Pre Employment Immunisation and Screening
INFORMATION FOR APPLICANTS
NON-CLINICAL CONTACT CAREGIVERS DO NOT NEED TO COMPLETE THIS FORM
Please read this information carefully
1.
It is a requirement of your employment at St John of God Subiaco Hospital that
you complete a pre-employment screening and immunisation assessment. This
is to ensure that compliance with current Australian Infection Control and
Occupational Health requirements is met in order to protect you and our
patients from exposure to vaccine preventable diseases.
2.
Caregivers are classified according to the degree of clinical contact they will have with
patients and the risk of exposure to infectious agents in the work place. Each caregiver
is assessed individually; however the following are general guidelines:
3.

Clinical Contact: generally this is caregivers who will provide direct clinical
care to patients, and have potential exposure to blood / body fluids. It also
includes caregivers that have less direct patient contact but may be exposed to
infection spread through the air. This category includes all nursing, midwifery,
medical, allied health, patient care assistants, some patient service assistants,
administrative assistants (e.g. ward clerks) and caregivers employed in SSD,
environmental services, pastoral care, maintenance and waste management.

Non-Clinical Contact: Many caregivers work in areas of the hospital where they
have no greater risk of exposure to infectious diseases than in the general
community. This includes caregivers in departments such as medical records,
accounts, catering, admissions and administration etc. Non Clinical Contact
caregivers are not required to complete the Immunisation Screening
Form.
Caregivers in the Clinical Contact category above must complete the Immunisation
Screening Form and return it with your application along with written evidence of
immunisations. All details must be completed to enable an informed decision to be
made when reviewing your status and making any recommendations for attendance at
the staff immunisation clinic.
Tuberculosis testing (Quantiferon/Mantoux) – All direct Clinical Contact caregivers are
required to provide evidence of previous TB testing results if available. If you have
never had a TB test, or are unable to provide evidence of a previous one, you will be
required to have a Quantiferon blood test.
If you require any blood tests to check your immune status or further vaccinations
these will be identified when your immunisation status form is reviewed. You will be
advised where to attend for these. You will not be charged for the cost of any testing
performed or vaccines provided.
Please note – failure to attend for recommended tests or vaccinations
within the required period may impact on your ongoing employment at
St John of God Subiaco Hospital.
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INFECTION CONTROL – IMMUNISATION REQUIREMENTS
PLEASE PRINT CLEARLY
Family Name
Date of Birth
/
Given Names
Country of Birth
Address
Suburb
Position Applied for
Tel No
/
Sex M
F
Postcode
Dept/Ward
Declaration
I declare that the information I have provided is accurate and I have not withheld any
relevant information.
Applicant’s Signature:
Date:
Attach copies of previous tests and vaccination records to this form.
Complete both sides of form.
The Staff Health Screening and Immunisation Clinical Nurse will determine what vaccinations
or tests are required.
If you suffer from any infectious disease, you must discuss your work practices with the Staff
Health Screening and Immunisation Clinical Nurse or your medical practitioner.
1.
2.
1.
Does your new position involve direct patient contact? (refer point 2 on front page)
2.
Are you likely to have contact with blood or body fluids?
MRSA
1.1
Have you worked, or been a patient in a hospital outside WA in the past 12 months?
1.2
Have you worked in a residential care facility in WA in the past 12 months?
1.3
Have you been screened for MRSA in Western Australia within the last 12 months?
TUBERCULOSIS (TB)
Yes
Yes
No
Yes
No
No
Have you had TB?
Date:
Have you had a mantoux / Quantiferon test?
Date:
Have you had a BCG vaccination?
Date:
Have you had a chest Xray for TB?
Date:
Result:
Result:
Have you had the following Vaccinations? (Please complete in full)
3.
HEPATITIS B
Yes
No
Yes
No
Have you had at least three (3) doses of Hepatitis B vaccine?
Have you had a blood test to confirm immunity?
4.
HEPATITIS A
Have you been vaccinated against Hepatitis A?
Complete second page
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INFECTION CONTROL – IMMUNISATION REQUIREMENTS
5.
VARICELLA (VZV) (Chickenpox)
Yes
No
Yes
No
Have you ever had chickenpox or shingles?
If NO – have you had at least two (2) doses of Varicella vaccine?
If YES – have you had a blood test to confirm immunity?
6.
MEASLES (MMR)
Have you had at least two (2) doses of Measles (MMR) vaccine?
If YES – have you had a blood test to confirm immunity?
Have you had Mumps?
Have you had Measles?
Have you had Rubella (German Measles)?
Have you had a blood test to confirm immunity to Rubella?
7.
Result:
PERTUSSIS (WHOOPING COUGH)
Yes
No
Have you had at least one (1) dose of Pertussis (dTPa) vaccine?
OFFICE USE ONLY (Recruitment to complete)
Date of Commencement __/__/__
International Recruit:
Yes
No
Yes
No
Evidence supplied
Hepatitis A Vaccination
Hepatitis B Vaccination
Mantoux/Quantiferon
Measles Immunity
Mumps
Rubella
MRSA Screen
Pertussis Vaccination
Varicella Immunity
REQUEST
ACTIONED
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Pathology letter
Vaccination letter
Alesco entry
Yes
Yes
Yes
INVESTIGATION
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No
No
No
DATE
RESULT
COMMENT