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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