Occupational Medicine Unit
Canberra Hospital, Building 1, level 10
Phone: 6244 2321 Fax: 6244 3450
Screening and Immunisation Form
Staff have a professional responsibility to protect patients in their care from disease
that can be potentially transmitted in a health care setting.
Surname: ___________________________ Given name: __________________________
Date of birth: __________________
Gender: □ male □ female
Address: __________________________________________ Postcode: ________
Phone: __________________________ Email: ____________________________________
Division of Health Directorate: ______________________________________
Risk categories: □ A (Clinical) □ B (Non-clinical)
AGS no.: _____________________
Work area: ______________________
Job title (e.g. RN, EN, Intern, RMO, ASO, Ward assistant etc...): __________________
Commencement date: ________________________________________________
Hepatitis B:
History of a full course of Hepatitis B vaccine (Total of 3 doses)? □ Yes □ No
Do you have documentation of Hep B antibody titre level? □ Yes □ No
Measles/Mumps/Rubella:
History of a full course of MMR vaccine (Total of 2 doses)? □ Yes □ No
Do you have documentation of Measles, Mumps & Rubella antibody? □ Yes □ No
Birth date before 1966: □ Yes □ No
Varicella (Chicken pox):
History of a full course of varicella vaccine (Total of 2 doses)? □ Yes □ No
Do you have documentation of varicella antibody? □ Yes □ No
Diphtheria/Tetanus/Pertussis (Whooping cough):
History of one adult dose of diphtheria/tetanus/pertussis vaccine Pertussis (Whooping cough)?
□ Yes, which year? ______ □ No
ALLERGIES:
Do you have any known allergies? □ Yes □ No
Please give details: _____________________________________________________
_____________________________________________________________________
Signature: __________________________________ Date: ______________
Office use only: ______________________________________________________
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Immunisation Record (office use only)
Hepatitis B:
Consent form  yes
1. Date ______________ Batch ___________________ Expiry date _________
Given by ___________________________________
2. Date ______________ Batch ___________________ Expiry date _________
Given by ___________________________________
3. Date ______________ Batch ___________________ Expiry date _________
Given by ___________________________________
Booster dose date ___________________ Batch ______________ Expiry date _________
Given by ___________________________________
Serology date: ___________________________ Hepatitis B result: ______________________
Measles/Mumps/Rubella:
Consent form  yes
1. Date ______________ Batch ___________________ Expiry date _________
Given by ___________________________________
2. Date ______________ Batch ___________________ Expiry date _________
Given by ___________________________________
Varicella:
Consent form  yes
1. Date ______________ Batch ___________________ Expiry date _________
Given by ____________________________________
2. Date ______________ Batch ___________________ Expiry date _________
Given by ____________________________________
Diphtheria/Tetanus: ADT Consent form  yes
Date ______________ Batch ___________________ Expiry date _________
Given by _______________________
Pertussis (Whooping cough)/Diphtheria/Tetanus: Boostrix
Consent form  yes
Date ______________ Batch ___________________ Expiry date _________
Given by _________________________________
Issued: Staff Screening and Immunisation Policy September 2008
OMU update: 01/06/2013
Review date: 2015
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