Norfolk Island
Customs and
Immigration Service
How to complete this form
Applicant
 complete Part A before attending the radiological examination.
 complete Part B in the presence of the examining radiographer.
Form
NF/160
Radiographer

 sight valid passport or national identity document, record passport or national identity document number below. Certify and attach a copy of the passport bio-data page or a copy of the national identity document. Date to be included.
you must ensure the applicant has provided answers to all the questions in Part A and assist applicant with Part B before the applicant signs the declaration in Part B .
 complete Part C
Radiologist
 complete Part D .
To be completed by RADIOGRAPHER (or staff)
Valid passport sighted?
Yes  Passport number
Country of Passport
Please firmly attach a recent passport size photograph of yourself to the form by pin or other means.
Another copy of the same photo should be used for form
NF/22.
Note: If you are in Australia
Medibank Health Solutions will take this photograph.
Details of identity card or identity number issued to the applicant by his/ her government (if applicable) e.g. National identity card.
Note: If the applicant is the holder of multiple identity numbers because he/she is a citizen of more than one country, you need to enter the identity number on the card from the country that the applicant lives in.
Passport and photograph verified?
No Yes
Identity number
Country of Issue
Please attach a copy of the bio-data page of the passport sighted to identify the applicant. The copy should be certified by the examining doctor.
Applicant's full name
(as it appears in passport or national identity document)
No  Reasons not presented
Family Name
Given Names
DAY MONTH YEAR
Date of birth
Please attach a copy of the national identity document sighted to identify the applicant, if applicable. The copy should be certified by the examining doctor.
Office use only
File Number
Date of application
Permit class
Name and address of office processing the application
Administration of Norfolk Island
Customs and Immigration Services
Customs House, Norfolk Island, 2899
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NF160 (Design date 06/11)
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To be completed by the applicant before attending the radiological examination. Please use a black pen and write neatly in English using BLOCK LETTERS.
11 Have you ever undertaken a medical examination for a Norfolk
Island Permit
No
Yes  Give details 1 Your full name
(as it appears in your passport or national identity document)
Family Name
Given Names
DAY MONTH YEAR
2 Date of birth
3 Sex Male Female
4 Your telephone numbers
Office Hours
After hours
COUNTRY CODE AREA CODE NUMBER
( ) ( )
( ) ( )
5 Your Residential Address
6 Intended occupation in Norfolk Island
7
8
How long do you intend to stay
Permanently
Temporarily  For how long
Years
POSTCODE
9 What is the permit that you are applying for?
For more information see page 1 of form NF160i
Months
If you are in Norfolk Island - If outside Norfolk Island see question 9
How long have you been here
Years Months
What permit do you currently hold
Temporary Entry Permit General Entry Permit
10 Have you lodged a permit application?
No  At which office do you intend to lodge an application?
12 For female applicants
Are you pregnant
No
Yes
Go to Part B (Page 3)
 What is the expected Date of Birth
DAY MONTH YEAR
Note: Please read the information under 'pregnant permit applicants and the chest x-ray requirement' on page 1 of NF160i.
Please and sign the pregnant permit applicant's declaration below
Pregnant permit applicant's declaration
I have read the information on page 1 of this form and understand that the government recommends that:
 a pregnant permit applicant does not undergo a chest x-ray;

 a pregnant permit applicant defers her chest x-ray, and therefore the decision on her permit application, until after the child's birth; and if a pregnant permit applicant is prepared to undergo a chest xray, she consults her doctor before undergoing the x-ray and that special precautions are taken (eg. using a protective lead shield and waiting until at least the second trimester).
I understand that undergoing a chest x-ray does not guarantee the grant of the permit.
In full knowledge of the above, I elect to undergo a chest x-ray while pregnant.
Yes  At which office?
Applicant's signature
DAY MONTH YEAR
Date
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To be signed and dated by the applicant in the presence of the examining radiographer .
Before signing this declaration you must have completed all the questions in Part A - Applicant's details
Note : A parent or guardian should sign on behalf of a child under
16 years of age. In exceptional circumstances a child under 16 may sign if he or she is able to understand and verify the information given on the form.
 I declare the information I have provided on this form is correct.


