Model Document: Screening Questionnaire & Medical Practitioner Form for HCW Immunisation
v1.0 June 2014
Screening Questionnaire
and Medical Practitioner Form
for the assessment of immune status for vaccinepreventable infections in Health Care Workers
(including blood borne virus screening questions
and contact details for tuberculosis screening)
Instructions for Health Care Workers: Please complete as much of this form as you are
able. Take this form and any records you have of vaccinations and blood test results to your
doctor to verify your immune status. Where “Documentation required” is stated, this refers
to original or valid copies of vaccination records or blood test results.
June 2014
Acknowledgements: Many of the questions in this screening questionnaire have been adapted, with permission, from the
Flinders University Health Advisory Booklet for Health Profession Students, School of Medicine, 2013, available from
http://www.flinders.edu.au/medicine/fms/sites/gemp_promo/documents/Health%20Advisory%20Booklet.pdf
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Model Document: Screening Questionnaire & Medical Practitioner Form for HCW Immunisation
v1.0 June 2014
PART 1: VACCINE PREVENTABLE DISEASES
CHICKENPOX (VARICELLA-ZOSTER VIRUS)
Have you had chickenpox in the past? Documentation not required.
 YES …GO TO DIPHTHERIA and TETANUS

You are considered to be immune to chickenpox and do not need to take further action.
OR
 NO or UNSURE


You need to have a blood test (IgG to varicella-zoster virus) to see if you are immune to
chickenpox.
If the blood test result shows you are not immune, you need to have two doses of varicella
vaccine given at least 4 weeks apart. You do NOT need to have a blood test following this
vaccination to test for immunity.
DIPHTHERIA, TETANUS and PERTUSSIS
Have you had a booster dose of a diphtheria/ tetanus/ pertussis toxoid-containing vaccine (e.g. dTpa)
in the last 10 years? Documentation required.
 YES …GO TO HEPATITIS A
 You are considered to be immune to diphtheria, tetanus and pertussis.
 Please show your doctor the documentation of your most recent booster dose.
OR
 NO or DON’T KNOW


You need to have a booster dose of a diphtheria/ tetanus/ pertussis-containing vaccine (e.g.
dTpa vaccine).
There is no reliable blood test to check for immunity to diphtheria or tetanus or pertussis.
HEPATITIS A





If you have had two hepatitis A vaccines in the past, at least 6 months apart, you are
considered to be immune to Hepatitis A …GO TO HEPATITIS B
If you were born before 1950 OR spent your early childhood in hepatitis A endemic areas,
including Indigenous Australian communities OR have had an unexplained previous episode
of hepatitis or jaundice, you should consider having a hepatitis A blood test to check your
immune status as you may already be immune.
If you are not already immune, hepatitis A vaccine is strongly recommended for health care
workers, including student HCWs, who work in remote Indigenous communities or with
Indigenous children.
If you are not already immune, hepatitis A vaccine may be considered by all other HCWs,
including student HCWs. Please discuss Hepatitis A vaccine with your doctor.
If Hepatitis A vaccine is recommended, it may be given along with Hepatitis B vaccine for
those who are not immune to both infections. See HEPATITIS B for the option of combined
Hepatitis A and B vaccination.
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Model Document: Screening Questionnaire & Medical Practitioner Form for HCW Immunisation
v1.0 June 2014
HEPATITIS B
Have you completed a full course of hepatitis B vaccine (either 3 doses OR two doses if given at
secondary school)?
AND
Have you had a blood test to confirm immunity (Hepatitis B surface antibody [anti-HBs]  10
mIU/mL)? Documentation required.
 YES to BOTH questions
…GO TO INFLUENZA
 You are considered to be immune to hepatitis B
 Please provide documentation of the blood test result confirming immunity.
OR
 NO or DON’T KNOW




You need to have blood tests to assess your immune status for hepatitis B. Please discuss
these tests with your doctor before and after the tests are done.
If the blood tests show that you have immunity to hepatitis B you do not need to take
further action.
If the blood tests show that you are Hepatitis B surface antigen negative and do NOT have
immunity to hepatitis B, you will need to have 3 doses of hepatitis B vaccine at 0, 1 and 6
months, followed by a blood test 4-8 weeks after the last vaccine to check for immunity.
See also HEPATITIS A for the option of combined Hepatitis A and B vaccination.
If the blood tests show you are positive to Hepatitis B surface antigen you should seek
confidential medical and career advice from an infectious diseases specialist and not
undertake any exposure prone procedures.
INFLUENZA


