Fillable Form 1392: Pregnancy health undertaking (Department of Home Affairs)

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Form 1392: Pregnancy health undertaking (Department of Home Affairs)

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Country of origin: AUSTRALIA
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1392 (Design date 07/19) - Page 1© COMMONWEALTH OF AUSTRALIA, 2019
Pregnancy health undertaking
Form
1392
Department of Home Affairs
Important – Please read this information carefully before you
complete your pregnancy health undertaking. Once you have
completed your pregnancy health undertaking we strongly
advise that you keep a copy for your records.
Who is required to sign a pregnancy health
undertaking?
A pregnancy health undertaking is required for pregnant visa
applicants who have not had the required chest x-ray.
What is a pregnancy health undertaking for?
Tuberculosis is a serious infectious disease of public concern
in Australia and a chest x-ray is the best screening tool for
active tuberculosis.
You have been asked to sign a pregnancy health undertaking
because you have not undergone a chest x-ray as part of the
health examinations required for your visa application due to
your pregnancy.
A pregnancy health undertaking is an agreement that is
made with the Australian Government, which obliges you
to undergo a chest x-ray at the Migration Medical Services
Provider after the birth of your child.
By signing this pregnancy health undertaking you also agree
to undergo any course of treatment or investigation that the
health clinic directs.
Important: You must contact the Migration Medical Services
Provider within 9 months of the grant of your visa and make
an appointment.
How to make an appointment for a pregnancy health
undertaking
For information on how to make an appointment for a
pregnancy health undertaking see
https://immi.homeaffairs.gov.au/help-support/meeting-
our-requirements/health/health-undertaking
What do I do now?
Should you agree to abide by the pregnancy health
undertaking, you should sign this form and return it to
the Department of Home Affairs (the Department) office
processing your visa application.
You will then be provided with a copy of this form.
Please keep the copy as you will need it when you
attend your appointment at the health clinic.
Where do I go?
The Migration Medical Services Provider will advise you which
health clinic you should attend to undergo your chest x-ray
in Australia. Once you contact the Migration Medical Services
Provider your health information will be referred to that
nominated health clinic.
Please keep this information page for your reference
Costs
The cost of the chest x-ray is paid by you directly to the
Migration Medical Services Provider.
Why should I attend a health clinic?
It is in your best interests to comply with the requirements of
your pregnancy health undertaking. The health examination
is necessary to minimise the risk of spread of tuberculosis to
close family, friends and the community. If the doctor thinks it
is necessary, treatment for tuberculosis will be arranged.
Your co-operation with the pregnancy health undertaking is
vital to assist the Australian Government to protect you, your
family and the Australian community.
Important information about privacy
Your personal information is protected by law, including the
Privacy Act 1988. Important information about the collection,
use and disclosure (to other agencies and third parties,
including overseas entities) of your personal information,
including sensitive information, is contained in form 1442i
Privacy notice. Form 1442i is available from the Department’s
website www.homeaffairs.gov.au/allforms/ You should
ensure that you read and understand form 1442i before
completing this form.
This page is intentionally blank
1392 (Design date 07/19) - Page 3© COMMONWEALTH OF AUSTRALIA, 2019
Pregnancy health undertaking
Form
1392
Department of Home Affairs
Please read the information about your pregnancy health undertaking
on page 1 of this form.
Your details
Family name
Given names
Your full name
Date of birth
DAY MONTH YEAR
1
2
33
Do you have a passport?
No
Yes
DAY MONTH YEAR
Passport number
Country of passport
Date of issue
Date of expiry
Issuing authority/
Place of issue as
shown in your
passport
Give details
Visa applicants will be required to hold a valid passport before they can
be granted a visa. It is strongly recommended that the passport be valid
for at least 6 months.
If you change your passport after you have been granted a visa
you must notify the nearest Australian Visa Office or office of the
Department.
WARNING: You will not be granted a visa without this information.
HAP ID
ICSE Client ID
Office use only
4
5
6
Telephone numbers
Mobile
Office hours
After hours
No
Yes Give details
Fax number
Email address
Do you agree to the Department communicating with you by fax,
email, or other electronic means?
POSTCODE
Note: Give full residential address, including postcode and telephone
number where possible. If you do not know what your address in
Australia will be, you must give the name and address of a person in
Australia who will know how to contact you (for example, a relative,
a friend, your employer or a staff member at your proposed study
institution).
Address
Contact details in Australia
(AREA CODE )
(AREA CODE )
(AREA CODE )
Intended duration of stay in Australia
permanent
temporary Indicate length of stay in Australia
months weeks days
3
Tick where applicable
Please open this form using Adobe Acrobat Reader.
Either type (in English) in the fields provided or print this form
and complete it (in English) using a pen and BLOCK LETTERS.
1392 (Design date 07/19) - Page 4 © COMMONWEALTH OF AUSTRALIA, 2019
Client undertaking Consent for release of health information
7
8
I undertake the following:
• to contact the Migration Medical Services Provider within 9 months
of the grant of my visa;
• to report to the health clinic which the Migration Medical Services
Provider refers me to;
• to present my copy of this document to that health clinic, to place
myself under the health clinic’s professional supervision and
undergo a chest x-ray, any required course of treatment, and other
examination or investigation;
• to inform the Migration Medical Services Provider each time I
change my address in Australia throughout the period during which
my health is being monitored;
• to inform the Migration Medical Services Provider whenever I am
about to leave Australia and to report upon my return, throughout
the period during which my health is being monitored; and
• (for applicants outside Australia) to inform the Australian Visa Office
where I lodged my visa application if, before my departure, I change
my proposed address in Australia or travelling times.
As a part of the pregnancy health undertaking the Department,
the Migration Medical Services Provider, state and territory health
authorities and the relevant health clinic need to release health
information to each other. Information will only be released if it relates
to the visa and will be strictly guided by the Privacy Act 1988.
I consent to the Department disclosing my personal information to
the Migration Medical Services Provider, state and territory health
authorities and the relevant health clinic for the purpose of monitoring
this pregnancy health undertaking.
I consent to authorise the Migration Medical Services Provider, state
and territory health authorities and the relevant health clinic to disclose
to the Department:
• the result of the chest x-ray; and
• information about any follow-up treatment required.
Your
signature
Your
signature
We strongly advise that you keep a copy of your pregnancy
health undertaking for your records and provide a copy to the
health clinic.
WARNING: Giving false or misleading information is a serious offence.
Date
Date
DAY MONTH YEAR
DAY MONTH YEAR
-
-
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Form 1392: Pregnancy health undertaking (Department of Home Affairs)

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Completed 16 February 2021

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