Immunisation Status Assessment Form
Western Health Employees
Chief Executive Statement
Employees working within the Healthcare industry may be exposed to, and transmit, vaccine-preventable diseases
such as Hepatitis B, influenza, measles, mumps, Varicella (chicken pox) and Pertussis (whooping cough). If staff are
not already immune to certain infections, they can be potential sources of infection to patients and other staff.
Maintaining immunity in the health care worker population helps prevent the transmission of vaccine-preventable
diseases to and from health care workers, patients and visitors to Western Health.
Completing the Immunisation Status Assessment Form
Before commencing employment with Western Health all staff are required to:
1. Complete the Immunisation Status Assessment Form and return it to People Services, Level 5 Western
Hospital
2. Provide evidence of any immunity status listed in this form.
Staff Responsibilities
The Occupational Health and Safety Act (2004) places a duty of care on employers to ensure workplace health and
safety where occupational infectious disease hazards exist. Healthcare workers also have a responsibility and duty
of care to ensure the safety of patients, staff and visitors in the workplace by adhering to infection prevention
measures implemented by the employer.
Staff Group
Obligations
Staff and students with direct Staff are required to have immunisation against:
patient contact or possible contact
 Hepatitis A & B
with blood or body fluids
 Measles, Mumps, Rubella
 Varicella (Chicken Pox)
 Adult Diphtheria/Tetanus (ADT) and Boostrix
Staff are also required to have had a Mantoux Test or Quaniferon TB Gold
Test for Turberculosis within the last 12 months.
Staff who may be involved in work Provide evidence of positive Hepatitis A serology.
on sanitation or sanitation piping
Volunteers, Visiting Clinicians and Provide information based on their exposure risk prior to commencement.
Work Experience Students
Contractors
All contractors are advised to know their vaccine status. Risk is dependent
on the type of work and where they are working in the health service.
Contractors who are working in clinical areas pose the greater risk of
transmitting infection to patients and staff.
Vaccination Evidence
Evidence of immunity may include any vaccination records or serology test results as per table below. Vaccination
records can be obtained from your previous employer, your General Practitioner (GP) and or the Local Council
where you could have received childhood immunisations.
In the absence of documented evidence of vaccination or immunity, an immunisation assessment should be
organised through your GP or Nurse Immuniser.
Reviewed: October 2014, Version 5
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Immunisation Status Assessment Form
Western Health Employees
Vaccine
Vaccination Evidence
Hepatitis B
Record of 3 doses of Hepatitis B vaccine OR Hepatitis B antibody test with an anti-Hbs count
of greater than 20mIU/mL.
Influenza
Record of last annual vaccination
Measles, Mumps or
Rubella
Record of vaccination of 2 doses of MMR OR documented serological evidence of immunity.
Varicella
pox)
Positive history of disease or record of vaccination (2 doses as adult) OR documented
serological evidence of immunity.
(chicken
Pertussis
(whooping cough)
Record of childhood immunisations, 3 vaccines and boosters at 4 years and at 12-17 years.
A booster is recommended for staff working with young children or neonates
Hepatitis A
Record of 2 doses of Hepatitis A vaccine OR documented serological evidence of immunity.
Tuberculosis
Documentation of the two step Mantoux testing or Quantiferon Gold In Tube test result
(within the last 12 months) is required.
Confidentiality and Privacy
Please note confidentiality and privacy of all records is ensured. A copy of your medical screening record may also
be provided upon written request.
Non Participation
Staff who refuse any recommended vaccine may be subject to imposed work restrictions, required to wear personal
protective equipment (PPE) at all times, or may be redeployed from high-risk areas. If you do not wish to participate
in the recommended immunisation schedule including the annual influenza vaccination you are required to complete
the mandatory non-participation declaration provided.
Further Information
Further information can be obtained by contacting Infection Prevention on 8345 6113 or 8345 0210.
Associate Professor Alex Cockram
Chief Executive Officer
Western Health
Reviewed: October 2014, Version 5
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Immunisation Status Assessment Form
Western Health Employees
Employee Number:
Work start date:
Name (Print):
Home phone:
Date of birth:
Mobile number:
Gender:
 Male
 Female
Email Address:
Country of birth:
Ward/Department:
Year of arrival in Australia:
Job Role:
GENERAL
Have you ever lived overseas for 6 months
or more (except country of birth)?
Do you have any of the following allergies?
Do you have any medical reasons for not
receiving vaccinations?
HEPATITIS B
Have you had the Hepatitis B vaccine?
Have you had an antibody blood test for
Hepatitis B?
 No
 Yes, where?
 Latex
 Detergents
 Eggs (anaphylactic reaction)
 Other ________________________________________
 No
 Yes, details:
 Yes
 No
 Number of doses ____________
 Completion date ____________
 Yes, result (tick one):
 No
o Less than 10 iu/l
o More than 10 iu/l
o Not Detected
o Known Non Responder
MEASLES, MUMPS AND RUBELLA (MMR)
If born after 1966, have you had 2 doses of  Yes, date:
MMR?
Have you ever had Measles?
 Yes, date:
 No
 No
Do you have serological evidence of
immunity to Measles?
Have you ever had Mumps?
 Yes (attach document)
 No
 Yes, date:
 No
Do you have serological evidence of
immunity to Mumps?
Have you ever had Rubella (German
Measles)?
Do you have serological evidence of
immunity to Mumps?
 Yes (attach document)
 No
 Yes, date:
 No
 Yes (attach document)
 No
VARICELLA (CHICKEN POX)
Have you had the disease chickenpox?
 Yes, date:
 No
Have you ever had shingles?
 Yes, date:
 No
Have you been vaccinated for chickenpox
(2x vaccines)?
Do you have serological evidence of
immunity to chickenpox?
 Yes, date:
 No
 Yes (attach document)
 No
Reviewed: October 2014, Version 5
Action Required
 No action
 Vaccination
 Antibody Test
 Booster Dose
Action Required
 No action
 Vaccination
 Measles Antibody Test
 Mumps Antibody Test
 Rubella Antibody Test
 Booster Dose
Action Required
 No action
 Vaccination
 Antibody Test
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Immunisation Status Assessment Form
Western Health Employees
DIPHTHERIA, TETANUS AND PERTUSSIS (ADT & DTPA)
Have you been vaccinated for adult  Yes, date:
diphtheria / tetanus (ADT)?
Have you ever received a dose of pertussis  Yes, date:
containing vaccine as an adult e.g.
Boostrix?
If you are over 50 years old have you  Yes, date:
received a booster of ADT or dTpa in the
past 5 years?
Will you be working with any paediatric,  Yes
neonatal or maternity patients?
TUBERCULOSIS (TB)
Have you ever had Tuberculosis?
 No
 No
 No
 No
 Yes, date:
 No
Have you ever been in contact with
someone with Tuberculosis?
Have you received the BCG vaccine?
 Yes, date:
 No
 Yes, date:
 No
Have you had a Mantoux test?
 Yes, results (attach evidence):
 Positive
 Negative
 Yes, results (attach evidence):
 Positive
 Negative
 Yes (attach evidence)
Results ___________________
 No
Have you had a Quaniferon TB Gold test, or
other interferon gamma release assay?
Have you had a chest x-ray to look for
possible evidence of previous TB?
HEPATITIS A
Have you had the Hepatitis A vaccine?
Have you had an antibody blood test for
Hepatitis A?
OTHER VACCINES
Have you received a vaccine for Polio
(Sabine Vaccine)?
Have you have the influenza vaccine this
year?
List any other vaccines you have received:
Reviewed: October 2014, Version 5
Action Required
 No action
 Vaccination
 Antibody Test
 Booster Dose
Action Required
 No action
 Clearance from ID
 Quantiferon TB Gold
 Mantoux Test
 Chest X-Ray
 No
 No
 Yes
 No
 Number of doses ____________
 Completion date ____________
 Yes, result (tick one):
 No
Action Required
 No action
 Vaccination
 Antibody Test
 Booster Dose
 Yes, date:
 No
 Yes, date:
 No
Action Required
 No action
 Polio Vaccination
 Influenza Vaccination
o Less than 10 iu/l
o More than 10 iu/l
o Not Detected
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Immunisation Status Assessment Form
Western Health Employees
DECLINE OF WESTERN HEALTH’S IMMUNISATION PROGRAM
I understand the conditions of Western Health’s immunisation program and decline to participate in the following
recommended immunisations listed below (tick immunisations declined):






