Fillable Peer reviewed self-assessment form (Bay of Plenty District Health Board New Zealand)

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Peer reviewed self-assessment form (Bay of Plenty District Health Board New Zealand)

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The Peer reviewed self-assessment form (Bay of Plenty District Health Board New Zealand) form is 3 pages long and contains:

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  • 36 check-boxes
  • 9 other fields

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VACCINATOR AUTHORISATION IN THE AUCKLAND REGION
Peer reviewed self-assessment form
Auckland Regional Public Health Service | vaccinator@adhb.govt.nz I www.arphs.health.nz/vaccinator Page 1 of 3
• This form is for authorised vaccinators who would like to renew their authorisation in the Auckland region.
• This form must be sent with a completed “Application for vaccinator authorisation” form.
• Section A must be completed by you (the applicant) first.
• Section B must be completed by a peer reviewer who is currently an authorised vaccinator and has observed
you providing vaccinations with the last 2 years.
SECTION A: FOR APPLICANT
Please complete entire section
Name of applicant
Standard 1
The vaccinator is competent
in the immunisation
technique and has the
appropriate knowledge and
skills for the task (selected
required characteristics)
You are equipped to deal with:
☐ anaphylaxis
☐ other reactions related to immunisation
☐ resuscitation
☐ spillages (blood or vaccine)
☐ safe disposal of equipment
Standard 2
The vaccinator obtains
informed consent to
immunise
In your vaccination practice, you consistently:
☐ obtain consent
☐ communicate immunisation information effectively and in a culturally
appropriate way
☐ support communication with suitable health education material
☐ allow time to answer questions and obtain feedback
☐ keep a written record that consent has been obtained
Standard 3
The vaccinator provides
safe immunisation
In your vaccination practice, you consistently:
☐ ensure continuity of the cold chain
☐ advise that vaccinees remain under observation for a minimum of 20 minutes
after immunisation
☐ inform the vaccine/caregiver about care after immunisations
☐ ascertain date of last immunisation
☐ enquire about reactions following previous vaccinations
☐ check for true contraindications
☐ determine current health of the vaccinee
☐ use aseptic techniques in preparing and administering all vaccines
☐ visually check the vaccine
☐ reconstitute vaccines with diluent provided (as appropriate)
☐ change needle between preparing and administering vaccine
☐ use correct needle size and length
Peer reviewed self-assessment form
August 2020
Auckland Regional Public Health Service | vaccinator@adhb.govt.nz I www.arphs.health.nz/vaccinator Page 2 of 3
SECTION A: FOR APPLICANT
Continued
Standard 3 continued
The vaccinator provides
safe immunisation
In your vaccination practice, you consistently:
☐ position vaccinee appropriately
☐ administer vaccine in appropriate site
☐ insert needle at correct angle, give vaccine gently
☐ dispose of needles and syringes in sharps container
☐ encourage comfort measures before, during and after vaccination
Standard 4
The vaccinator documents
information on the
vaccine(s) administered and
maintains patient
confidentiality
In your vaccination practice, you consistently:
☐ document relevant information, including recall date (if appropriate) in clinical
records and vaccinee-held records
☐ ensure the immunisation certificate is accurately completed, if applicable
☐ obtain the vaccinee’s/caregiver’s consent to inform the usual provider, if you
are not the usual provider
☐ ensure all personal documentation is appropriately treated and stored
☐ give immunisations according to the National Immunisation Schedule
recommendations for age
Standard 5
The vaccinator administers
all vaccine doses
In your vaccination practice, you consistently:
☐ plan catch-up immunisation with a minimum number of visits, if required
☐ defer or avoid vaccinating only if contraindicated or on vaccinee/caregiver
request
Comments
If you have any additional comments about your vaccination practice, please write below.
Declaration
I confirm that this self-assessment represents a true and accurate record of my vaccination practice.
Signature of applicant
Date
click to sign
signature
click to edit
Peer reviewed self-assessment form
August 2020
Auckland Regional Public Health Service | vaccinator@adhb.govt.nz I www.arphs.health.nz/vaccinator Page 3 of 3
SECTION B: FOR PEER REVIEWER
Please complete entire section
Name of peer reviewer
Phone
Email
Organisation
I am currently an authorised vaccinator and have observed the applicant providing vaccinations within the last 2 years
☐ Yes
☐ No (you cannot act as peer reviewer for this applicant)
Comments
If you have any comments about the applicant’s vaccination practice, please write below.
Declaration
To my knowledge, the applicant’s self-assessment is an accurate record of her/his vaccination practice. In my
judgement the applicant demonstrates appropriate clinical skills to be a competent vaccinator.
Signature of peer reviewer
click to sign
signature
click to edit
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Peer reviewed self-assessment form (Bay of Plenty District Health Board New Zealand)

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Completed 13 November 2020

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