Fillable Form 26: for an Australian visa Medical examination (Department of Home Affairs)

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Form 26: for an Australian visa Medical examination (Department of Home Affairs)

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26 (Design date 08/19) - Page 1© COMMONWEALTH OF AUSTRALIA, 2019
Medical examination
for an Australian visa
Form
26
Department of Home Affairs
This form is for applicants who are required to undergo a
medical examination as part of an application for an Australian
visa. For information on heath examinations see
https://immi.homeaffairs.gov.au/help-support/meeting-
our-requirements/health
The Department of Home Affairs (the Department) is
authorised to collect the personal information on this form
under section 60 of the Migration Act 1958. When you
complete this form and give it to the panel physician or clinic,
the Commonwealth of Australia becomes the owner of the
personal information on the form. The panel physician is
required to send the form to the Department.
Your responsibilities
You must truthfully disclose your medical history and details
of any known medical conditions.
If outside Australia you must attend the same panel
physician during the course of your health examinations.
Visa subclass and visa name
To assist the Department to link your health examinations
with your visa application you must write the visa subclass
number and the name of the visa you are applying for on
page 4 of this form.
For example:
• Subclass 405 – Investor Retirement
• Subclass 600 – Sponsored Family Visitor stream
• Subclass 890 – Business Owner
This information is required for the visa decision-maker to
process your visa application.
You can find the visa subclass number and the name of the
visa on the Department’s website
https://immi.homeaffairs.gov.au/visas/getting-a-visa/
visa-listing
Completing health examinations before you lodge your
visa application
In some circumstances, the Department allows visa applicants
to complete health examinations before they lodge their visa
application. The Department’s website provides information
on where this is possible. For details see
https://immi.homeaffairs.gov.au/help-support/meeting-our-
requirements/health/when-to-have-health-examinations
You must undertake the required health examinations, as
requested by the panel physician.
Please be aware that if you do complete your health
examinations before lodging your visa application you may
need to undertake additional health examinations if:
• you later lodge a visa application for a different visa
subclass;
• you decide to stay in Australia for a longer period;
• you do not complete all the required health examinations;
or
• your health examinations expire prior to a decision being
made on your visa application.
If you have not lodged a visa application and a significant
health condition is identified which may impact on your ability
to meet the health requirement you will not be provided with
an opinion of the Medical Officer of the Commonwealth until
after you lodge your visa application.
Costs
The costs of health examinations are paid by you directly to
the panel physicians or clinics undertaking the examinations.
There may be additional costs if further tests or couriers are
required.
Outside Australia
If you are an applicant for a visa under Australia’s Offshore
Refugee and Special Humanitarian Programme the Australian
Government will cover the costs of your health examinations.
How to make an appointment for your medical
examination
Outside Australia
To undertake a medical examination outside Australia, please
contact your closest panel physician. For details see
https://immi.homeaffairs.gov.au/help-support/contact-
us/offices-and-locations/list
In Australia
To make an online booking to undertake a medical
examination in Australia you must contact the Migration
Medical Services Provider. For information on how to contact
the Migration Medical Services Provider see
https://immi.homeaffairs.gov.au/help-support/meeting-our-
requirements/health/arrange-your-health-examinations
For women
Women should not attend this medical examination during
menstruation as blood will taint the urinalysis.
What to bring to the examination
• Any prescription spectacles or contact lenses that you
may wear.
• Where you have a known medical condition, any existing
specialist reports.
Identification
A valid original passport is the form of identity documentation
preferred by the Australian Government.
You must bring a valid original passport with you where
possible.
There are limited circumstances in which the Department will
accept alternative identity documentation. For details see
https://immi.homeaffairs.gov.au/help-support/meeting-our-
requirements/health/your-health-examinations-appointment
Panel physicians are required to confirm the identity of
individuals who present at their clinic for Australian
immigration health examinations.
