DOJ Vaccination Request Form

"*" indicates required fields

Employee Name*

First Last

Date of Birth*

DD slash MM slash YYYY

Phone Number*

Email*

Worker Identification Number*

Position Title*

Department Work Group

Doctor or Nurse in custodial Health Centres.

Uniformed Officer (ie Prison Officers, Youth Custodial Officers, VSOs, SOG Officers, DDU Officers).

Uniformed Officer at Boronia and Bandyup where infants/ children cohabitate with mothers in custody.

Teacher in Banksia Hill.

Uniformed Officer or Prisoner working in Farms or Abattoirs at Karnet, Wooroloo and Pardelup.

Specific Drug Detection Unit Officer

Community Work Officer (CS)

Criminal Injuries Compensation Case Managers and Recoveries Officer (CTS)

Field Officer (BD&M)

Guardian (OPA)

Sheriff’s Officer (CS)

Customer Service Officer (CTS)

First Aid Officer

Work Location*

Vaccinations required*

Hepatitis B

Hepatitis A

Tetanus (dTpa)

Measles Mumps Rubella (MMR)

Varicella

Q Fever

Hepatitis B serology testing

Unsure

Preferred location for appointment*

Any additional comments?

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