Fillable Application for vaccinator authorisation (Bay of Plenty District Health Board New Zealand)

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Application for vaccinator authorisation (Bay of Plenty District Health Board New Zealand)

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The Application for vaccinator authorisation (Bay of Plenty District Health Board New Zealand) form is 3 pages long and contains:

  • 1 signature
  • 29 check-boxes
  • 12 other fields

Country of origin: NEW-ZEALAND
File type: PDF

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VACCINATOR AUTHORISATION IN THE AUCKLAND REGION
Application for vaccinator authorisation
Auckland Regional Public Health Service | vaccinator@adhb.govt.nz I www.arphs.health.nz/vaccinator Page 1 of 4
• Complete this form to become an authorised vaccinator in the Auckland region.
• Complete all sections of the form.
• Allow up to four weeks for your application to be processed.
• Refer to the “Guide to becoming an authorised vaccinator in the Auckland region” for more information.
NAME AND CONTACT DETAILS
Given name(s)
Family name
Street address/PO Box
Suburb
City/town
Postcode
Phone (mobile)
Phone (home)
Email
EMPLOYMENT DETAILS
Organisation
Phone (work)
Please tick ONE box that best applies to you:
☐ Registered nurse or nurse practitioner
☐ Registered midwife
☐ Paramedic
☐ Other
If other, please specify:
INTENDED VACCINATION PRACTICE
Please tick ONE OR MORE boxes that apply to you:
☐ I intend to vaccinate babies and infants
☐ I intend to vaccinate pre-schoolers and/or school aged children
☐ I intend to vaccinate adults
Application for vaccinator authorisation
August 2020
Auckland Regional Public Health Service | vaccinator@adhb.govt.nz I www.arphs.health.nz/vaccinator Page 2 of 4
VACCINATOR AUTHORISATION STATUS
Please tick ONE box that best applies to you:
☐ I have never had vaccinator authorisation and I am applying for the first time (go to Checklist 1 below)
☐ I have current vaccinator authorisation for the Auckland region that has not yet expired (go to Checklist 2 below)
☐ I had past vaccinator authorisation for the Auckland region that has now expired (go to Checklist 3 below)
☐ I have current or had past vaccinator authorisation for another region in New Zealand (go to Checklist 4 below)
REQUIRED DOCUMENTS
Checklist 1
For applicants who have never had vaccinator
authorisation and are applying for the first time, please
enclose the following:
Checklist 2
For applicants who have current vaccinator authorisation
for the Auckland region that has not expired, please
enclose the following:
☐ Copy of APC
☐ Copy of CPR certificate (completed within last 2 years)
☐ Copy of vaccinator training course certificate
☐ Copy of clinical assessment
☐ Copy of APC
☐ Copy of CPR certificate (completed within last 2 years)
☐ Copy of last vaccinator update certificate
☐ ARPHS peer reviewed assessment form
Checklist 3
For applicants who had past vaccinator authorisation for
the Auckland region that has expired, please enclose the
following:
Checklist 4
For applicants who have current or had past vaccinator
authorisation for another region in NZ, please enclose
the following:
☐ Copy of APC
☐ Copy of CPR certificate (completed within last 2 years)
☐ Copies of vaccinator training course certificates and/
or vaccinator update certificates (completed since
last authorisation)
☐ ARPHS peer reviewed assessment form (if
authorisation expired less than 6 months ago)
OR
☐ Copy of repeat clinical assessment (if authorisation
expired more than 6 months ago)
☐ Copy of APC
☐ Copy of CPR certificate (completed within last 2 years)
☐ Copy of last vaccinator authorisation certificate for
other region
☐ Copies of all vaccinator training course certificates
and vaccinator update certificates (completed at any
time)
☐ Copy of last clinical assessment
Application for vaccinator authorisation
August 2020
Auckland Regional Public Health Service | vaccinator@adhb.govt.nz I www.arphs.health.nz/vaccinator Page 3 of 4
DECLARATION
• I understand that authorised vaccinators can independently administer vaccines but cannot prescribe
vaccines.
• I understand that authorised vaccinators can only independently administer vaccines that are part of the
National Immunisation Schedule or an officially approved local immunisation programme.
• I can competently administer vaccines according to the “Immunisation standards for vaccinators” in the
Ministry of Health Immunisation Handbook.
• I understand that vaccinator authorisation does not override my responsibility to work within my scope of
practice as required by the Health Practitioner Competence Assurance Act 2003.
• I understand that vaccinator authorisation is not transferable (i.e. a health professional without authorisation
cannot independently administer vaccines on behalf of an authorised vaccinator).
• I have a current CPR certificate that meets the “Resuscitation requirements for vaccinators” in the Ministry of
Health Immunisation Handbook.
• I declare that all the information that I have provided is true and correct at the time of application.
Signature of applicant
Date
SEND YOUR APPLICATION FORM AND REQUIRED DOCUMENTS TO ARPHS
Email:
Post:
vaccinator@adhb.govt.nz
(PDF documents only)
Vaccinator Authorisation
Auckland Regional Public Health
Service Private Bag 92 605
Symonds Street
Auckland 1150
NOTE
Authorised vaccinators may occasionally receive relevant communications from health sector organisations, such as
DHBs, IMAC or ARPHS.
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Application for vaccinator authorisation
August 2020
Auckland Regional Public Health Service | vaccinator@adhb.govt.nz I www.arphs.health.nz/vaccinator Page 4 of 4
IF YOU HAVE ANY QUESTIONS
If you need more information, refer to the “Guide to becoming an authorised vaccinator in the Auckland region”. If
you still have questions, contact us.
Email vaccinator@adhb.govt.nz or phone (09) 623 4600 ext. 27091
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Application for vaccinator authorisation (Bay of Plenty District Health Board New Zealand)

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Completed 13 November 2020

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