I understand that if I have given false or misleading information my application may be refused, and any permit issued may be cancelled.
I understand that the Administration of Norfolk Island (the department) becomes the owner of the information on this form and that the doctor is required to send the form to the department.
 I consent to the the department passing on relevant health information to the Hospital Medical Superintendent/Panel doctor(s) who examined me for comment. The reasons for this release of information may include, but are not limited to, investigation of inconsistencies between the Radiologist and/or
Panel doctor's examination and a subsequent health assessment, investigation of a complaint against the Panel doctor or follow up with the Radiologist/Panel doctor of adverse audit results.
Such information will be shared in order to ensure the quality of the work undertaken by the Hospital Medical
Superintendent, Radiologist and/or the Panel doctor network.
 I consent to the the department passing on health information to the Office of the Administrator. I understand this information may be used by that office and /or the Department of
Immigration and Citizenship (Australia) in making a decision for a permit and may be used to determine an immigration appeal.
Applicant's signature
Date
DAY MONTH YEAR
If signing on behalf of a child under 16 years of age -
Name of parent or guardian
Relationship
To Applicant
Please provide large posteroanterior (PA) film if possible, otherwise
100mm minimum.
The x-ray film must bear the date of the examination, the applicant's family and given names, and the file number (if available).
This information is to be automatically inscribed during the photographic process or written in white ink.
Refer, if known, to any history or clinical evidence of tuberculosis.
If the examinee is pregnant the film must be full sized, the field size must be strictly limited and there must be abdominal shielding. If the pregnant woman does not wish to be x-rayed, please comment and return this form. Refer, if known, to any history or clinical evidence of tuberculosis.
DAY MONTH YEAR
1 Date of X-ray
2 Is this person pregnant?
No Yes
3 Signature of radiographer
I certify that I have carried out the x-ray of the person whose photograph and signature are on this form.
Signature of
Radiographer
DAY MONTH YEAR
Date
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7
6
5
4
3
Please use a pen and write neatly in English. Illegible forms will be returned for clarification.
2
1
Comment is required on any and all aspects found not to be entirely normal.
Skeleton and soft tissue
Normal Abnormal 
Cardiac Shadow
Normal Abnormal 
Hilar and Lymphatic glands
Normal Abnormal 
Hemi diaphragms and costophrenic angles
Normal Abnormal 
Lung
Normal
Evidence of TB
Absent
Abnormal
Present


Details of other abnormalities
If insufficient space, attach an additional statement
8 Recommendation
Please consider the information you have provided about this applicant. You must consider if there exists any significant finding on the x-ray. 'Significant' means that a finding has a current or potential future health impact. The presence of congenital fusion of the rib, benign rib anomalies, old rib fractures, cervical ribs, and mild scoliosis, should be graded as A .
All other abnormalities, including those of the heart and other soft tissue and bony structures, must be graded B . This includes, but is not limited to, sternal wiring, valve replacements, vascular stents, missing breasts, osteolytic lesions. All TB, whether old and likely to be inactive, or active, must be reported as B .
Note: This is not a rating of whether the applicant will meet the health criteria.
A No abnormal findings present
B Abnormal findings present
 Please list significant history or abnormal
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9 Radiologist or Hospital Medical Superintendent declaration
This declaration must be signed and dated by the Radiologist/
Medical officer who personally performed the examination.
I declare that I have examined the applicant and that this is a true and correct record of my findings
Place of
Examination
Postal Address
Radiologist or
Hospital Medical
Superintendent signature
DAY MONTH YEAR
Contact telephone number
Email Address
COUNTRY CODE AREA CODE NUMBER
( ) ( )
Date
Full name
(please print)
To the Radiologist or Hospital Medical Superintendent
Please put this completed form NF/160 together with any further reports required and the packaged x-rays, into a secured envelope. Seal the envelope and place your signature or rubber stamp over the junction of all flaps of the envelope. Place the envelope inside another envelope and return it direct to the office specified in the attached covering letter and/or specified on the "Office use only" section on the front of this form.
For permit applicants outside Norfolk Island - Do not give the form and report/s to the applicant.
You may, however, provide the applicant with a copy of your report/s for their records then place the original completed form NF/160 together with any further reports required and the packaged x-rays, into a secured envelope. Seal the envelope and place your signature or rubber stamp over the junction of all flaps of the envelope. Place the envelope inside another envelope and return it direct to the office specified in the attached covering letter and/or specified on the "Office use only" section on the front of this form.
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© Administration of Norfolk Island 2011