Fillable Volunteer HCW Section 1: Immunisation screening INSTRUCTIONS (Australian National University)

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Volunteer HCW Section 1: Immunisation screening INSTRUCTIONS (Australian National University)

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1
Section 1: Immunisation screening
INSTRUCTIONS
> Please complete this form and obtain as much of the required documentation as possible.
> Agency/Locum/Contract HCW and Education Facilitator: please take this form and the supporting documents to your own
doctor or a designated immunisation provider (doctor or authorised Immunisation Nurse) if directed by your Agency or
educational institution.
> Volunteer HCW: please take this form and supporting documents to the SA Health person managing your Volunteer
po
sition.
Surname:
First Name:
Contact Number: Preferred Name:
Address: Post Code:
Preferred Email: Date of Birth
1. Hepatitis B virus (HBV)
Have you completed a full course of
HBV vaccine (either 3 doses, or
2 doses if given between 11 to
15 years of age)
AND had a blood test result
showing immunity (hepatitis B
surface antibody [anti-HBs]
≥10mIU/mL)?
OR
Have you had resolved HBV
infection in the past AND had a
blood test to confirm you are
immune (hepatitis B core
antibody)?
YES, you are considered immune to
HBV.
Documentation required
Blood test result indicating the
required titre level.
NO, You can commence work in SA Health once you have
started the vaccine course, agreed to complete the course,
and have the blood test to check immunity after starting in
your role.
DON’T KNOW, you need to see your doctor to have a
blood test to check your immunity.
> If the blood test shows you are immune you do not
need to take further action.
> If the blood test does not show immunity you need to
see your immunisation provider to commence the
hepatitis B vaccine course followed by a blood test 4-8
weeks after the last vaccine to check for immunity.
> If you have had a full vaccine course but no blood test,
you should see your immunisation provider for a
hepatitis B booster vaccine and blood test 4 weeks later.
2. Measles, Mumps, Rubella (MMR)
2a. Were you born before 1966? YES, measles, mumps and rubella
vaccination not required. Go to 3.
NO, go to 2b
2b. Do you have evidence of
vaccination with at least
2 doses of a MMR vaccine?
YES, you are considered immune to
measles, mumps and rubella.
Go to 3.
Documentation required
Vaccination record for both doses
NO go to 2c
2c. Do you have evidence of
immunity to measles, mumps
and rubella infection
(laboratory evidence of past
infection or immunity)?
YES, you are considered immune to
measles, mumps and rubella.
Documentation required
Blood test result indicating immunity
for measles, mumps and rubella
NO or DON’T KNOW, you need to see your immunisation
provider to commence/complete the MMR vaccine
course.
> If you are pregnant, planning to get pregnant, or if your
immune system is suppressed you should NOT have
these vaccines and discuss this with your doctor.
> You do NOT need to have a blood test to check
immunity following this vaccination course.
> If you are confident you have had two doses of MMR
vaccine but do not have the documentation, consider
seeing your doctor to have a blood test to check for
immunity before having the vaccine course.
Agency / Contract / Locum HCW / Education Facilitator /
Volunteer HCW
Health Care Worker Immunisation Screening Form
NDAYISABA
EMMANUEL
0469817233
MANNY
6 ELGIN PLACE, HAMPSTEAD GARDENS
5086
16/12/1985
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■
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2
Surname:
First Name:
3. Chickenpox (varicella-zoster virus)
3a Have you had chickenpox in the
past?
YES, you are considered immune to
chickenpox. Go to 4.
Documentation not required
NO, go to 3b
3b Have you had a blood test
showing immunity to
chickenpox?
B
lood test result showing immunity
to chickenpox.
NO, go to 3c
3c. Have you had two doses of a
varicella-containing vaccine
(or one dose if given before
14 years of age)?
YES, you are considered immune to
chickenpox.
Documentation required
Vaccination record for both doses
(or for one dose if given before
14 years of age).
