Fillable Application for new local immunisation programme (Bay of Plenty District Health Board New Zealand)

Fill Online, Printable, Fillable, Blank Application for new local immunisation programme (Bay of Plenty District Health Board New Zealand) Form

Use Fill to complete blank online BAY OF PLENTY DISTRICT HEALTH BOARD NEW ZEALAND pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Application for new local immunisation programme (Bay of Plenty District Health Board New Zealand)

On average this form takes 14 minutes to complete

The Application for new local immunisation programme (Bay of Plenty District Health Board New Zealand) form is 4 pages long and contains:

  • 1 signature
  • 0 check-boxes
  • 53 other fields

Country of origin: NEW-ZEALAND
File type: PDF

Use our library of forms to quickly fill and sign your Bay of Plenty District Health Board New Zealand forms online.

BROWSE BAY OF PLENTY DISTRICT HEALTH BOARD NEW ZEALAND FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
VACCINATOR AUTHORISATION IN THE AUCKLAND REGION
Application for new local immunisation programme
Auckland Regional Public Health Service | vaccinator@adhb.govt.nz I www.arphs.health.nz/vaccinator Page 1 of 4
• Complete this form to obtain approval to deliver a new local immunisation programme in the Auckland region
using authorised vaccinators.
• Allow up to four weeks for your application to be processed.
• Refer to the Ministry of Health Immunisation Handbook for more information.
SECTION 1
Please complete entire section
Name(s) of programme manager(s)
Organisation name
Street address
Postal address
Phone
Email
SECTION 2
Please complete entire section
1
Do you have knowledge of the provisions contained in the following legislation?
(Available at www.hdc.org.nz and www.legislation.govt.nz)
• Health and Disability Commissioner (Code of Health and Disability Services
Consumers’ Rights) Regulations 1996
Yes ☐ No ☐
• Privacy Act 1993 (in relation to the storage and transfer of information)
Yes
☐
No
☐
• Health and Safety at Work Act 2015 (in relation to having a suitable area for post-
vaccination observation, correct disposal of vaccines, etc.)
Yes ☐ No ☐
• Medicines Act 1981
Yes
☐
No
☐
• National Standards for Vaccine Storage and Transportation for Immunisation
Providers 2017
Yes ☐ No ☐
Application for new local immunisation programme
January 2021
Auckland Regional Public Health Service | vaccinator@adhb.govt.nz I www.arphs.health.nz/vaccinator Page 2 of 4
SECTION 2
Continued
2
Do you have a venue that allows for the safe management of immunisation delivery?
• privacy
• a resting space
• a waiting space
• ensuring privacy of records
•
emergency personnel can gain easy access
Yes ☐ No ☐
3
Do you have the following compulsory emergency equipment available for vaccinations?
• Emergency kit containing:
o adrenaline 1:1000 (minimum of 3 ampules)
Yes
☐
No
☐
o syringes (1mL), 25mm needles for IM injection (minimum of 6)
Yes
☐
No
☐
o adrenaline IM dose chart (ideally laminated)
Yes
☐
No
☐
o cotton wool balls, gauze
Yes
☐
No
☐
• cell phone or phone access
Yes
☐
No
☐
• sharps box
Yes
☐
No
☐
• bag valve mask resuscitator (e.g. Ambu bag) suitable for the population being
vaccinated
Yes
☐
No
☐
• pen and paper for emergency use
Yes
☐
No
☐
• appropriately sized syringes and needles for specific vaccine programme
Yes
☐
No
☐
• cotton wool balls, gauze, surgical tape or plasters
Yes
☐
No
☐
• vaccines
Yes
☐
No
☐
• cold chain equipment as required by the National Standards for Vaccine Storage
and Transportation for Immunisation Providers 2017 (2
nd
edition)
Yes
☐
No
☐
• data logger with a probe, external display and alarm
Yes
☐
No
☐
• gloves, tissues, vomit bowl
Yes
☐
No
☐
• appropriate surface cleaner
Yes
☐
No
☐
• approved biohazard bag
Yes
☐
No
☐
4
Optional additional emergency equipment
The Ministry of Health Immunisation Handbook lists the following optional additional emergency equipment:
• oxygen cylinder, flow meter, tubing and paediatric/adult masks; airways – infant through to adult;
• intravenous cannula and administration sets; intravenous fluids; hydrocortisone for injection; and
saline flush.
5
Do you have a current cold chain accreditation certificate? (Attach copy of certificate)
Yes
☐
No
☐
Application for new local immunisation programme
January 2021
Auckland Regional Public Health Service | vaccinator@adhb.govt.nz I www.arphs.health.nz/vaccinator Page 3 of 4
SECTION 3
Please write all responses on a separate sheet of paper
6
List the DHBS where immunisations will be delivered by this programme.
7
Describe the settings where immunisations will be delivered by this programme.
(E.g. rest homes, medical centres, business premises)
8
List the names of the vaccines that will be delivered by this programme.
(List each vaccine by generic name rather than brand. Note any combination vaccines.)
9
Will there be at least one authorised vaccinator plus another competent adult who has a basic life support
certificate present during vaccinations? If no, please explain.
10
Describe what pre-vaccination information is provided to individuals, either verbally or in writing,
(including consent and vaccine information)?
(Attach copies of all forms and written information)
11
Describe how each individual’s details will be recorded?
(Attach copies of all forms and written information)
12
Describe how information on vaccine administration and any post-vaccination adverse events will be
recorded? (Attach copies of all forms and written information)
13
Describe how notice of vaccine administration will be provided to the primary care provider?
(Attach copies of all forms and written information)
IMPORTANT: If you are not the usual primary care provider, then you must actively inform the individual’s
primary care provider of the vaccinations given by mail, fax etc.
14
Describe what information will be provided to the vaccinee post-vaccination (including provision of emergency
care)?
(Attach copies of all forms and written information)
15
Describe how information on adverse reactions will be reported?
(Attach copies of all forms and written information)
16
List the names (first name and family name) of all authorised vaccinators who will be vaccinating in this
programme:
IMPORTANT: You must contact us if the authorised vaccinators in your programme change at any time in the
future.
Application for new local immunisation programme
January 2021
Auckland Regional Public Health Service | vaccinator@adhb.govt.nz I www.arphs.health.nz/vaccinator Page 4 of 4
SECTION 4
Please read the declaration and sign
• I understand that as programme manager I am responsible for ensuring that the procedures and resources
referenced in this application are in place when vaccinations are delivered.
• I understand that as programme manager I must promptly inform Auckland Regional Public Health Service
before any changes are made to the programme referenced in this application.
• I understand that this programme must comply with the requirements stated in the Ministry of Health
Immunisation Handbook, including current cold chain accreditation (refer to “Immunisation standards fo
r
v
accinators and guidelines for organisations offering immunisation services” and “Authorised vaccinators
delivering a local immunisation programme”).
• I declare that all the information that I have provided is true and correct at the time of application.
Signature(s) of programme manager(s)
Date
SEND YOUR APPLICATION FORM AND REQUIRED DOCUMENTS TO ARPHS
Email: vaccinator@adhb.govt.nz
Post: Vaccinator Authorisation
Auckland Regional Public Health Service
Private Bag 92 605
Symonds Street
Auckland 1150
IF YOU HAVE ANY QUESTIONS
If you need more information, refer to the Ministry of Health Immunisation Handbook. If you still have questions,
contact us.
E
mail vaccinator@adhb.govt.nz or phone (09) 623 4600 ext. 27091
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application for new local immunisation programme (Bay of Plenty District Health Board New Zealand)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 7 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document