.
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2.2
NSW working with children (WWCC) – Allied Health students only1
Student that may undertake a placement in NSW are required to obtain a NSW Working with
Children Volunteer Check. This is compulsory for the Doctor of Physiotherapy Students.
There are a number of steps to follow in order to obtain your check:
Website:
http://www.kidsguardian.nsw.gov.au/working-with-children/working-with-childrencheck/volunteers-and-students
Complete the online https://wwccheck.ccyp.nsw.gov.au/Applicants/Application
You will receive an Application Number.
Take your Application Number and proof of your identity to a NSW motor registry or Roads and
Maritime Services (RMS) Office for your application to be activated (use the following web link to
search for alternate locations. https://www.service.nsw.gov.au/service-centre )
The closest location to Bond University is:
Services NSW
13-17 Rivendell Road
Tweed Heads South
Phone: 137 788
Identification: Australian driver’s license or passport and bank card, proof of your Queensland
address OR Campus Accommodation Agreement;
You will receive a letter either by post or email providing a Working with Children Check number.
You must then provide a copy of this letter to the Compliance Officer with your date of birth for
online verification by Bond University.
If you have not received your results within four weeks, please email your details and application
number to newcheck@kids.nsw.gov.au.
The NSW Check is free for students and Physiotherapy students will be asked to provide evidence of
successfully lodging their application, by providing your Application Number or WWCC number and
verification letter, at the O Week Compliance Meeting.
1
Allied health is Physiotherapy and Nutrition & Dietetics only
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2.3
National Criminal Police Checks
2.3.1 Australians, Australian residents and International students:
All students MUST ACQUIRE a National Criminal Police Check (NCPC) also called a national police
check (NPC) using the routes described below to ensure that they have the appropriate clearance to
work with vulnerable people (aged care, children and people with a disability).
On the application please tick the appropriate box: Care, instruction or supervision of children/ Care
of intellectually disabled persons/Aged Care staff/volunteers
A National Police Check name check only (no need for a fingerprint check) is a requisite all programs.
This check is intended to identify people who might, because of convictions such as violence or
sexual offences, put personal safety or health at risk.
As such, prospective students should be aware an NPC identifying ‘Disclosed Court Outcomes’ may
prevent placement opportunities in some organisations and industries as well as potentially limiting
your ability to fulfill aspects of your Program’s curriculum. Furthermore, criminal convictions
involving violence or sexual offences will jeopardise continued enrolment in a Program and/or
employment opportunities after completing the Program. Students with a criminal history should
consult their relevant Registration Board for any restrictions on registration to practice due to their
criminal history.
International Students and Students residing in the Australian Capital Territory (ACT) are required
to obtain their NPC through the Australian Federal Police: http://www.afp.gov.au/what-wedo/police-checks
Students residing in other states of Australia (other than the ACT) are required to:
Either:
1. Visit their local police station to request a NPC (will take 15 working days).
OR
2. Use an accredited broker organization which can be found on the CRIMTRAC website
https://www.crimtrac.gov.au/national-police-checks. Navigate to the National Police
Checks > Information for individuals section and click on the link “Who can organize my
check” to find an accredited organization or broker organization and apply online.
A National Criminal Police Check is valid for 3 years and a copy must be certified by a JP (or similar
person see page 5) and submitted to Bond University at the compliance meeting and the original
must be taken to placement.
More information for international students on the following page…
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2.3.2 International students
AS WELL AS the Australian NPC, an original of one of the following is also required for your
Compulsory Compliance Requirements: (Note: New Zealanders are not considered International
students from the perspective of residency status and they do not need the additional NPC)
1. Police Certificate with no convictions/charges from your home country or any country that
you have resided in (translated into English);
OR
2. A JP (or other recognized person) witnessed Statutory Declaration stating no
convictions/charges and signed in Australia. International Students only NSW Statutory
Declaration
2.4
First aid and CPR certificates
You are required to provide evidence of both qualifications to the HSM Compliance Officer during
your O Week Compliance meeting. The specific qualification requirements are:
•
•
A nationally accredited, “Apply First Aid” (HLTAID003) qualification - valid for three years;
A nationally accredited, “Perform Cardiopulmonary Resuscitation” qualification
(HLTAID001) - valid for one year.
Definition:
•
•
HLTAID003 - First Aid (including CPR) – Provide First Aid and CPR
HLTAID001 – Provide CPR only
Please note the First Aid/CPR certificate must be obtained through an Australian training provider.
Qualifications obtained via an online provider will not be accepted.
It is the student's responsibility to:
•
•
•
Pass and meet the costs of an accredited First Aid/CPR course;
Ensure these qualifications are valid for the duration of the Program
Submit a photocopy and show the original certificate to the compliance officer