NO or DON’T KNOW, you need to see your doctor to
EITHER have two doses of varicella vaccine OR a blood test
to see if you are immune to chickenpox.
> If the blood test result shows you are immune, you do
not need to take further action.
> If the blood test result does not indicate immunity you
need to commence/ complete the varicella vaccine
course.
> You do NOT need to have a blood test to check your
immunity following this vaccination course.
4. Diphtheria, Tetanus and Pertussis (dTpa)
Have you had a primary course
(3 doses) of a diphtheria / tetanus /
pertussis toxoid-containing vaccine
(usually given in childhood)
AND
had a booster dose of dTpa vaccine
in the last 10 years?
YES, you are considered immune to
diphtheria, tetanus and pertussis.
Documentation required
Vaccination record for the most
recent booster dose.
Documentation not required for the
primary course.
NO or DON’T KNOW,
> You need to see your immunisation provider to
commence/ complete the primary dTpa vaccine course.
> If you have had a primary course but no booster in the
last 10 years, you need to see your immunisation
provider for a dTpa booster vaccine.
> You do NOT need to have a blood test to check
immunity following this vaccination.
5. Influenza
Have you had the seasonal
influenza vaccine this year?
YES.
Documentation not required
NO or DON’T KNOW, it is highly recommended that you
have a seasonal influenza vaccination from your
immunisation provider every year.
6. Poliomyelitis
Have you received a full 3 dose
course of polio vaccination (by
mouth or by injection) usually given
in childhood?
YES, no further action required.
Documentation not required
NO or DON’T KNOW, you need a three dose course of
inactivated poliomyelitis vaccine (IPV).
> You do NOT need to have a blood test to check
immunity following this vaccination.
7. Hepatitis A
Only complete this question if you
are working or likely to be working
in remote Indigenous communities,
with Indigenous children, or with
people with developmental
disabilities.
Have you received 2 doses of
hepatitis A vaccine, at least
6 months apart?
YES, you are considered immune to
hepatitis A.
Documentation required
Vaccination record
NO or DON’T KNOW, you should have two doses of
hepatitis A vaccine, at least 6 months apart.
> You do NOT need to have a blood test to check
immunity following this vaccination.
YES, you are considered immune
to chickenpox. Go to 4.
Documentation required
NDAYISABA
EMMANUEL
■
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3
Section 2: Tuberculosis screening
INSTRUCTIONS
> Only complete this section if required by your agency, educational institution or SA Health employee managing volunteer
placements.
> If asked to complete this section, please ensure you attach evidence of your previous tuberculosis screening records and relevant
blood test results if applicable.
Surname: First Name:
Previous Surname: Date of Birth
1. Exposure risk
a) Were you born in Australia? Yes No If no, Country of birth?
Year of Arrival in Australia? Years Spent in Country of Birth:
b) Have you worked or lived outside of Australia for periods of more than 3 months?
Yes (please give details from most recent dates below) No
Country Year left Length of stay
c) Have you volunteered in a developing nation or travelled in a high TB endemic region where you had close contact amongst locals?
Yes (please give details from most recent dates below) No
Country Date Activity Length of stay
2. TB contact history
a) Have you ever been involved in the care of patients with TB, or had close contact with someone who had TB (e.g. family member, friend)?
Yes No If yes did you wear an N95 or P2 respirator mask that had been fit tested? Yes No
Please provide details:
3. TB history
a) Have you ever had Tuberculosis in the past? Yes No
If yes, Were you treated?
Yes No
Please provide details:
b) Do you currently have any of the following symptoms?
Cough
Yes No
If yes, duration (weeks)?
Fever
Yes No
If yes, duration (days/weeks?
Weight loss
Yes No
If yes, estimate (kgs)?
4. TB immunisation / screening tests
NOTE - Attach supporting evidence
a. Have you had a BCG vaccination against
TB?
Yes No
Date:
b. Have you had a Mantoux Skin Test? Yes No
Result in mm: Date:
c. Have you had a blood test for TB? Yes No
Result: Date:
d. Have you ever had a chest x-ray?