Annual vaccination with the seasonal influenza vaccine is required.
Please keep your influenza vaccination record so that you can produce it if requested.
MEASLES
Were you born in Australia before 1966?
 YES
You are considered immune to measles …GO TO MUMPS
Do you have evidence of vaccination with at least 2 doses of a measles-containing vaccine (e.g.
measles-mumps-rubella [MMR] vaccine)? Documentation required.
 YES
You are considered immune to measles. Please show your doctor the
documentation to verify your immune status …GO TO MUMPS
Do you have evidence of immunity to measles infection (e.g. blood test results)? Documentation
required.
 YES
You are considered immune to measles. Please show your doctor the
documentation to verify your immune status …GO TO MUMPS
If NO, go to next page...
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Model Document: Screening Questionnaire & Medical Practitioner Form for HCW Immunisation
v1.0 June 2014
 NO or DON’T KNOW



You need to complete a two dose course of MMR vaccine.
While there are reliable blood tests to check for immunity to measles it is NOT necessary to
check serology BEFORE or AFTER vaccinating with MMR vaccine.
If you are confident you have had two doses of MMR vaccine but do not have the
documentation, you may consider having a blood test to check for immunity to mumps and
rubella.
MUMPS and RUBELLA
Do you have evidence of vaccination with at least 2 doses of a mumps and rubella-containing vaccine
(e.g. measles-mumps-rubella [MMR] vaccine)? Documentation required.
OR
Do you have evidence of immunity to mumps and rubella infection (e.g. blood test results)?
Documentation required.
 YES to ANY ONE of these questions (GO TO POLIOMYELITIS)
 You are considered immune to mumps and rubella.
 Please show your doctor the documentation to verify your immune status.
OR
 NO or DON’T KNOW



You need to complete a two dose course of MMR vaccine.
While there are reliable blood tests to check for immunity to mumps and rubella, it is NOT
necessary to check serology BEFORE OR AFTER vaccinating with MMR vaccine.
If you are confident you have had two doses of MMR vaccine but do not have the
documentation, you may consider having a blood test to check for immunity to mumps and
rubella.
POLIOMYELITIS
Have you received a full 3 dose course of polio vaccination (by mouth or by injection) as a child?
Documentation not required.
YES

You do not need to take further action unless you are planning to travel to a country where
polio is epidemic or endemic (please contact a doctor with travel medicine experience for
advice) or you are a healthcare worker, including laboratory worker, in possible contact
with poliomyelitis cases or poliomyelitis virus (a further booster dose of polio vaccine is
recommended).
OR
NO or DON’T KNOW


You need to complete a 3 dose course of polio vaccination
There is no reliable blood test to check for immunity to poliomyelitis.
OTHER VACCINE PREVENTABLE DISEASES

If you are considering elective placements in developing country contexts, you are strongly
advised to seek medical advice from a doctor experienced in travel medicine so that
appropriate additional vaccinations and prophylactic medications may be discussed.
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Model Document: Screening Questionnaire & Medical Practitioner Form for HCW Immunisation
v1.0 June 2014
PART 2: BLOOD BORNE VIRUS INFECTIONS
(EXCLUDING HEPATITIS B)
HUMAN IMMUNODEFICIENCY VIRUS (HIV)
Do you have the results from a recent HIV antibody test?
 NO or DON’T KNOW
 You need to know your HIV status but you do not need to inform SA Health of the result.
OR
 YES AND HIV antibody positive

You need to seek confidential medical and career advice from an infectious diseases
specialist and not undertake any exposure prone procedures.
OR
 YES AND HIV antibody negative

You do not need to take further action unless you are potentially exposed to HIV in the
future, including occupational or non-occupational exposure, when a further blood test
may be indicated.
HEPATITIS C VIRUS
Do you have the results from a recent Hepatitis C antibody test?
 NO or DON’T KNOW.
 You need to know your HCV status but you do not need to inform SA Health of the result.
OR
 YES AND HCV antibody positive

You need to seek confidential medical and career advice from an infectious diseases
specialist and not undertake any exposure prone procedures until cleared to do so by an
infectious diseases physician following recommended testing.
OR
 YES AND HCV antibody negative

You do not need to take further action unless you are potentially exposed to HCV in the
future, including occupational or non-occupational exposure, when a further blood test
may be indicated.
PART 3: TUBERCULOSIS
SA Tuberculosis Service is providing an online Tuberculosis screening questionnaire which can be
accessed at: http://www.pages.on.net/questionnaire.php
For student Health Care Workers: You must complete this screening questionnaire and be given
clearance from SA Tuberculosis Service prior to clinical placement in any SA Health facility.
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Model Document: Screening Questionnaire & Medical Practitioner Form for HCW Immunisation
v1.0 June 2014
SA HEALTH SERVICES OR EDUCATION PROVIDER HEADER HERE
MEDICAL PRACTITIONER FORM
COMPLIANCE WITH IMMUNISATION AND BLOOD-BORNE VIRUS POLICY
For student Health Care Workers this form must be completed before you will be permitted to commence clinical
placement.
NAME …………………………………………………………….… STUDENT ID (if a student) ………………………………………………
Instructions for Medical Practitioner: Please tick ONE OR MORE box for each vaccine preventable disease
(if appropriate). Use the Acceptable evidence of immunity to specific VPDs for Health Care Workers table on
the back of this form as a reference.
Disease
Immune Status
IMMUNE
Chickenpox
(VaricellaZoster)
Diphtheria,
Tetanus and
Pertussis
Hepatitis A*
NOT IMMUNE
If vaccine given at this
visit: vaccine name,
dose, batch & date
 confirmed by history of past infection  serological testing
recommended
 confirmed by blood test result
 vaccination recommended
 confirmed by vaccination record
 confirmed by vaccination record
 vaccination recommended
of booster dose
(booster)
 confirmed by vaccination record
 confirmed by blood test result
 serological testing
recommended