26 (Design date 08/19) - Page 2 © COMMONWEALTH OF AUSTRALIA, 2019
If you do not bring acceptable identification documentation to
the medical examination the processing of your visa
application may be delayed or may not proceed if the panel
physician is not satisfied with the identification
documentation.
Note: If you are a refugee, humanitarian or protection visa
applicant special arrangements regarding identification may
apply.
What tests may be required
Permanent visas
All applicants for permanent visas to Australia 15 or more
years of age are required to undergo Human
Immunodeficiency Virus (HIV) testing. Applicants for
permanent visas under 15 years of age must also undergo HIV
testing if they are being adopted, have a history of blood
transfusions, or have other clinical indications.
Note: These requirements also apply to applicants applying
for a provisional visa that has a permanent visa pathway.
Temporary visas
Applicants for temporary visas to Australia are not normally
required to undergo HIV testing except for certain groups or
if the panel physician decides it is clinically indicated.
Doctors, dentists, nurses and paramedics
Applicants intending to work as (or studying to be) a doctor,
dentist, nurse or paramedic are required to undergo a chest
x-ray and medical examination as well as HIV, Hepatitis B and
Hepatitis C testing.
Medical information
Medical information such as a chest x-ray is used to assess an
applicant’s standard of health. After a decision has been made
on the visa application it is usual for the Department to retain
the medical information. The medical information is retained
by the Department for use when assessing the applicant’s
health in the future and for panel physician audits to ensure
the quality of work undertaken by the panel physician
network.
Immunisation
Visa applicants are encouraged to be immunised against
infectious diseases before travelling to Australia. Visa
applicants who are unable to arrange their immunisation
before departure from their home country are encouraged to
seek advice on arrival in Australia. The Australian state and
territory health authorities assist people to obtain general
medical help and advice, including immunisation.
Parents are strongly encouraged to have their children
immunised against hepatitis B, diphtheria, tetanus, pertussis
(whooping cough), poliomyelitis, haemophilus influenzae
type-b (Hib), pneumococcal and meningococcal infections,
mumps, measles, rubella and varicella (chickenpox). Babies
between the ages of 2 and 8 months of age (only) are also
encouraged to be immunised against rotavirus.
Parents should bring any immunisation records for their
children with them to Australia.
Rubella vaccinations are strongly encouraged for women of
child-bearing age.
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.
Please keep these information pages for your reference
26 (Design date 08/19) - Page 3© COMMONWEALTH OF AUSTRALIA, 2019
Medical examination
for an Australian visa
Form
26
Department of Home Affairs
How to complete this form
Applicant
Examining
physician
Person
taking blood
• Complete Part A and Part B before attending the medical examination.
All questions must be answered.
• Complete Part C in the presence of the examining physician.
• Certify in writing across the top of the photograph and on the form (without
obliterating the image) that it is a true likeness of the examinee. Date to be included.
• Sight valid passport/national identity document (if provided) and record
passport/national identity document number below.
• You must ensure the applicant has provided answers to all the questions in Part A
and Part B before the applicant signs the declaration at Part C.
• Complete Part D.
• Certify in writing across the bottom of the photograph and on the form (without
obliterating the image) that it is a true likeness of the examinee. Date to be included.
YOUR PHOTOGRAPH
In Australia
If you need to bring a photo(s)
to the medical appointment at
the Migration Medical Services
Provider, they will advise you at
the time you make your
appointment.
Outside Australia
Please firmly attach a
recent passport size
photograph of yourself to
the form by staples or
other means. Another
copy of the same photo
should be used for
form 160 (if required).
To be completed by EXAMINING PHYSICIAN (or staff)
Valid passport sighted?
No
Yes
DAY MONTH YEAR
Passport number
Country of passport
Passport and photograph verified?
No Yes
Please attach a copy of the national identity card sighted to
identify the applicant, if applicable. The copy should be certified
by the examining physician.
Please attach a copy of the bio-data page of the passport
sighted to identify the applicant. The copy should be certified
by the examining physician.