Yes No
Result: Date:
Agency / Contract / Locum HCW / Education Facilitator /
Volunteer HCW
Health Care Worker Immunisation Screening Form
NDAYISABA
EMMANUEL
16/12/1985
■
RWANDA
■
■
■
■
■
■
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NEG
2016
4
Section 3: Other health information
INSTRUCTIONS
> Only complete this section if required by your agency, educational institution or SA Health employee managing
volunteer placements.
Surname:
First Name:
Date of Birth
1. Hepatitis C virus (HCV)
Do you know your status in relation
to HCV?
YES
> If you are HCV antibody negative,
you do not need to take further
action.
> If you are HCV antibody positive,
you must seek confidential
medical and career advice from
an infectious diseases specialist
and not undertake any exposure
prone procedures until cleared to
do so by the specialist
Documentation not required
NO or DON’T KNOW
2. Human immunodeficiency virus (HIV)
Do you know your status in relation
to HIV?
YES
> If you are HIV antibody negative,
you do not need to take further
action.
> If you are HIV antibody positive,
you must seek confidential
medical and career advice from
an infectious diseases specialist
and not undertake any exposure
prone procedures until cleared to
do so by the specialist
D
ocumentation not required
NO or DON’T KNOW
3. Do you have a skin condition that affects your hands or forearms (e.g. dermatitis, eczema or psoriasis)? Yes No
If yes, please provide details
4. Do you have any allergies to latex, chemicals or substances? Yes No
If yes, please provide details
Agency / Contract / Locum HCW / Education Facilitator /
Volunteer HCW
Health Care Worker Immunisation Screening Form
> As a health care worker you have a responsibility to
know your HIV status by having a blood test for HIV
antibody.
> You do not need to inform SA Health of your status.
> As a health care worker you have a responsibility to
know your HCV status by having a blood test for HCV
antibody.
> You do not need to inform SA Health of your status.
NDAYISABA
EMMANUEL
■
■
■
■
5
S
urname:
First Name:
5. Do you have a medical condition or are you having treatment that might suppress your immunity? Yes No
If yes, please provide details here or arrange to see the Worker Health Nurse / Infection Control Practitioner once you have started work or
placement.
6. Have you ever been Fit tested for a N95/P2 mask? Yes No
When:
Where:
Mask type/make:
Mask size:
Do you know how to perform a fit check? Yes No
Have you ever experienced difficulty wearing a N95/P2 mask? Yes No
Thank
you for completing these Health Care Worker Screening forms
NDAYISABA
EMMANUEL
■
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2021
SA HEALTH
M3
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This page is left blank
intentionally
6
CERTIFICATE OF COMPLIANCE
Health Care Worker Immunisation Policy Directive (SA Health)
Replace with your logo here
Immunisation provider (medical practitioner or authorised immunisation nurse) instructions:
> Based on the acceptable evidence of immunity to specific vaccine preventable diseases (VPD) for health care workers (HCW) table on the back of this form please tick all relevant boxes for
each VPD.
