Fillable form under section 60 of the Migration Act (Department of Home Affairs)

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form under section 60 of the Migration Act (Department of Home Affairs)

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160 (Design date 08/19) - Page 1© COMMONWEALTH OF AUSTRALIA, 2019
Radiological report on chest x-ray of an
applicant for an Australian visa
Form
160
Department of Home Affairs
This form is for applicants who are required to undergo a
chest x-ray 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 and use 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
information on the form. The panel physician is required to
send the form to the Department.
Your responsibilities
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 outside Australia you must attend the same radiology clinic
during the course of your health examinations.
If you are an applicant for a visa under Australia’s Offshore
Refugee and Special Humanitarian Programme the Australian
Government provides arrangements to cover the costs of your
health examinations.
In Australia
If you are in Australia and you have applied for a protection
visa, special arrangements may apply in regard to the costs of
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 (Residence).
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.
How to make an appointment for your chest x-ray
Outside Australia
If you only require a chest x-ray, please contact your closest
panel radiology clinic and if necessary, obtain a referral from a
panel physician. If you also require a medical examination,
first contact a panel physician who will refer you to a panel
radiologist. 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 chest x-ray 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
Pregnant visa applicants and the chest x-ray
requirement
A pregnant visa applicant who is required to complete a chest
x-ray needs to discuss her options with her own treating
doctors and/or the examining panel physician or radiologist.
A pregnant visa applicant may choose to either proceed with
the chest x-ray or defer until after the child’s birth.
If you decide to defer the chest x-ray until after the child’s birth
A pregnant visa applicant should advise the Department if she
decides to defer her chest x-ray until after the child’s birth.
160 (Design date 08/19) - Page 2 © COMMONWEALTH OF AUSTRALIA, 2019
If you are prepared to undergo a chest x-ray while pregnant
If a pregnant visa applicant is prepared to undergo a chest
x-ray, it is recommended that she consults with her doctor
before arranging her appointment for a chest x-ray and that
special precautions are taken (eg. using a double protective
lead shield and waiting until at least the second trimester).
A pregnant visa applicant must sign the declaration on page 4
before undergoing a chest x-ray.
Undergoing a chest x-ray does not guarantee the grant of a
visa. Where a chest x-ray shows abnormalities, the visa
applicant may be asked to undergo more specific tests and a
course of treatment.
What to bring to the examination
Any previous chest x-ray films you have, particularly those
from the last 5 years. The radiologist may ask you to submit
these film(s) to the Department if they consider it necessary
to assess your health.
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
The radiology clinic is required to confirm the identity of
individuals who present at their clinic for Australian
immigration health examinations.
If you do not bring acceptable identification documentation
the processing of your visa application may be delayed or may
not proceed if the clinic is not satisfied with the identification
documentation.
Note: If you are a refugee, humanitarian or protection visa
applicant special arrangements regarding identification may
apply.
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.
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
160 (Design date 08/19) - Page 3© COMMONWEALTH OF AUSTRALIA, 2019
Radiological report on chest x-ray of an
applicant for an Australian visa
Form
160
Department of Home Affairs
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 26 (if required).
How to complete this form
Applicant
Radiographer
Radiologist
• Complete Part A (with the exception of the ‘Pregnant visa applicant’s declaration’)
before attending the radiological examination. All questions must be answered.
• Complete Part B in the presence of the radiographer.
• 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 card (if provided) and record
passport/national identity card number below.
• You must ensure the applicant has provided answers to all the questions in Part A
before the applicant signs the declaration at Part B.
• Complete Part C.
• Complete Part D.
To be completed by RADIOGRAPHER (or staff)
Part A – Applicant’s details
2
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 radiographer.
Please attach a copy of the bio-data page of the passport
sighted to identify the applicant. The copy should be certified
by the radiographer.
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
4
Date of birth
To be completed by the applicant before attending the radiological
examination.
3
DAY MONTH YEAR
Date of birth
Family name
Given names
Your full name (as it appears in your passport or national identity document)
5
Your telephone numbers
( ) ( )
( ) ( )
COUNTRY CODE AREA CODE NUMBER
Office hours
After hours
File number/PRID/CID
Date of application
Visa class
Name and address
of office processing
the application
Office use only
Sex Male Female
1
Your HAP ID
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
Indeterminate /
Intersex / Unspecified
160 (Design date 08/19) - Page 4 © COMMONWEALTH OF AUSTRALIA, 2019
6
Your residential address
POSTCODE
7
Intended occupation/activity in Australia
8
How long do you intend staying in Australia?
11
Have you undertaken a health examination for an
Australian visa in the last 12 months?
Permanently
Temporarily
For how long?