Note: If you are a registered Health Practitioner (e.g. RN, Medical Officer, etc.) you ARE STILL
REQUIRED TO SUBMIT a current First Aid and CPR Certificate.
FOR YOUR INFORMATION
•
•
•
•
Australian Red Cross
St John Ambulance (or interstate equivalent)
Queensland Government First Aid Training Providers
Paradise First Aid www.paradisefirstaid.com.au (provides discounts to students)
P a g e | 12
2.5
Specific Placement Requirements
2.5.1 QLD Health – Medical program and other (non-allied health) programs
(See Section ‎1.5 for a list of programs to determine if you are allied health or not)
QLD Health provides a comprehensive online orientation program for students undertaking
placements in the Queensland public health system. Medical program and other non-allied health
program students are required to read and complete the Clinical Placement Orientation
requirements and online training modules.
STEPS TO FOLLOW TO COMPLETE THIS PROCESS:
1. Click on and follow this link: https://www.health.qld.gov.au/employment/clinicalplacement/requirements/students/default.asp
2. Read the whole webpage and follow the instructions and links to online training
3. Complete all the online training (should take ~2-3 hours)
4. PRINT out and complete:
a. “Student Orientation Checklist“ a list of training sections completed;
b. “Student Deed Poll“ OR
c. “Overseas Student Deed Poll“ (International students only)
d. OHS online training modules “Certificates of completion” printed and signed (click
on the
next to each module to find out how to get the certificate).
AT YOUR COMPLIANCE MEETING
Bring copies of all the above documents in RED to submit for compliance.
Note: You will not be permitted to commence your placement in any Queensland Health facility if
you have not completed and signed the orientation documents.
2.5.2 QLD Health – Allied Health programs only2
(See Section ‎1.5 for a list of programs to determine if you are allied health or not)
Queensland Health has a series of online training requirements which all Allied Health Students are
required to complete prior to placement. This content and websites are managed by QLD Health and
are subject to change and may be updated regularly. It is the responsibility of students to check prior
to each placement to ensure compliance. Refresher training of some modules will be required
annually.
STEPS TO FOLLOW TO COMPLETE THIS PROCESS:
1. Click on this link to go to Allied Health Clinical Education and Training:
https://www.health.qld.gov.au/ahwac/html/cet.asp
2. Read the whole webpage and follow the instructions step by step and follow the links to the
various parts of Allied Health Student Training
2
Allied health is Physiotherapy and Nutrition & Dietetics only
P a g e | 13
3. Complete all the training requirements for student placements. (Note this will take some
time ~5-7hrs has been estimated by students from previous years).
a. PRINT out and read the “Allied health student training: A guide for Students”
b. Register on iLearn, and LEO to complete training
c. PRINT out and complete an
i. “Evidence Record of allied health student training“
ii. “Student Orientation Checklist“;
iii. “Student Deed Poll“ OR
iv. “Overseas Student Deed Poll“ (International students only)
v. Allied Health and OHS online training modules “Certificates of completion”
printed and signed (click on the
next to each module to find out how to
get the certificate). TIP: Use the Evidence Record to keep track of which
modules you have completed and PLEASE NOTE only some of the modules
produce certificates.
AT YOUR COMPLIANCE MEETING
Bring copies of all the above documents in RED to submit for compliance.
Note: you will not be permitted to commence your placement in any Queensland Health facility if
you have not completed and signed the orientation documents. You are required to carry the
original documents and submit on the first day of your placement.
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2.5.3 NSW Health – Tweed Hospital
NSW Health Hand Hygiene Module
It is required that in 2nd Year all students allocated to The Tweed Hospital must complete the Hand
Hygiene Australia online module. If you have completed the module previously, you must complete
it again prior to your placement.
(The module is located - http://www.hha.org.au/LearningPackage/medicallearningpackage.aspx)
It will take approximately 10-15 minutes and once completed successfully, it will generate a PDF
certificate. At the end of the questions it asks your name, company – you can either enter Bond
University or The Tweed Hospital.
Please send your PDF certificate PRIOR
tweedstudentcoordinator@ncahs.health.nsw.gov.au
to
your
placement
commencing
to
If you have any queries, please contact Kelly Jenkings on 5506 7797 or Melissa Johnston on 5506
7660.
2.5.4 NSW Health – All facilities
All students attending a placement in NSW Health will be required to comply with the NSW Health
security clearance requirements as well as immunisation and vaccination requirements (information
and instructions regarding immunisation and vaccination requirements are in Section 3).
For further information visit the NSW Government Health – Clinical Placements Information website
http://www.health.nsw.gov.au/careers/student_clearance/pages/default.aspx
Placements in any NSW Health facility cannot commence until a ‘NSW OSV Certificate’ has been
issued which is only done after NSW Health has reviewed your compliance documentation.
You will be asked to show this certificate on the first day of each placement in a NSW Area Health
District or facility if you do not have one you may not attend. You must also ensure your Certificate
is with you at all times whilst on placement. If you have not yet received your Certificate please
ensure you have a copy of your Verification number on you at all times.
ACTION PRIOR TO YOUR COMPLIANCE MEETING
Read the following documents and print and complete the forms:




Follow the link to NSW Health Code of Conduct Policy (Read)
Print and complete “Form 2” and “Form 3“(from the Policy document appendix)
Follow the link to the NSW Code of Conduct Agreement
Print and complete “Code of Conduct”
And for International Students only:


NSW Health Statutory Declaration (this form must be certified by a JP (or similar person)
Print and complete in the presence of a JP or similar person “Statutory Declaration”
P a g e | 15
AT YOUR COMPLIANCE MEETING
Bring copies of all the above documents as required for domestic or international students in RED to
submit for compliance.
FOR YOUR INFORMATION







Clinical Placement in NSW Health (pd2013_015)
NSW Health Notice to Students - Clinical Placement Requirements
Student Risk Assessment to Determine Suitability for Clinical Placement
NSW Health Privacy Manual (pd2005_593)
NSW Health Infection Control Policy (pd2007_036)
NSW Health Policy Directive: HIV, Hepatitis B or Hepatitis C - Health Care Workers
Infected (pd2005_162)
ACCESS AND UNDERSTAND




NSW Health Policy Directive: Occupational Assessment, Screening and Vaccination Against
Specified Infectious Diseases (pd2011_005)
NSW Health Employment Checks - Criminal Record Checks and Working with Children
Checks (pd2013_028)
NSW Health Code of Conduct (pd2015_049)
P a g e | 16
Section 3: Immunisations and Vaccinations
The duties and experiences of students participating in placements will vary according to the
Program in which you are admitted and also the facility in which each placement will occur. As you
prepare to embark on your studies it is important that you understand the risks of infection that may
occur between health care workers (HCW) [students are considered to be health care workers] and
your patients/clients during a placement. HCW have an ethical duty to take all reasonable steps to
protect patients/clients with whom they interact from adverse outcomes including the acquisition of
avoidable infectious diseases.
Guidelines for vaccination against infectious diseases of all Australians, including HCW are available
in the Australian Immunisation Handbook. This document has informed the development of the
HSM Vaccination Policy which will govern your participation in your Program. Consequently, it is
important that you consider or seek advice regarding these important issues before you commence
your program, as they may have an impact on your future career pathways. Students may want to
approach the relevant Registration Board for further information in this regard.
3.1
Immunisation, testing and screening requirements
As a condition of entry into your Program you are required to meet the specific immunisation,
testing and screening requirements provided below and to ensure they are maintained for the
duration of enrolment, unless written exemption has been provided by a Health Care Specialist.
You are advised to take the “HSM Immunisation and Health Record Form“(located in Section 4) with
you, along with the Additional guidelines to assist in completion of the immunisations and
vaccinations (located on page 20) when you consult with your registered medical practitioner or
nurse. You are also advised to undertake all vaccinations and screening (if required) as soon as
possible, as fulfilling some of these requirements may take several months to complete.
In order to demonstrate compliance, separate evidence is required for each item listed and all
evidence must be provided as certified copies of the original documents which will be collected for
your records. Your completed Health Record Form and the supporting evidence will be collected at
your Orientation Week HSM Compliance meeting.
Please refer to Section 3 for the required Immunisations and Vaccinations.
3.1.1. Seasonal Influenza
Influenza vaccinations are only compulsory for Doctor of Physiotherapy students. Placement
facilities notify the Compliance Officer when influenza vaccinations are required for students
studying other programs.
3.1.2 Tuberculosis (TB)
This testing is not usually required (unless requested at a later date) but should be supplied if
available. NOTE: You may be advised by the compliance officer during your first year of study that
TB screening has been requested by NSW Health. Until this request is made screening is not a
requirement. NSW Health require that testing be undertaken at an NSW Health approved provider
and will not accept TB screening from other providers.
P a g e | 17
If you are required to be tested for TB please refer to the Queensland Government Tuberculosis
website or call 1300 367 840 for an appointment at the NSW Facility.
For your information see “List of Countries with a Tuberculosis Incidence of 40 cases per
1000,000 Persons or Greater”.
3.1.3 Additional Vaccination Requirements
Please be aware in certain specialised clinical settings, for example, in transplant, oncology or
neonatal wards, the health facility may require additional vaccinations or other evidence of
protection to ensure that the risk to vulnerable patients is minimised.
3.2
Conscientious Objection
Bond University HSM, Queensland Health and NSW Health do not honour conscientious objection
with regard to vaccination. You should seek the advice from your General Practitioner and notify the
HSM Compliance Officer to clarify any vaccine issues you may have.
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3.3
Exposure Prone Procedures (EPP)
Exposure Prone Procedures (EPPs) are procedures where there is a risk of injury to the student
resulting in exposure of the patient’s open tissues to the blood of the worker. These procedures
include those where the workers hands (whether gloved or not) may be in contact with sharp
instruments, needle tips or sharp tissue (spicules of bone or teeth) inside a patient’s open body
cavity, wound or confined anatomical space where the hands or fingertips may not be completely
visible at all times.
As a HSM student you will be called upon to undertake EPPs ANNUALLY as they are an essential
assessment item that must be passed in order to graduate from your admitted program. You must
therefore understand your responsibilities to protect yourselves as individuals and your
responsibilities to protect patients from the hazards of blood borne and other infectious diseases. In
an effort to protect patients the following has been adopted to minimize the risk of transmission of
Blood-Borne Viruses (BBV).
1. Students are required to complete and sign the Exposure Prone Procedures Declaration
Form and provide the HSM Compliance Officer with a copy during the O Week
Compliance meeting.
2. Students have a professional obligation to undergo serological testing for BBVs annually,
with more frequent testing to be performed if the student has been exposed to an
increased risk of infection, whether occupational or non-occupational.
3. At the commencement of every May semester (for May program intake or January for
January program intake) for the duration of your program you will be required to
provide the HSM Compliance officer a Consultation Note that has been completed and
signed by a registered medical practitioner. The Consultation Note proves that you have
been undertaking annual BBV serology testing and you are fit to conduct EPPs.
4. If a student has been performing EPPs, or if it is likely that they will be called upon to
perform EPPs in their current position, AND his/her BBV status has changed, the student
MUST advise the HSM Compliance Officer or appropriate placement supervisor
immediately. All information provided will be treated as private and confidential and
only referred to on a need to know basis.
5. Infected students must seek advice from a registered medical practitioner with
appropriate expertise or an infectious diseases physician, in regard to their clinical
