COVID-19 Vaccine Rollout
Eligibility Declaration Form
I,
(name)
(Name and address of
person receiving the
vaccine)
(address)
confirm that I meet one or more of the below criteria:
1.
I am aged 40 years or older
2.
I am employed in an eligible occupation
3.
I am a household contact of a quarantine or border worker
4.
I am a resident of a residential aged care facility or living in a disability care facility
5.
I am a person with a specified underlying medical condition, with significant disability or who
is a National Disability Insurance Scheme (NDIS) participant
6.
I am a carer of a person with a specified underlying medical condition, with significant
disability, who is a NDIS participant or who is elderly
I confirm that the statement in this form is true.
Signature of person receiving the
vaccine:
Date:
(OR, if the vaccine recipient is unable to sign:) I confirm that I am the patient’s legal guardian or
substitute decision-maker, and I confirm that the statement in this form is true.
Guardian/substitute decisionmaker’s name:
Guardian/substitute decisionmaker’s signature:
Date:
Eligibility Declaration Information
Use the COVID-19 Vaccine Rollout – Eligibility Declaration Form when you need to provide evidence
that you are eligible for COVID-19 vaccination and you do not have other evidence.
Other evidence you can use to show that you are eligible for COVID-19 vaccination includes:
1.
standard form of identification (e.g. drivers licence, passport) indicating you are aged 40 years
or older
2.
government issued document with date of birth (e.g. Centrelink, Medicare, Department of
Veterans Affairs) indicating you are aged 40 years or older
3.
a current work ID card showing employment at an eligible occupation
4.
a letter from your employer confirming that you are currently employed in an eligible
occupation
5.
for household contacts of a quarantine / border worker, proof of occupation of the quarantine /
border worker and evidence to demonstrate you live at the same residential address. For
instance, this could include: bills or rates notices with both of your names and address, or
separate documentary evidence that shows each of your names while showing the same
address
6.
a letter from your aged or disability residential care provider
7.
details to enable the vaccine provider to access your MyHealth Record, if you have one
8.
a referral from your GP or treating specialist confirming that you have a specified underlying
medical condition
9.
proof in the form of an alternative medical record that is dated within the last 5 years which
shows that you have a specified underlying medical condition. This includes:

a printout of your medical history as recorded in your clinical records – i.e. your
patient medical summary as printed out from your GP’s practice

a printout of your chronic disease care plan from your GP

a discharge summary from a hospital or other medical facility

a script in your name for a medication that you have been prescribed to treat one or
more of the relevant medical conditions or one or more of the procedures in the form
attached.
10.
a condition-specific identifier that you have been issued with, such as a National Diabetes
Services Scheme membership card
11.
documentation confirming you are a carer
12.
travel exemption letter from the Australian Border Force which includes a statement saying
you are eligible for COVID-19 vaccination
If you cannot provide any of the above as evidence of your eligibility, you may use the Eligibility
Declaration Form attached. Note that for eligibility due to travel exemption, the only form of evidence
acceptable is the travel exemption notification from the Australian Border Force as outlined above.
If you are eligible for vaccination because you are an Aboriginal or Torres Strait Islander
person, verbal self-identification is the only evidence needed. You do not need to complete the
Eligibility Declaration Form.
People aged between 18-59 years can choose to receive the AstraZeneca vaccine:
 following an appropriate assessment of suitability by a qualified health professional
 if they provide verbal or written consent.
If you choose this option, you will need to provide evidence that you are aged 18 years or older.
Instructions to complete the Eligibility Declaration Form
To complete the Eligibility Declaration Form, you must:

confirm that you are eligible for COVID-19 vaccination. More information about
people who are eligible for COVID-19 vaccination is available at www.health.gov.au
by searching for ‘When will I get a COVID-19 vaccine.’

complete the details on the first page of this document. You can do this either on your
computer, or other electronic device, or by hand.

sign the form and bring it with you to your appointment to receive the vaccine.
If the person receiving the vaccine is not capable of completing and signing the form themself, a legal
guardian or substitute decision maker (e.g. someone acting under an enduring power of attorney) can
complete the form on their behalf.
Last Updated: 19 July 2021