Reason not presented
Details of national identity card or identity number issued to the applicant by
his/her government (if applicable).
Note: If the applicant is the holder of multiple identity numbers because he/
she is a citizen of more than one country, you need to enter the identity
number on the card from the country that the applicant lives in.
National identity
card number
Country of issue
Applicant’s full name (as it appears in passport or national identity card)
Family name
Given names
Date of birth
File number/PRID/CID
Date of application
Visa class
Name and address of office processing the application
Office use only
Sex Male Female
Indeterminate /
Intersex / Unspecified
26 (Design date 08/19) - Page 4 © COMMONWEALTH OF AUSTRALIA, 2019
7
Intended occupation/activity in Australia
8
Countries in which you have spent more than 3 consecutive months
in the last 5 years
11
If you are in Australia:
9
How long do you intend staying in Australia?
12
: :
Permanently
Temporarily For how long?
What is the visa subclass number and name of the visa that you are
applying for?
• how long have you been here?
• what visa subclass do you currently hold?
YEARS MONTHS
YEARS MONTHS
For more information please refer to page 1 of this form.
Part A – Applicant’s details
2
4
3
DAY MONTH YEAR
Date of birth
Family name
Given names
Your full name (as it appears in your passport)
5
Your telephone numbers
( ) ( )
( ) ( )
COUNTRY CODE AREA CODE NUMBER
Office hours
After hours
6
Your residential address
POSTCODE
14
In Australia, will you be:
(c) working or studying to be a doctor, dentist,
nurse or paramedic?
(a) attending or teaching classes?
(b) working in childcare/creche?
No Yes
No Yes
No Yes
10
If you are applying for a temporary visa, would you like your health to
be assessed ‘up-front’ for a permanent stay in Australia?
No
Yes
13
Are you:
No Yes
No Yes
No Yes
(d) a child for adoption by an Australian resident?
(b) an unaccompanied minor refugee child?
(c) a refugee?
No Yes
No Yes
No Yes
(a) a protection visa applicant?
(e) an Australian State or Territory Welfare
Supported child?
(f) a non-migrating family member of an applicant?
1
Your HAP ID
Additional medical examinations may be required.
To be completed by the applicant before attending the medical
examination.
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.
Indeterminate /
Intersex / Unspecified
Male Female
Sex
26 (Design date 08/19) - Page 5© COMMONWEALTH OF AUSTRALIA, 2019
DAY MONTH YEAR
Part B – Applicant’s medical history
15
If yes, list the relevant details, including dates
17
18
19
No Yes
No Yes
No Yes
No Yes
No Yes
Have you ever been diagnosed with, or had to
take treatment for, Tuberculosis (TB)?
Have you ever been admitted to hospital and/or
received medical treatment for an extended
period for any reason (including for a major
operation or treatment of a psychiatric illness)?
Do you suffer, or have you ever suffered, from
mental health problems?
Have you ever been told you are HIV positive?
28
Please list any prescribed pills or medication
(excluding oral contraceptives, over-the-counter
medication and natural supplements) you are taking
29
For female applicants – Are you pregnant? No Yes What is the expected date of birth?
16
Have you ever been in close contact at home
with a person known to have Tuberculosis (TB)?
20
Do you have, or have you ever had, hepatitis,
problems with your liver or yellowing of the skin?
21
Do you have, or have you had, cancer in the
last 5 years?
22
Do you have high blood sugar/diabetes?
23
Do you have heart problems, including high
blood pressure or a heart condition that you
were born with?
24
Do you have a blood condition?
25
Do you have bladder or kidney problems?
26
Do you have a physical or intellectual
disability that make it difficult for you to
function (for example, to move around or
learn) or work full-time?
27
Do you need to take drugs or drink
alcohol regularly?