assessment and medical care and seek advice from that practitioner about their
continued involvement in direct patient care. Evidence of counselling must be submitted
to the HSM Compliance Officer by completing and submitting a Consultation Note.
6. Students who are unaware of their current status or do not undertake annual serology
testing will not be able to participate in EPPs.
7. Students who are BBV positive MUST NEVER PERFORM EXPOSURE PRONE PROCEDURES.
What is a Blood-Borne Virus?
Blood-borne viruses (BBVs) are those viruses that are transmitted from the blood of one person to
the blood of another person. Of particular concern are Hepatitis B Virus (HBV), Hepatitis C Virus
(HCV) and Human Immunodeficiency Virus (HIV).
P a g e | 19
3.4
Hepatitis B Vaccine Non-Responders
It is not uncommon for a minority of students (5% to 10%) to not respond to Hep B vaccination. This
has potentially significant implications as such students remain unprotected from Hep B and do not
meet the Queensland and NSW Health requirements for study in their health facilities.
Non-responders should be aware of the risk of infection and recommended management in the
event of potential exposure. They are also encouraged to discuss risks and post-exposure treatment
with their GP or an Infectious Disease specialist.
Non-responders are required to complete and provide the Non-responder to Hepatitis B vaccine –
Acknowledgement Form (In Section 4) to the Compliance Officer during your Orientation Week
Compliance meeting or prior to week 5 of your 1st semester.
Please note: ACCELERATED HEP B COURSE WILL NOT BE ACCEPTED
3.5
Vaccine reactions
HSM will make all reasonable effort to place a student who has a severe/allergic vaccine reaction
and is unable to complete the course of vaccination, but placement cannot be guaranteed in this
situation which may impact on your program progression. It is recommended that a medical
practitioner be consulted to discuss any allergy/reaction including alternative vaccine brands.
P a g e | 20
3.6 Additional guidelines to assist in completion of the immunisations
and vaccinations
Infectious
diseases
Hepatitis B
Acceptable evidence to demonstrate protection
1. Evidence of a completed age appropriate course of
hepatitis B vaccine and post vaccination test for HepBsAb ≥
10mIU/mL.
•
•
Use of the minimum interval between doses is acceptable i.e.
one month between doses 1 and 2, three months between
doses 2 and
3. The post vaccination blood test should be done one month
after the 3rd dose of vaccine.
Use of accelerated schedules (e.g. 0, 7, 21 days) or any
schedule of lesser duration than the above recommended
dosage schedule is not appropriate and the person will not
be considered to have evidence of protection until a 4th
dose of vaccine at 12 months is administered.
OR
2. Vaccinated applicants without documented evidence of
vaccine doses may not need to recommence the vaccination
course. The applicant must document Hep B vaccine history,
undergo serological testing (HepBsAb and HepBsAg) and then
obtain a booster dose.
Hep B non-responder
If HepBsAb is <10mIU/mL after completion of a full course of Hep
B vaccinations, please undertake testing for HepBsAg levels (and
attach results).
If HepBsAg results are negative the student will need to receive
further vaccinations. Please commence either:
• Another course of 3 x vaccinations (with at least one month
between each dose);
OR
• a stat double dose of Hepatitis B vaccine.
A serology should then be taken four weeks after the 3rd /
double stat dose. If results are again <10mIU/mL, student to
complete Appendix A: Hepatitis-B Non-Responder.
If HepBsAg results are positive the student needs to exclude
themselves from exposure prone procedures, and refer to the
relevant policies in the attached Exposure Prone Procedures
Declaration Form. Please attach pathology results.
Non-responders are encouraged to discuss risks and postexposure treatment with their GP or an Infectious Disease
specialist.
Acceptable
vaccine brands
Engerix B;
H-B Vax II
OR Twinrix
P a g e | 21
Infectious
diseases
Acceptable evidence to demonstrate protection
Measles,
Mumps,
Rubella
(MMR)
1. Documented evidence of 2 doses of MMR vaccine at least
one month apart;
OR
2. Documented evidence of positive IgG for measles and
mumps and rubella.
Acceptable
vaccine
brands
Priorix
MMR
•
Diphtheria,
Tetanus,
Pertussis
(dTpa)
Varicella
(Chickenpox)
A statement of a history of measles, mumps or rubella is not
accepted as evidence of protection.
• Post- vaccination serological testing for MMR is not
recommended and should not routinely be undertaken.
• Tuberculin skin testing must be delayed for a month after
this vaccine.
One documented dose of adult dTpa vaccine.
•
Serological testing for dTpa is not recommended, and will not
be considered as evidence of protection.
• Recorded dose must be after 2004.
• The batch number MUST be recorded.
1. Documented evidence of age appropriate varicella
vaccination.
OR
2. Documented evidence of a positive varicella IgG blood test;
OR
3. Statement of a history of chickenpox; or documentation of
physician-diagnosed shingles;
•
Tuberculosis
Influenza
Vaccination
Adacel
Adacel Polio
Boostrix
Infanrix IPV
Varilrix
Varivax
Persons with a negative or uncertain history of varicella
should have serological testing to identify if vaccination is
required.
• Persons with negative IgG require 2 doses of vaccine at least
a month apart.
• Post vaccination serology is not recommended. The available
tests are not always sufficiently sensitive to detect low
antibody levels following vaccination.
• Tuberculin skin testing must be delayed for a month after this
vaccine.
Students required to complete Forms 2 and 3 TST (Mantoux)
http://www0.health.nsw.gov.au/policies/pd/2011/pdf/pd2011_0
05.pdf.
Your information will be sent to NSW Health for review. After
review if deemed necessary you will be required to undergo
Tuberculin skin testing at a Government recognised TB clinic.
One documented dose of seasonal influenza vaccination for each
year of enrolment in your Program (All DPhty students require
this vaccination for placements and recommended for other
programs).
P a g e | 22
Infectious
diseases
Acceptable evidence to demonstrate protection
Acceptable
vaccine
brands
HIV & Hep C Student must be aware of status having been tested in the past
12 months. For students that will be preforming Exposure
Prone Procedures, please read the EPP section of this
document and also sign the EPP form in the Documents to
Complete.
Optional
Hepatitis A and Polio are both optional vaccines. However, it is
vaccines
recommended you undergo vaccination.
3.7.
Compulsory compliance costs
There are various compulsory compliance requirements that students must obtain. Bond University
endeavours to keeps associated costs to a minimum.
REQUIREMENT
APPROXIMATE COST
IMPORTANT DETAILS
Serology
Free on campus
Free through on-campus clinic
Elsewhere may cost $60 - $150
Hepatitis B
$25 per vaccination
A series of 3 vaccinations
Measles, Mumps and
Rubella (MMR)
$30 per vaccination
A series of 2 vaccinations
Diphtheria, Tetanus &
Pertussis (dTpa)
$40 per vaccination
1 vaccination only
$70 per vaccination
A series of 2 vaccinations
$25 per vaccination
1 vaccination per year
Varicella (Chicken Pox)
Seasonal Influenza
Vaccination
Tuberculosis Screening
(Mantoux)
National Police Check
$49
Blue Card (student)
Free for initial application &
renewals
CPR/First Aid
$150 for a combined course.
$56 to renew CPR only
Polio/dTpa
$75
To be organized by the student
upon request from NSW Health
Valid for 3 years
Valid for 3 years
First Aid valid for 3 years CPR
valid for 1 year
Valid 10 years [adult booster]
Bond University Campus Medical Clinic (07) 5595 4043
Notes:


Costs may vary between providers.
Pricing is based on Bond University Health Services estimates as of February 2014.
P a g e | 23
3.8
Website addresses
3.8.1 Immunisations and vaccinations
•
•
•
Australian Immunisation Handbook
http://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home
QLD Health Policy for Immunisation of Health Care Workers
http://www.health.qld.gov.au/qhpolicy/docs/gdl/qh-gdl-321-9.pdf
NSW Health Policy Directive: Occupational Assessment, Screening and Vaccination Against
Specified Infectious Diseases
http://www0.health.nsw.gov.au/policies/PD/2011/PD2011_005.html
3.8.2 Working with children checks
•
•
•
•
•
•
•
Queensland Government Blue Card Services http://www.bluecard.qld.gov.au/
Victoria Department of Justice http://www.workingwithchildren.vic.gov.au/
ACT Government Justice and Community Safety
http://www.ors.act.gov.au/community/working_with_vulnerable_people_wwvp
Northern Territory Working with Children
http://www.workingwithchildren.nt.gov.au/index.html
Western Australia Working with Children http://www.checkwwc.wa.gov.au/checkwwc
South Australia Department for Communities and Social Inclusion
http://www.dcsi.sa.gov.au/services/screening
Tasmanian Government Department of Justice Working with Children http://www.justice.tas.gov.au/working_with_children
Bond University Working with Children Policy (COR 1.02)
http://www.bond.edu.au/student-resources/student-related-university-policies/BD3_026397
3.8.3 National criminal police checks
•
•
Australian Federal Police (AFP) http://www.afp.gov.au/what-we-do/police-checks/national-policechecks
Queensland Police Station Locator
http://www.police.qld.gov.au/stationlocator/station_locator.asp
3.8.3 First aid & CPR qualifications
•
•
•
Australian Red Cross
http://www.redcross.org.au/firstaid.aspx
St John Ambulance
http://www.stjohn.org.au/index.php?option=com_content&view=article&id=14&Itemid=24
Queensland Government First Aid Training Providers
https://bookings.qld.gov.au/services/firstaid/
P a g e | 24
3.8.4 Queensland Health
•
•
•
•
QLD Health Student Orientation http://www.health.qld.gov.au/employment/clinicalplacement/requirements/student- orientation/default.asp
QLD Health Student Orientation Checklist
http://www.health.qld.gov.au/employment/clinicalplacement/requirements/student- orientation/default.asp
QLD Health Student Deed Poll http://www.health.qld.gov.au/employment/clinicalplacement/requirements/student- orientation/default.asp
3.8.5 New South Wales Health
•
•
•
•
•
•
NSW Health Code of Conduct Policy
http://www0.health.nsw.gov.au/policies/pd/2015/pdf/PD2015_049
.pdf
NSW Health Privacy Manual
http://www0.health.nsw.gov.au/policies/pd/2005/PD2005_593.ht
ml
NSW Health Infectious Disease Control Guidelines
http://www.health.nsw.gov.au/policies/pd/2007/PD2007_036.ht
ml
NSW Health Directives & Guidelines
http://www.health.nsw.gov.au/policies/pd/2005/pd2005_162.ht
ml
NSW Health Clinical Placement Information
http://www.health.nsw.gov.au/careers/student_clearance/pages/default.aspx
P a g e | 25
Section 4:
PRINT ALL THE FORMS AFTER THIS PAGE
SINGLE SIDED PRINTING PLEASE
Remember to click on the links in the electronic copy of the following
few pages to find the documentation from the two Health
Departments (QLD and NSW). These must also be included in your
compliance submissions.
Use the checklist as a guide for what to bring to your Compliance
meeting.
If you have any questions please email or call:
HSM Compliance Officer
HSMCompliance@bond.edu.au
+61 7 5595 1760
P a g e | 26
Compulsory Compliance meeting checklist
Please use the table summarising the Compliance Requirements for HSM Programs
on page 4 as a guideline for what is required for your program.
Security, Compliance and Orientation Documents
 Completed QLD Blue Card Application with sufficient identification or Blue card letter/card. (See
Section ‎2.1)
 Certified copy & Original of Australian National Criminal Police Check (See Section ‎2.3)
 Photocopy & original of current CPR and/or First Aid Certificate (See Section ‎2.4)
 QLD Health Student Orientation Checklist – printed & signed (See Section ‎2.5)
 QLD Health Student Deed Poll – printed & signed (See Section ‎2.5)
 QLD Health Overseas Student Deed Poll – alternative Deed Poll for International Students –
printed & signed (See Section ‎2.5)
 QLD Health Occupational Health & Safety certificates– printed & signed (See Section ‎2.5)
 Allied Health only: (See Section ‎2.5)

