Occupational Assessment Screening and Vaccination Against
Specified Infectious Diseases
Appendix 6: Undertaking/Declaration Form
All new recruits/other clinical personnel/ students /volunteers / facilitators must complete
each part of this document and Appendix 7 Tuberculosis (TB) Assessment Tool and provide a
NSW Health Vaccination Record Card for Health Care Workers and Students and serological
evidence of protection as specified in Appendix 4 Checklist: Evidence required from Category A
Applicants and return these forms to the health facility as soon as possible after acceptance of
position/enrolment or before attending their first clinical placement. (Parent/guardian to sign if student
is under 18 years of age).
New recruits/other clinical personnel/ students /volunteers / facilitators will only be
permitted to commence employment/attend clinical placements if they have submitted this form, have
evidence of protection as specified in Appendix 4 Checklist: Evidence required from Category A
Applicants and submitted Appendix 7 Tuberculosis (TB) Assessment Tool. Failure to complete
outstanding hepatitis B or TB requirements within the appropriate timeframe(s) will result in
suspension from further clinical placements/duties and may jeopardise their course of study/duties.
The education provider/recruitment agency must ensure that all persons whom they refer to a
NSW Health agency for employment/clinical placement have completed these forms, and forward the
original or a copy of these forms to the NSW Health agency for assessment. The NSW Health agency
must assess these forms along with evidence of protection against the infectious diseases specified in
this policy directive.
Part Undertaking/Declaration (tick the applicable option) √
1
I have read and understand the requirements of the NSW Health Occupational Assessment, Screening and
Vaccination against Specified Infectious Diseases Policy
2
a. I consent to assessment and I undertake to participate in the assessment, screening and vaccination
process and I am not aware of any personal circumstances that would prevent me from completing these
b. (For existing workers only) I consent to assessment and I undertake to participate in the assessment,
screening and vaccination process; however I am aware of medical contraindications that may prevent me
from fully completing these requirements and am able to provide documentation of these medical
contraindications. I request consideration of my circumstances.
3
I have provided evidence of protection for hepatitis B as follows:
a. history of an age-appropriate vaccination course, and serology result Anti-HBs ≥10mIU/mL OR
b. history of an age-appropriate vaccination course and additional hepatitis B vaccine doses, however my
serology result Anti-HBs is <10mIU/mL (non-responder to hepatitis B vaccination) OR
c. documented evidence of anti-HBc (indicating past hepatitis B infection) or HBsAg+ OR
d. I have received at least the first dose of hepatitis B vaccine (documentation provided) and undertake to
complete the hepatitis B vaccine course (as recommended in The Australian Immunisation Handbook,
current edition) and provide a post-vaccination serology result within six months of my initial verification
4
I have been informed of, and understand, the risks of infection, the consequences of infection and
management in the event of exposure (refer Appendix 5 Specified Infectious Diseases: Risks and
Consequences of Exposure) and agree to comply with the protective measures required by the health
service and as defined by PD2017_013 Infection Prevention and Control Policy.
Declaration: I, ____________________________, declare that the information provided is correct
Full name: Worker cost centre (if available):
D.O.B: Worker/Student ID (if available):
Medicare Number: Position on card: __ Expiry date: ______/____________
Email:
NSW Health agency / Education provider:
Signature:
Date:
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