(including non-migrating family member of
an applicant)
YEARS MONTHS
No
Yes
Give details (including HAP ID if available)
12
For female applicants
No
Yes
Are you pregnant?
What is the expected date of birth?
Note: Please read the information under ‘Pregnant visa
applicants and the chest x-ray requirement’ on pages 1–2
of this form. Then, after consultation with a doctor and/or
radiologist, read and sign the declaration below.
DAY MONTH YEAR
Go to Part B
Applicant’s
signature
Date
DAY MONTH YEAR
9
If you are in Australia:
: :
• how long have you been here?
• what visa subclass do you currently hold?
YEARS MONTHS
10
What is the visa subclass number and the name of the visa that
you are applying for?
For more information please refer to page 1 of this form.
Part B – Applicant’s declaration
To be signed and dated by the applicant in the presence of the
radiographer.
Before signing this declaration you must have completed all the
questions in Part A – Applicant’s details.
A parent or guardian should sign on behalf of a child under 16 years of age.
In exceptional circumstances a child under 16 years of age may sign if he
or she is able to understand and verify the information given on the form.
13
• 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 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 radiologists/panel
physicians 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 (including
digital x-ray images and photographs) 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
-
-
Pregnant visa applicant’s declaration
To be signed and dated by the pregnant visa applicant after
consultation with a doctor and/or radiologist.
I have read the information on pages 1–2 of this form and understand
that the Department of Home Affairs requires that
a pregnant visa
applicant:
• consults her doctor and/or the examining panel physician or
radiologist to discuss her options before undergoing a chest x-ray.
• is provided with a full explanation of the risks.
• takes special precautions (eg. using a double protective lead shield
and waiting until at least the second trimester).
• makes a decision on this basis of whether to proceed with the chest
x-ray or defer until after the child’s birth.
I understand that undergoing a chest x-ray does not guarantee the
grant of the visa.
In full knowledge of the above, I wish to proceed with the required
chest x-ray while pregnant.
160 (Design date 08/19) - Page 5© COMMONWEALTH OF AUSTRALIA, 2019
Part C – Radiographer to complete
Please provide large (14 x 17 inch) posteroanterior (PA) film if possible.
The x-ray film must bear the date of the examination, the applicant’s
family and given names, the HAP ID (if available), and the name of the
clinic. This information is to be automatically inscribed during the
photographic process or written in white ink.
If the examinee is pregnant the film must be full sized, the field size
must be strictly limited and there must be double abdominal shielding.
If the pregnant woman does not wish to be x-rayed, please comment
and return this form.
Signature of
radiographer
Date
DAY MONTH YEAR
2
Is this person pregnant?
1
DAY MONTH YEAR
Date of x-ray
No Yes
3
Radiographer’s certification
I certify that I have carried out the x-ray of the person whose
photograph and signature are on this form.
Part D – Radiologist to complete
Please use a pen and write neatly in English. Illegible forms will be returned for clarification.
Comment is required on any and all aspects found not to be entirely normal.
1
Skeleton and soft tissue
Normal Abnormal
2
Cardiac shadow
Normal Abnormal
3
Hilar and lymphatic glands
Normal Abnormal
4
Hemidiaphragms and costophrenic angles
Normal Abnormal
5
Lung fields
Normal Abnormal
6
Evidence of Tuberculosis (TB)
Absent Present
8
Details of other abnormalities
Give a full description of all abnormal findings.
If insufficient space, attach an additional statement
7
Are there strong suspicions of active
Tuberculosis (TB)?
No Yes
-
160 (Design date 08/19) - Page 6 © COMMONWEALTH OF AUSTRALIA, 2019
9
Please consider the information that you have recorded regarding this client and provide a grading on their radiology
examination below. Supporting comments must be provided if you decide to provide a B grading.
No evidence of active
Tuberculosis (TB), or changes
consistent with old or inactive TB,
or changes suggestive of other
significant diseases identified.
Evidence of active Tuberculosis
(TB), or changes consistent
with old or inactive TB, or
changes suggestive of other
significant diseases identified.
Please list significant history or abnormal findings
Examination grading
A
B
I declare that I have examined the x-ray and that this is a true
and correct record of my findings.
10
Signature of
radiologist
Date
DAY MONTH YEAR
Full name (please print)
Contact telephone number
( ) ( )
COUNTRY CODE AREA CODE NUMBER
Address
Email address
POSTCODE
To the radiologist:
Place the form and report(s) inside a secure envelope.
If outside Australia:
• attach the envelope to the packaged x-ray;
• do not give the envelope containing the form and the report
to the applicant. You may, however, provide the applicant with a
copy of the form and your report for their records.
If you are in Australia, the x-ray does not need to be included.
Return the package direct to:
• the officer of the Department specified in the attached covering
letter; and/or
• the return address specified in the ‘Office use only’ section on
page 3 of this form; or
• to the referring panel physician, if applicable; or
• as specified in the ‘Where to send Australian immigration medical
forms, results and x-rays’ document; or
• for cases examined in Australia, according to local arrangements
with
the Migration Medical Services Provider.
Radiologist’s declaration
-
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form under section 60 of the Migration Act (Department of Home Affairs)

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Completed 16 February 2021

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