NSW Working with Children Check application number or WWCC letter

QLD Health Evidence Record for Allied Health Student Training – printed & signed

QLD Health Allied health student training certificates – printed & signed
 Bond University Permission to Disclose Information to NSW Health (See Section 4)
 NSW Health Code of Conduct Agreement (‎2.5.4)
 International students only (See Section ‎2.3.2)

Certified copy & Original of Overseas Police Check OR

Statutory Declaration of no criminal convictions
 NSW Health Hand Hygiene Certificate (See Section ‎2.5.3) (only complete in Year 2 or subsequent years)
Immunisation and Vaccinations (Section 4)
 HSM Immunisation and Health Record Form - completed by a registered medical practitioner or
nurse is ESSENTIAL
 Certified copies of the all required supporting evidence i.e.

Hepatitis B: Vaccine evidence INCLUDING batch number AND serology

Measles; Mumps & Rubella (MMR): EITHER MMR vaccine evidence x 2 OR POSITIVE
serology

dTPa: Vaccine evidence INCLUDING batch number

Varicella: EITHER Vaccine evidence x 2 OR POSITIVE serology OR confirmed history
Not compulsory

Tuberculosis: If testing has been done in the past please provide this. (Ensure any
evidence includes information on service provider.)
 NSW Health TB assessment tool FORM 2 (See Section ‎2.5.4)
 NSW Health Student Declaration/Undertaking FORM 3 (See Section ‎2.5.4)
 HSM Exposure Prone Procedure Declaration Form (See Section 4)
 HSM Vaccination Evidence Assessment – Hepatitis B (required if batch numbers or primary
vaccination details are not available) (See Section 4)
 HSM Non-responder to Hepatitis B vaccine – Acknowledgement (only if required) (See Section 4)
Doctor of Physiotherapy Only
 Seasonal Influenza – Provide evidence of vaccination (recommended for all programs)
P a g e | 27
Permission to disclose additional information to NSW Health
In order to arrange your clinical placement, we will provide NSW Health with the
following essential information about you:
- Student Identification Number
- First name and last name
- Health discipline
- Pathway of study
- Gender
Privacy laws allow us to provide NSW Ministry of Health with this information about
you as it is directly related to your clinical placement.
In addition to this information, NSW Health requests the following information
to be provided for students who attend NSW Health facilities for clinical
placement:



Year of birth
Indigenous status
Student funding source (i.e. whether you are a HECS or International student)
This information will be used by NSW Ministry of Health to assist with workforce
planning. Please complete the details below:
I consent to the above information being provided to NSW Ministry of Health to assist
with workforce planning:
Signature:
Name:
Print)
Student ID:
Date:
(Please
P a g e | 28
HSM Immunisation and
Health Record Form
Information Summary
The forms in this section relate to Immunisations and Vaccinations.
Please ensure your medical practitioner completes the vaccination history record form AND
supplies supporting evidence for‎each‎of‎the‎vaccinations‎and‎serology’s‎which‎are‎recorded
in the form.
Please provide certified copies of all supporting evidence at your compliance meeting.
NOTE:‎‘Accelerated‎course‎of‎Hepatitis‎B‎schedule IS NOT ACCEPTED

Hepatitis B
Age appropriate vaccine evidence AND serology

Measles
POSITIVE Serology OR vaccine evidence x 2

Mumps
POSITIVE Serology OR vaccine evidence x 2

Rubella
Serology OR vaccine evidence x 2

dTpa
Vaccine evidence INCLUDING batch number

Varicella
Vaccine evidence x 2 OR POSITIVE serology OR confirmed history

Tuberculosis
NOT COMPULSORY. However if TB screening (Mantoux test) results
are available please provide them. Unless requested during course of degree.

NSW Health

NSW Health Student Declaration/Undertaking LINK: (CLICK THIS LINK TO GO THERE: Form 3)

HSM Exposure Prone Procedure (EPP) Declaration Form –attached
TB assessment tool (CLICK THIS LINK TO GO THERE: Form 2)
o
HIV – Awareness of current status having been tested in the last 12 months
o
Hepatitis C – Awareness of current status having been tested in the last 12 months

