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
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signature
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