Hepatitis A
Varicella (Chickenpox)
Measles
Mumps
Rubella (German measles)
Adult diphtheria/tetanus


Pertussis (whooping cough)
Polio
I am aware of the potential risks my decline of immunisation for vaccine preventable diseases may pose and that this may require
my employer to impose work restrictions or may require me to wear personal protective equipment (PPE) or be redeployed from
high-risk areas. The consequences of my refusing to be vaccinated for vaccine preventable diseases could endanger my health
and the health of those with whom I have contact including; patients in this healthcare setting, my co-workers, my family and my
community.
I am aware that I may commence the recommended immunisation schedule at any time should I wish to participate.
Name:
Signature:
Date:
Reason for declining:
DECLINE OF ANNUAL INFLUENZA VACCINATION
Western Health provides free influenza vaccinations every year for all staff. If you wish to decline the vaccine for this year you are
required to sign this declination form.
I understand the conditions of Western Health’s immunisation program and decline to participate in the recommended free
annual influenza vaccination. I acknowledge that I am aware of the following facts:

Influenza vaccination is recommended for me and all other healthcare workers to minimise the transmission of influenza
and its complications, including death.

Influenza (commonly known as "the flu") is a serious respiratory disease that kills an average of 3,500 Australians,
hospitalises more than 18,000 and causes around 300,000 GP consultations each year.

If I contract influenza, I will shed the virus for 24 to 48 hours before the symptoms appear. My shedding the virus can
spread the influenza infection to vulnerable patients and colleagues at the facility.

If I become infected with influenza, even when my symptoms are minimal or non apparent, I can spread severe illness to
patients and staff.

I understand that the strains of virus that cause influenza infection change almost every year, which is why a different
influenza vaccine is recommended each year.

I cannot get the influenza disease from the influenza vaccine.

The consequences of my refusing to be vaccinated could endanger the health of patients, colleagues as well as my
family and the community.
I understand that I may change my mind at any time and accept the influenza vaccination if the vaccine is available. I have read
and fully understand the information on this declination form.
Name:
Signature:
Date:
Reason for declining:
Office Use Only
 Data entered
Reviewed: October 2014, Version 5

Sent to Infection Prevention for review

Review completed
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