HSM Vaccination Evidence Assessment – Hepatitis B (only if required) – attached

HSM Non-responder to Hepatitis B vaccine – Acknowledgement (only if required) - attached
Doctor of Physiotherapy Only
Seasonal Influenza required provide evidence of vaccination (although it is
recommended for all programs)
Page 1 of 7
HSM IMMUNISATION AND HEALTH RECORD FORM
STUDENTS DETAILS
Name
DOB
ID number
I give consent for the doctor / registered nurse identified below to complete this form in relation to my
health information. I understand the cost associated with any required blood tests and vaccines need to
be met by myself (the student).
Signature
Date
HOW TO FILL OUT THIS FORM
1.
Please complete Sections I to VIII of the Health Record Form
2.
Attach pathology results and vaccination supporting evidence for all sections
3.
Provide the student with the completed form and supporting evidence
4.
Contact the Compliance Officer if you have any queries on (07) 5595 1760
NOTE:
Vaccine batch numbers are recommended, however are not essential to confirm immunity. Where batch
numbers are not available please provide alternative evidence of vaccination such as a detailed letter
with the Practice letterhead, or serological results to support immunity. The exception is dTpa, for which
serological results will not be accepted and a batch number is required to confirm adequate immunity.
An accelerated Hepatitis B schedule is not accepted.
The purpose of this form is to summarise the student’s vaccination status for diseases outlined in
NSW Health and QLD Health Requirements. Please include ALL vaccination records / evidence and
serology results as supporting evidence for the information entered here.
COMPLETING DOCTOR / REGISTERED NURSE DETAILS
NAME
Qualification/Registration
No.
Section(s) of the Form
Completed (I-VIII)
Practice Name
Suburb/State
Phone Number
Signature
Updated December 2015
Date
Page 2 of 7
SECTION I — HEPATITIS B (HBV)
PART A: Primary vaccination details
PRIMARY Vaccination Details: If primary vaccination details are unavailable, please go to Part B.
Please attach evidence for both vaccine brand and batch number
Date Administered:
Vaccine Brand:
1st Dose
D
D
M
M
Y
Y
2nd Dose
D
D
M
M
Y
Y
3rd Dose
D
D
M
M
Y
Y
Batch Number”
Antibody Results: HBsAB
Date
D
D
M
M
Y
Y
Serology to be taken 4 weeks after final vaccine dose- Please
attach evidence.
HbsAb Level* (mIU/mL
mIU/mL
*If level is <10mIU/mL please go to Part C
PART B: Primary vaccination details not available
If primary vaccination details are not accessible and HBsAbs are positive, it is recommended that the student
receive a booster dose after serological testing to ensure lifelong immunity. Please attach serology results
and evidence of vaccine.
ALSO Student to complete Appendix A: Assessment of Hep B Evidence of Protection when vaccination
documentation is not accessible and antiHBs is positive.
Post Serology Booster: Please attach evidence for both vaccine brand and batch number
Date Administered:
BOOSTER
D
D
M
M
Vaccine Brand:
Y
Batch Number
Y
PART B: Primary vaccination details not available
If HBsAb is <10mIU/mL after completion of a full course of Hep B vaccinations, please undertake testing
for HBsAg (Antigen) levels (and attach results).
IF HBsAg RESULTS ARE NEGATIVE:
The student will need to receive further vaccinations. Please commence either:

