Employee Health Information
Hepatitis B Chickenpox (Varicella)
Have you had the Hepatitis B vaccine:
Have you had the chickenpox disease?
If not had disease had the chickenpox vaccine? Provide evidence of vaccine*
Provide serology result*
Measles, Mumps, Rubella (MMR) Diphtheria, Tetanus, Pertussis
Have you had the MMR vaccines: Have you had the childhood DTPa vaccines
2 doses Have you had an adult booster of dTpa?
1 dose Date of last vaccine:
(e.g. Boostrix or Adacel)
Have you had the disease:
Provide evidence of vaccine*
Annual influenza vaccine
Date of last vaccine:
Provide evidence of vaccine or serology* (if born after 1966)
Hand Hygiene – only complete if you have direct patient contact
Do you currently have any type or degree of skin problem on your hands, wrists, or forearms? Do
you have any proven skin allergies (e.g. by patch testing) on your hands, wrists, or forearms?
Do you ever need to wear a brace, splint, or compression garment on your hands, wrists, or forearms at work?
If you answered yes to any of the above, please provide more detail on the reverse of this form.
Office use only
evidence of past
How to get an immunisation history statement - Services Australia
click here for the Immunisation history website.
COVID-19 vaccines evidence*
Date of vaccines: