Fillable Application to add vaccines to existing local immunisation (Bay of Plenty District Health Board New Zealand)

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Application to add vaccines to existing local immunisation (Bay of Plenty District Health Board New Zealand)

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VACCINATOR AUTHORISATION IN THE AUCKLAND REGION
Application to add vaccines to existing local immunisation
programme
Auckland Regional Public Health Service | vaccinator@adhb.govt.nz I www.arphs.health.nz/vaccinator Page 1 of 2
• Complete this form to add new vaccines to a local immunisation programme that has previously been
approved in the Auckland region.
• 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
Programme reference number
Name(s) of programme manager(s)
Organisation name
Street address
Postal address
Phone
Email
SECTION 2
Please write all responses on a separate sheet of paper
1
List the names of the vaccines to be added to this programme.
(List each vaccine by generic name rather than brand. Note any combination vaccines.)
2
What pre-vaccination information is provided to individuals for these vaccines (including consent and
vaccine information)?
(Attach copies of all forms and written information)
3
What information will be provided to the vaccinee post-vaccination (including provision of emergency care)?
(Attach copies of all forms and written information)
Application to add vaccines to existing local immunisation programme August 2020
Auckland Regional Public Health Service | vaccinator@adhb.govt.nz I www.arphs.health.nz/vaccinator Page 2 of 2
SECTION 3
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 for
vaccinators 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 need more
information, contact us.
Email vaccinator@adhb.govt.nz or phone (09) 623 4600 ext. 27091
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Application to add vaccines to existing local immunisation (Bay of Plenty District Health Board New Zealand)

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Completed 13 November 2020

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