> If immunity is confirmed, complete the second signature box below. If a recommended course of vaccination has commenced, complete the first signature box and arrange follow-up. O
nce
immunity is confirmed, then complete the second box
Name
Date of birth (dd/mm/yyyy)
Student ID (if student)
VPD
Immune status
Blood test result or date vaccination given
(to be completed following review of Screening Questionnaire)
Immunity confirmed by
Not immune
Chickenpox
(varicella-zoster)
History of past infection
Vaccination record
Blood test result: Immune Not immune
Blood test result
Blood test result
Vaccine (dose 1) given: Yes No
Date:
Vaccination record
Vaccine (dose 2) given: Yes No
Date:
Diphtheria, tetanus
and pertussis
Vaccination record of booster dose in
last 10 years
Vaccination recommended (booster) Vaccine (booster) given: Yes No Date:
Poliomyelitis Vaccination history Vaccination recommended Primary vaccination course started: Yes No
Measles, mumps and rubella
Vaccination record
Vaccination recommended
Vaccine (dose 1) given: Yes No
Date:
Blood test result
Vaccine (dose 2) given: Yes No
Date:
Born before 1966
Hepatitis B
Blood test result
Serological testing recommended
Blood test result: Immune Not immune
Vaccination recommended
Vaccine (dose 1) given: Yes No Date:
Vaccine (dose 2) given: Yes No Date:
Vaccine (dose 3) given: Yes No Date:
Hepatitis A
Recommended for HCWs working
in remote Indigenous
communities, with Indigenous
children or people with
developmental disabilities
History of past infection
Vaccination record
Blood test result: Immune Not immune
Blood test result
Blood test result
Vaccine (dose 1) given: Yes No
Date:
Vaccination record
Vaccine (dose 2) given: Yes No
Date:
Authorised Immunisation Provider Declaration
In Progress
The above-named person has
commenced a course of vaccination (as
indicated above) and will require further
follow up.
Practice Stamp or
Address Here
Compliant
The above-named person has acceptable
evidence of immunity to the vaccine-
preventable diseases noted above.
Practice Stamp or
Address Here
Provider No:
Print Name:
Provider No:
Print Name:
Signature:
Date:
Signature:
Date:
7
EMMANUEL NDAYISABA
16/12/1985
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Acceptable evidence of immunity to specific vaccine preventable diseases (VPD) for health care workers
VPD Acceptable evidence of immunity
Chickenpox
(varicella-zoster)
> Documented serological evidence of varicella antibody (IgG) or
> Documented evidence of age-appropriate varicella vaccination or
> History of prior chickenpox or shingles (no documentation required for history of infection).
> Confirmation of immunity post-vaccination not required.
Diphtheria
> Documented evidence of booster dose of diphtheria-containing vaccine in the last 10 years.
> Confirmation of immunity post-vaccination not required.
Hepatitis A
> Documented serological evidence of hepatitis A antibody (IgG) or
> Documented evidence of completed course of hepatitis A vaccine or
> Documented laboratory evidence of past infection
> Confirmation of immunity post-vaccination not required.
Hepatitis B
> Documented evidence of hepatitis B core antibody or documented level of hepatitis B surface antibody (>10mlU/ml) following completion of course of hepatitis B vaccine.
> Confirmation of immunity post-vaccination is required for all HCWs after completion of vaccination course.
> All HCW who have lived in a hepatitis B endemic country for at least 3 months are required to have serology, including hepatitis B surface antigen, prior to vaccination.
Measles
> Documented serological evidence of measles antibody (IgG) or
> Documented evidence of two measles-containing vaccines at least 1 month apart or
> Born before 1966 or
> Documented laboratory evidence of past infection.
> Confirmation of immunity post-vaccination not required.
Mumps
> Documented serological evidence of mumps antibody (IgG) or
> Documented evidence of two mumps-containing vaccines at least 1 month apart or
> Born before 1966 or
> Documented laboratory evidence of past infection.
> Confirmation of immunity post-vaccination not required.
Pertussis
> Documented evidence of pertussis-containing booster vaccine in the previous 10 years.
> Confirmation of immunity post-vaccination not required.
Poliomyelitis
> History of vaccination with a primary course of three vaccinations (documentation not required).
> Confirmation of immunity post-vaccination not required.
Rubella
> Documented serological evidence of rubella antibody (IgG) or
> Documented evidence of two rubella-containing vaccines at least 1 month apart or
> Born before 1966 or
> Documented laboratory evidence of past infection.
> Confirmation of immunity post-vaccination not required.
Tetanus
> Documented evidence of a booster dose of tetanus-containing vaccine in the last 10 years.
> Confirmation of immunity post-vaccination not required.
8
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Volunteer HCW Section 1: Immunisation screening INSTRUCTIONS (Australian National University)

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