No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
No Yes
26 (Design date 08/19) - Page 6 © COMMONWEALTH OF AUSTRALIA, 2019
Part C – Applicant’s declaration
To be signed and dated by the applicant in the presence of the
examining physician.
Before signing this declaration you must have completed all the
questions in Part A – Applicant’s details and Part B – Applicant’s
medical history.
A parent or guardian should sign on behalf of a child under 16 years of
age. In exceptional circumstances a child under 16 may sign if he or
she is able to understand and verify the information given on the form.
30
• I declare the information I have provided on this form is correct and I
have answered all questions.
• I understand that if I have given false or misleading information, my
application may be refused, and any visa issued may be cancelled.
• I agree to the examining physician contacting my treating doctor to
discuss and seek further information about any medical condition(s)
that may relate to my health assessment for a visa.
• I understand that the Commonwealth of Australia becomes the
owner of the information on this form and that the panel physician is
required to send the form to the Department.
• I have read the information on page 2 at Medical information and I
consent to the Department retaining my medical information.
• I consent to the Department passing on relevant sensitive
information (including about my health) to the panel physician(s)
who examined me, clinic administrative staff, Australian law
enforcement, health agencies and international agencies, including
overseas recipients with whom we have a Memorandum of
Understanding. The reasons for this release of information may
include, but are not limited to, investigation and resolution of
inconsistencies, complaints or audit recommendations.
• I consent to the Department destroying my personal data after a
certain period of time where consistent with the Department’s
archiving obligations and any current disposal authorities.
Consequently if I do not request a copy of this data from the clinic I
attend when undergoing my immigration health examinations, I
understand it may not be available for me to retrieve at a later date.
Applicant’s
signature
Date
DAY MONTH YEAR
If signing on behalf of a child under 16 years of age –
Name of parent or guardian
Relationship
to child
-
26 (Design date 08/19) - Page 7© COMMONWEALTH OF AUSTRALIA, 2019
1
• Please answer ALL questions in English.
• For Hepatitis B, C and HIV testing, please ensure that pre and post-test counselling are carried out in accordance with the panel instructions, including
advice on vaccination for close contacts of those testing Hepatitis B surface antigen positive.
• Parents should be present when children are examined.
Was a chaperone present during the examination? No Yes Declined
Height and weight Centimetres Kilograms
Cardiovascular system
Part D – Physical examination — to be completed by the examining physician
Date of examination
DAY MONTH YEAR
3
Eyes (including fundoscopy) Normal Abnormal
Right LeftBest distance visual acuity (with or without correction)
4
Urinalysis
Complete for all persons 5 or more years of age, and those
persons under 5 years of age where clinically indicated.
In women, where an abnormality occurs due to menstruation, please
repeat and record urinalysis following completion of menstruation.
Blood
Protein
Glucose
Blood
Protein
Glucose
For a repeated test at a
later date – Date repeated
DAY MONTH YEAR
Note: If you notice any abnormalities in response to the following questions, you must provide details of the physical examination.
Normal Abnormal
Normal Abnormal
Blood pressure (required for all persons 15 or more years of age) Systolic Diastolic
2
6
Respiratory system
For current or previous tuberculosis, provide date and duration
of treatment and names, strengths and dosages of drugs used.
Please enclose old chest x-ray films and/or report if available.
Normal Abnormal
7
Nervous system: Sequelae of stroke
or cerebal palsy, other neurological
disabilities
Normal Abnormal
11
Mental and cognitive status
Normal Abnormal
12
Intellectual ability
8
Normal AbnormalGastrointestinal system
Normal Abnormal
9
Musculosketal system
(including mobility for all persons
60 or more years of age)
Normal Abnormal
10
Endocrine system
Normal Abnormal
13
Ear/nose/throat/mouth
Normal Abnormal
14
Hearing
5
26 (Design date 08/19) - Page 8 © COMMONWEALTH OF AUSTRALIA, 2019
If insufficient space, attach additional details
Negative Positive
23
Syphilis Test (VDRL or RPR)
Obtain and attach VDRL, RPR
or equivalent test results for:
• protection visa applicants
15 or more years of age
(see Question 13(a), of
Part A – Applicant’s
details);
• refugees 15 or more years
of age;
• any other person where
clinically indicated.