Another course of 3 x vaccinations (with at least 1 month between each dose); OR

A stat double dose of Hepatitis B vaccine
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~OR ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
IF HBsAg RESULTS ARE POSITIVE:
The student needs to exclude themselves from exposure prone procedures, and refer to the relevant
policies in the attached Exposure Prone Procedures Declaration Form. Please attach pathology results.
Updated December 2015
Page 3 of 7
SECTION II — MEASLES, MUMPS & RUBELLA (MMR)
The student must meet the criteria in ONE of the following sections:
Positive Serology Results (Y or N): Please note results must be positive. Low or Equivocal levels will not
suffice as appropriate evidence of protection. If low or equivocal levels are shown for any of the serology
results please administer a booster dose.
Positive Serology Measles
Positive Serology Mumps
Positive Serology Rubella
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~OR ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Evidence of 2 x MMR Vaccines: *MMR vaccines to be administered at least 4 weeks apart. Please attach
vaccination records.
Date Administered:
Vaccine Brand:
1st Dose
D
D
M
M
Y
Y
2nd Dose
D
D
M
M
Y
Y
Batch Number”
SECTION III — DIPTHERIA, TETANUS & PERTUSSIS (dTPa)
The student must have evidence of ADULT vaccination:
The dTpa vaccine must have an accompanying batch number, and have been administered after 2005 to
be considered appropriate evidence of protection. Check that it contains Pertussis please.
Serology results are NOT accepted as evidence of protection. Please attach vaccination records.
Date Administered:
D
D
M
M
Vaccine Brand:
Y
Batch Number”
Y
SECTION IV— VARICELLA
PART A: Primary vaccination details
Evidence of 2 x Varicella vaccines: *Varicella vaccines to be administered at least 4 weeks apart. Please
attach vaccination records.
Date Administered:
Vaccine Brand:
1st Dose
D
D
M
M
Y
Y
2nd Dose
D
D
M
M
Y
Y
Batch Number”
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~OR ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Serological Evidence of Immunity: Date of positive varicella IgG:
Date
D
D
M
M
Y
Y
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~OR ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
History of Chickenpox or Shingles: Approximate year of infection.
Updated December 2015
Page 4 of 7
SECTION V — TUBERCULOSIS (TB) SKIN TESTS
REQUIRED ONLY IF advised by NSW Health:
This evidence is not automatically required, during the first year of the medical program if it is required by
NSW Health these tests will be requested on a case by case basis. However if the information/results are
available please supply them here. Please attach appropriate supporting evidence.
Date of Mantoux Reading:
D
D
M
M
Y
Result (mm)
Y
If elected, date of BCG vaccine:
D
D
M
M
Y
Y
SECTION VI— INFLUENZA (Recommended NOT Mandatory
Evidence of seasonal influenza:
This evidence is not automatically required, during the first year of the medical program if it is required by
NSW Health these tests will be requested on a case by case basis. However if the information/results are
available please supply them here. Please attach appropriate supporting evidence.
Date administered:
D
D
M
M
Vaccine Brand:
Y
Y
SECTION VII – RECOMMENDED VACCINES
The following vaccines are recommended, however are not mandatory for placements.
EVIDENCE ATTACHED (Please tick if yes):
HEPATITIS A
Positive serology results OR evidence of administration of 2 doses of vaccine
POLIO
This can be administered with your dTpa vaccine (Boostrix IPV)
Updated December 2015
Page 5 of 7
VACCINATION EVIDENCE ASSESSMENT
(Hepatitis B)
STUDENT NAME:
STUDENT DOB:
STUDENT ID NUMBER:
This form is to be used for assessment of Hepatitis B evidence of protection when vaccination documentation is not accessible and antiHBs is positive
The policy for Hepatitis B (Hep B) protection is based on ensuring students have long-term/
lifelong protection for their career, not just for their studies.
If a student has provided a positive Hep B antiHBs serology (antiHBs ≥10mIU/mL) however they
cannot provide documentation of their age appropriate Hep B vaccination course they will
firstly be assessed by the HSM Compliance Officer whom must be convinced that the antiHBs
result supports that they have had a complete course of vaccination. A booster dose of Hep B
vaccine (post blood test) may be recommended.
The positive Hep B serology along with this form will be forwarded to an experienced
Occupational Vaccination clinician for final assessment.
Please answer the following questions with as much detail as possible for assessment:
1.
When did you have your hepatitis vaccination?__________________________________
2.
Who administered the vaccine? _______________________________________________
3.
Why were you vaccinated? __________________________________________________
4.
How many doses do you recall having? _________________________________________
5.
What was the timing between doses of vaccine? _________________________________
6.
What was the timing between vaccination and blood testing? ______________________
7.
Why can’t you produce documentation of vaccination? ____________________________
8.
Other relevant information:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Updated December 2015
Page 6 of 7
NON-RESPONDER TO HEPATITIS B
VACCINE-ACKNOWLEDGEMENT
STUDENT NAME:
STUDENT DOB:
STUDENT ID NUMBER:
STUDENT DECLARATION
I do not have adequate post-vaccination hepatitis B antibodies detected and
acknowledge that:
1.
I have read and understand the information in relation to hepatitis B on the
in the Australian Immunisation Handbook and also the NSW Health website;
2.
I am aware of my risk of hepatitis B infection and understand that I should
discuss risks and prevention with a GP or Infectious Disease Specialist prior to
my placement;
3.
I am aware of the recommended management in the event of a potential
exposure to hepatitis B, including the recommendations for administration
of hepatitis B immunoglobulin (HBIG);
4.
I understand that if I undertake exposure prone procedures (EPPs)
throughout the course of my study that I have a responsibility to have regular
hepatitis B screening at least annually and after any blood or body fluid
exposure.
___________________________
Signature
___________________________
Date
This form has been appropriated in accordance with recommendations from the Australian Immunisation Handbook
10th Edition) (http://www.health.gov.au/internet/immunise/publishing.nsf/Content/handbook10-4-5) and NSW Health
Policies.
Updated December 2015
Page 7 of 7
EXPOSURE PRONE PROCEDURES
DECLARATION FORM (EPP)
STUDENT NAME:
STUDENT DOB:
STUDENT ID NUMBER:
Exposure Prone Procedures (EPPs) are procedures where there is a risk of injury to the student resulting in exposure of the
patient’s open tissues to the blood of the worker. These procedures include those where the workers hands (whether
gloved or not) may be in contact with sharp instruments, needle tips or sharp tissue (spicules of bone or teeth) inside a
patient’s open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible
at all times.
As a HSM student you will be called upon to undertake Blood Borne Virus screening ANNUALLY as it is an essential
compliance requirement that must be monitored in order to ensure progression in your program. You must therefore
understand your responsibilities to protect yourselves as individuals and your responsibilities to protect patients from the
hazards of blood borne and other infectious diseases. In an effort to protect patients students must read, understand and
sign the below Declaration:
STUDENT DECLARATION
By signing this declaration I am acknowledging that:
1.
I agree to undergo serological testing for HIV and HCV annually, with more frequent testing to be performed
if I have been exposed to an increased risk of infection, whether occupational or non- occupational;
2.
As directed by the Faculty of Health Sciences & Medicine each year for the duration of my program I agree to
provide the HSM Compliance officer with the completed form that has been signed by a registered medical
practitioner/ registered nurse and proves that annual BBV serology testing has been conducted.
3.
If my BBV status has changed I agree to contact the HSM Compliance officer or Manager, Clinical Placements to
arrange a confidential meeting to discuss my exclusion from EPP’s and the possibility of alternative clinical
assessments;
4.
I agree to seek professional medical advice if infected or if I become infected with a BBV;
5.
I understand that by failing to be aware of my current infection status I am committing professional misconduct and I
will not be able to participate in EPP’s;
6.
I will NOT undertake EPP’s if infected or if I become infected with a BBV;
7.
All information I have provided is true and correct.
I give consent for the doctor / registered nurse identified below to complete this form in relation to my
Health information. I understand the cost associated with any required blood tests and vaccines need to be
met by myself (the student).
___________________________
Signature
___________________________
Date
**IMPORTANT: The below section must be completed by a registered General Practitioner or registered Nurse (Note: the
doctor/nurse must not be a relative or someone with whom you have a close personal relationship)
HUMAN IMMUNODEFICIENCY VIRUS & HEPATITIS C (HIV & HCV)
Students must be aware of their status, however they are not mandated to provide evidence of their status to the
This student is aware of their infectious status with regards to the HIV & HCV, and any subsequent implications on their ability
to perform EPPs.
Date of HIV testing:
NAME
M M
/
Y Y Y Y
Date of HCV testing
M M
Signature
Updated December 2015
Y Y Y Y
QUALIFICATION /REGISTRATION No.
Sections of the form completed
Suburb / State
Phone Number
**
Practice Name
/
Date