Pre Screening Vaccination Form – DoJ Step 1 of 2 50% Vaccination Pre-screening InformationAspen Corporate Health has been employed to provide vaccination services for your organisation. It is important we obtain information from you to be able to provide this service. You work in an industry where you will have specific Occupation-related risks of disease/s which can be vaccinated against to reduce risk. This, along with following your workplace practices, will help to minimise risk of infections which can have permanent and unwanted consequences. By completing this Vaccination Screening form , this helps us to understand what you have been vaccinated against in the past and also contains request for us to access the Australian Immunisation Register (AIR) using your Medicare details to see if there is record of vaccinations for you. It is important to understand that AIR was only broadened to include adult immunisations in 2016 (having initially been the Australian Childhood Immunisation Register from 1996) and also that whilst recommendation was to record all vaccinations on the Register, it was not mandated thus not having a record on this Register does not mean you were not vaccinated. We set a high standard to obtain this information due to vaccination providing very good protection against infection and to recognise that a Full vaccination (ie. Having all the recommended vaccinations at set intervals) is very important to achieve this protection. Incomplete or unavailable immunisation record can necessitate further vaccination or in some cases blood testing to check immune status. Other sources of immunisation record besides AIR can include the GP/immunisation centre at which you obtained your vaccination. Whilst personal history – you telling us what you have been vaccinated against without documentation being available – is useful, it is considered to be the least robust of all these methods to confirm vaccination status, particularly as there may be uncertainty about all the diseases the vaccine protected you against. If there is uncertainty you will be directed by the vaccine requirements as determined by your Employee in consultation with Aspen Medical and the Department of Health/ ATAGI guidelines. We will document this on the AIR for your future record. Our clinical vaccination team (Nurses/Doctors) are able to be contacted to discuss your circumstances and to document this to determine which vaccine/s are appropriate for you should you wish to clarify your history. It is also recognised that vaccination cannot be mandated but that not being vaccinated can have implications on what steps/urgency is needed should you become exposed to the infection. It is thus important for our clinical vaccination team to be aware of your circumstances so we can provide this information. As with all request for your information, we will treat it with the utmost respect and in accordance with the Privacy Act 1988 Employee DetailsEmployer(Required) Name(Required) First Last D.O.B(Required) Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Position Title(Required) Employee Number / TOMS number(Required) Academy class / Workplace(Required) Start Date(Required) Medicare DetailsMedicare Number(Required) Individual Reference Number(Required) Medicare Expiry date(Required) Immunisation HistoryPlease attach copies of your Vaccination records and/or blood test results as confirmation of immunity. Upload evidence of vaccination/immunity here:Max. file size: 200 MB.Have you been vaccinated for Diphtheria, Tetanus and Pertussis?(Required) Yes No Unsure Vaccination date/s: Have you been vaccinated for Hepatitis A?(Required) Yes No Unsure Vaccination date/s: Have you been vaccinated for Hepatitis B?(Required) Yes No Unsure Vaccination date/s: Serology date/result: Have you been vaccinated for Measles Mumps Rubella (MMR)?(Required) Yes No Unsure Vaccination date/s: Have you been vaccinated for Varicella (chickenpox)?(Required) Yes No Unsure Vaccination date/s: Have you been vaccinated for Q Fever?(Required) Yes No Unsure Vaccination date/s: Immunisation HistoryPlease attach copies of your Vaccination records and/or blood test results as confirmation of immunity. Upload evidence of vaccination/immunity here:Max. file size: 200 MB.Have you been vaccinated for Diphtheria, Tetanus and Pertussis?(Required) Yes No Unsure Vaccination date/s: Have you been vaccinated for Hepatitis A?(Required) Yes No Unsure Vaccination date/s: Have you been vaccinated for Hepatitis B?(Required) Yes No Unsure Vaccination date/s: Serology date/result: Have you been vaccinated for Measles Mumps Rubella (MMR)?(Required) Yes No Unsure Vaccination date/s: Have you been vaccinated for Q Fever?(Required) Yes No Unsure Vaccination date/s: Have you been vaccinated for Varicella (chickenpox)?(Required) Yes No Unsure Vaccination date/s:(Required) Have you been vaccinated for Rabies (Lyssa Virus)(Required) yes No Unsure Vaccination date/s:(Required) Have you been screened for Tuberculosis (Quantiferon)(Required) Yes No Unsure Date of test: Infection Risk AssessmentDo you work in a custodial Health Centre (i.e. Doctor/Nurse)(Required) Yes No Unknown/unsure Do you work in a custodial facility (i.e. Uniformed Officer)?(Required) Yes No Unknown/unsure Do you work closely with infants/children who cohabitate with their mother in a custodial facility?(Required) Yes No Unknown/unsure Do you work in child education (i.e. Teacher at Banksia Hill)?(Required) Yes No Unknown/unsure Do you work in rural or remote Indigenous Communities?(Required) Yes No Unknown/unsure Do you work with animals (e.g abattoir, farm)?(Required) Yes No Unknown/unsure Do you work with untreated sewage (i.e. specific DDU Officers)?(Required) Yes No Unknown/unsure Are you a Community Work Officer or Nominated First Aid Officer/Deputy First Aid Ofificer?(Required) Yes No Unknown/unsure Declaration and ConsentI have read and understood the above information and all information that I have provided is true and correct. Where possible, I have attached evidence of previous vaccinations and/or blood test results (where required).(Required) Yes No I consent to Aspen Corporate Health using my Medicare details to access the Australian Immunisation Register (AIR) to help determine my vaccination history and requirements.(Required) Yes No I authorise Aspen Corporate Health to release a copy of my vaccination records, serology results and this questionnaire to Department of Justice Work Health and Safety Team.(Required) Yes No I have read the disease fact sheets that were attached to the same email I accessed this form. Yes Declining vaccinationI am aware of the recommended vaccination requirements for my role with the Department of Justice and have chosen NOT to receive the recommended vaccinations. I understand that the Department will be notified of my decision. I have chosen to decline vaccinations. Please leave blank unless declining vaccinations.