Influenza
vaccination recommended
An annual influenza vaccination is required but need not be documented on
this form
Hepatitis B
 confirmed by blood test result
 serological testing
recommended
Measles
Mumps and
Rubella
Poliomyelitis
 vaccination recommended
 vaccination recommended
 confirmed by vaccination record
 confirmed by blood test result
 confirmed by birth before 1966
 confirmed by vaccination record
 confirmed by blood test result
 confirmed by history of
 vaccination recommended
 vaccination recommended
vaccination
*Hepatitis A: Screening and vaccination necessary for student health care workers who will be working in remote Indigenous
communities or with Indigenous children. It is also recommended for students in childcare and preschool settings and carers of
people with intellectual disabilities.
For student Health Care Workers: the student has confirmed that they have completed the
screening questionnaire provided by SA Tuberculosis Service
PLEASE CONTINUE ON NEXT PAGE
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 YES  NO
Model Document: Screening Questionnaire & Medical Practitioner Form for HCW Immunisation
v1.0 June 2014
Hepatitis C virus (HCV)
Human Immunodeficiency
Virus (HIV)
 screening test done
 no screening test done
 screening test
 no screening test done
HCWs need to know their HCV and HIV immune
status (but do not need to inform SA Health of the
result)
If the screening test for HCV or HIV is positive,
confidential medical and career advice should be
sought from an Infectious Diseases Physician.
I confirm that the above named person has provided me with evidence satisfying the above requirements.
SIGNATURE …………………………………………………… DATE ……………………………………………………………
MEDICAL PRACTITIONER’S NAME AND CONTACT DETAILS OR STAMP
……………………………………………………………………………………………………………
…………………………………………………………………………………………………………..
Acceptable evidence of immunity to specific VPDs for Health Care Workers
VPD
Acceptable evidence of immunity
Chickenpox
(VaricellaZoster)
Documented evidence of varicella antibody (IgG) on serology or documented evidence of
varicella vaccination or a history of prior chickenpox or shingles (no documentation
required for history of infection). Confirmation of immunity post-vaccination is not
required.
Documented evidence of a booster dose of diphtheria-containing vaccine in the last 10
years. Confirmation of immunity post-vaccination is not required.
Documented evidence of hepatitis A antibody on serology (IgG) or documented evidence
of completed course of hepatitis A vaccine. Confirmation of immunity post-vaccination is
not required.
Documented evidence of Hepatitis B core antibody or documented level of hepatitis B
surface antibody (>10mlU/ml) following completion of a course of hepatitis B vaccine*.
Confirmation of immunity post-vaccination is required after completion of the vaccination
course for all HCW.
Documented evidence of influenza vaccination during the current influenza season.
Confirmation of immunity post-vaccination is not required.
Documented evidence of measles antibody (IgG) on serology or documented evidence of
2 measles vaccinations at least one month apart or born before 1966. Confirmation of
immunity post-vaccination is not required.
Documented evidence of mumps antibody (IgG) on serology or documented evidence of
2 mumps vaccinations. Confirmation of immunity post-vaccination is not required.
Documented evidence of pertussis booster vaccination in the previous 10 years.
Confirmation of immunity post-vaccination is not required.
History of vaccination with a primary course of 3 vaccinations (documentation is not
required). Confirmation of immunity post-vaccination is not required.
Documented evidence of rubella antibody (IgG) on serology or documented evidence of 2
rubella vaccinations. Confirmation of immunity post-vaccination is not required.
Diphtheria
Hepatitis A
Hepatitis B
Influenza
Measles
Mumps
Pertussis
Poliomyelitis
Rubella
Tetanus
Documented evidence of a booster dose of vaccine containing tetanus in the last 10
years. Confirmation of immunity post-vaccination is not required.
*All HCW who have lived in a hepatitis B endemic country for at least 3 months are required to
have serology that includes hepatitis B surface antigen prior to vaccination. For a list of endemic
countries (intermediate and high risk) please see:
http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/hepatitis-b.aspx
For further details see the current edition of the Australian Immunisation Handbook
available from www.immunise.health.gov.au .
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