Negative Positive
Negative Positive
Negative Positive
20
Human Immunodeficiency
Virus test (HIV)
21
Hepatitis B surface antigen
blood test
22
Hepatitis C antibody
blood test
Results of initial test
If initial test is positive, repeat and perform
confirmatory test and record results
Absent Present
19
Evidence of drug taking
(eg. venous puncture marks)
18
Are there any physical or mental conditions
which may prevent this person from attending
a mainstream school, gaining full employment
or living independently now or in the future?
No Yes
Normal Abnormal
Not applicable
17
Breast examination where
indicated
Normal Abnormal
Not applicable
Developmental milestones
(if less than 5 years of age)
15
Normal Abnormal
16
Skin and lymph nodes
If required:
Pathology results
Please refer to the Health Examinations List to see whether the following blood tests are required, or perform if clinically indicated
and comment on the clinical indication(s).
Note: Attach the pathology report(s) to this form.
26 (Design date 08/19) - Page 9© COMMONWEALTH OF AUSTRALIA, 2019
24
Please consider the information that you have recorded regarding this client and provide a grading on their medical examination below.
Supporting comments must be provided if you decide to provide a B grading.
No significant history or abnormal findings present
Significant history or abnormal findings present Please list significant history or abnormal findings
Examination grading
For ALL VISA APPLICANTS except protection visa applicants or Australian state or territory supported visa applicants in Australia
A
B
25
Please consider the information that you have recorded regarding this client and provide a grading on their medical examination below.
Supporting comments must be provided if you decide to provide a B grading.
Note: This is not a rating of whether the applicant will meet the health criteria.
No significant history or abnormal findings related to
public health present
Examination grading
For PROTECTION visa applicants or STATE OR TERRITORY WELFARE SUPPORTED CHILD visa applicants in Australia only
A
B
Please list significant history or abnormal findings related to public healthSignificant history or abnormal findings present that may
indicate that the applicant has a disease or condition that
is, or may result in the applicant being, a threat to public
health in Australia or a danger to the Australian community.
Note: Any relevant results and reports should be referred
to a Medical Officer of the Commonwealth for opinion
I declare that I have examined the applicant and that this is a true and correct record of my findings.
26
Panel
physician’s
signature
Date
DAY MONTH YEAR
Full name
(please print)
Contact telephone
number
( ) ( )
COUNTRY CODE AREA CODE NUMBER
Place of
examination
Postal address
Email address
POSTCODE
This declaration must be signed and dated by the panel physician who personally performed the examination.
Declaration
Note: Australia strongly recommends all persons over one year of age to hold an international yellow fever vaccination certificate if, within the 6 days
prior to their arrival in Australia, they have stayed overnight or longer in a declared yellow fever infected country, in Africa, the Caribbean, Central or
South America. If the client does not hold an international yellow fever certificate, the client will still be permitted to enter Australia and will be issued
with a ‘Yellow Fever Action Card’ on arrival in Australia. The card provides instructions on what visa holders should do. For further information, refer
to www.health.gov.au
For visa applicants outside Australia — Do not give the form and report(s) to the applicant. You may, however, provide the applicant with
a copy of your report(s) for their records. Place the form and report(s) inside a secured envelope and return it directly to the office of the Department
specified in the attached covering letter, the return address specified in the ‘Office use only’ section on page 3 of this form or in the ‘Where to send
Australian immigration medical forms, results and x-rays’ document.
For protection visa applicants — Forward the form and report(s) according to local arrangements with the Migration Medical
Services Provider.
ALL VISA APPLICANTS
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Form 26: for an Australian visa Medical examination (Department of Home Affairs)

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Completed 16 May 2021

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