COVID-19 Vaccination form
1 of 1
COVID19_vaccination/4November2021/v0.11
Employee details
Person ID Personnel assignment number (if applicable)
Please indicate (tick) here if you work in more
than one (1) position in Queensland Health.
Family name First name/s
Area code Contact telephone number
Position number
Position title
Organisational unit number
Organisation unit name
Location
Privacy Notice:
Personal and health information collected by the Department of Health or by a Hospital and Health Service (Queensland Health) is collected and handled in accordance with
the Information Privacy Act 2009 (Qld). The personal and health information provided by you will be securely stored and only accessible by authorised employees of
Queensland Health (or its agents). Personal and health information disclosed on this form may be used for the purposes of ensuring compliance with the Health Employment
Directive 12/21, workforce rostering and planning
This information will not be disclosed to other third parties without consent unless the disclosure is authorised or required by or under law.
For information about how Queensland Health protects your personal information, or to learn about your right to access your own personal information, please see our
website at http://www.health.qld.gov.au/global/privacy.
For your rights as a Queensland Health employee, please consult the Office of the Information Commissioner's guidelines at: https://www.oic.qld.gov.au/guidelines/for-
government/guidelines-privacy-principles/collection/covid-19-vaccination-and-my-privacy-rights-as-a-queensland-health-employee
The following vaccination information is requested or as required to support Queensland Health's obligations to provide a safe workplace under section 19 of the Work
Health and Safety Act 2011, Health Employment Directive 12/21, HR policy B70 Employee COVID-19 vaccination requirements and other instruments including Public Health
Directions issued in accordance with the Public Health Act 2005, as well as an overall response in controlling the COVID-19 pandemic.
A Line Manager/support role can upload details "on behalf of" employees who do not have access to myHR.
Employee certification and signature
I certify that I have received a vaccination as detailed above and evidence has been provided to my manager/supervisor/delegate
I consent to my employer storing my COVID-19 vaccination information, listed above, on my employment record in myHR.
Employee's signature
Date
Supervisor/delegate's signature Date
Supervisor/delegate certification and signature
Contact telephone number
Supervisor/delegate's full name (please print)
Area code
Supervisor/delegate's position title
I certify that I have sighted the evidence required to support the vaccination information detailed above.
If entering this information on behalf of the employee, the employee consents to the use and storage of their COVID-19 vaccination information on their
employment record in myHR as outlined in the privacy notice.
One
Two
Vaccination type Vaccination brand
Evidence of
vaccination
Dose Date
*Enter if Other recognised COVID-19
vaccination or Other - COVID 19 Booster
selected
Not required for
booster
Enter date(s) for vaccination
dose received
Yes
Yes
