Health Record and Immunisa on Form
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Health Record and Immunisa on Form
I hereby request and give consent for the doctor iden fied on the bo om of page 4 to complete this form in rela on to my health informa on . I
understand that the informa on is being collected by James Cook University for the purpose of administra on of my admission and enrolment at
James Cook University including (without limita on) for the purpose of administra on of any professional experience placements. I authorise
James Cook University to disclose my personal/sensi ve informa on to:
(a) placement facili es; and
(b) The Australian Health Prac oner Regula on Agency (AHPRA) ‐ only if required under the AHPRA mandatory guidelines.
I understand that all blood test and vaccine costs will be the responsibility of the student.
Student name: Student Number:
Course of Study DOB
/ /
Student Signature
Doctor Instruc ons – How to fill out this form
Please complete sec ons 1 to 5 (where required); otherwise, the student cannot enrol in a course with a placement or a end placements.
Please provide the student with the completed form and, where possible, a ach pathology results.
Notes
1. Students should be vaccinated in accordance with the recommenda on of the current edi on of the Na onal Health and Medical Research
Council Australian Immunisa on Handbook, 10th ed.:
a) Hepa s B: The minimum recommended Hepa s B vaccina on schedule is 1st dose: day of vaccina on, 2nd dose: 1 month a er first
dose and 3rd dose: 4‐6 months a er the first dose, with serology tes ng undertaken one month a er the third dose. For adolescent
between the ages of 11‐15 Hepa s B vaccine may be given as a two‐dose course, with the two doses 4‐6 months apart. An accelerated
Hepa s B schedule of vaccina on is not recommended as the course will not be completed un l the 4th dose at 12 months, and NSW
Health does not accept an accelerated schedule for voca onal placement. An ‐HBs (Hepa s B surface an body) greater than or equal
to 10mIU/mL indicates immunity. If the result is less than 10 mIU/mL, this indicates a lack of immunity. Documented evidence that an
individual is not suscep ble to Hepa s B infec on and therefore does not require immunisa on may include serology tests indica ng
the presence of Hepa s B core An body (An ‐HBc) or a documented history of past Hepa s B infec on. Students who are Hepa s B
an gen posi ve (HBsAg), indica ng ac ve infec on (acute or chronic), do not have to disclose their Hepa s B infec on status unless
they perform exposure‐prone procedures.
a)Measles, Mumps and Rubella: Documented evidence of posi ve an body (IgG) for each indicates evidence of serological immunity
or documented proof of 2 MMR vaccina ons at least one month apart.
b) Varicella: Documented evidence of posi ve varicella an body (IgG) on serology or two doses of varicella vaccine at least one month
apart (evidence of one dose is sufficient if the person received their first dose before 14 years of age).
c) Pertussis: Documented evidence of pertussis booster vaccina on in the previous 10 years
2. Le ers from medical prac oners or other vaccine service providers should be on prac ce/facility le erhead, signed by the provider/
prac oner, including professional designa on and service provider number (if applicable).
3. Sec on 4: Inherent Requirements the fundamental abili es a ributes, skills and behaviours necessary to complete the learning and
prac cal outcomes of a course while preserving the academic integrity of JCU’s learning, assessment and accredita on process. To enable
a student to graduate from a course of study, the student must be able to complete all the components of the course, including all
mandatory laboratory, workplace simula on and professional experience placement requirements. James Cook University must ensure
that students are able to comply with work health and safety standards of all learning environments. If a student has a disability, long term
illness or mental health condi on, James Cook University may be able to provide adjustments to support the student to par cipate in their
program. Study adjustments are individualised to the student’s par cular circumstances and their program of study. The informa on
provided in Sec on 4—Inherent Requirements will be used to facilitate an ini al conversa on between the student, the Discipline
Placement Coordinator and AccessAbility Services in order to ascertain whether the student will be able to meet the inherent requirements
for the course in which the student is enrolled and to determine whether any reasonable adjustments are able to be made to assist the
student in mee ng the inherent requirements.
STUDENT NAME: Division of Tropical Health and Medicine, Version 3.6, June 2021
1
Health Record and Immunisa on Form
Sec on 1: Vaccine Preventable Diseases
VACCINE PREVENTABLE DATE OF VACCINATION DOCTOR / SEROLOGY OTHER
DISEASE (Including any childhood IMMUNISATION NURSE EVIDENCE
vaccina ons)
SIGNATURE
Please sign when dose given or Seek evidence of past immunity,
Please provide dates if available.
evidence sighted. if unavailable request serology
Measles, Mumps, Rubella Dose 1 Signature: Date ___ /___ /______
Evidence of comple on of ○ Serology confirms
○ Birth date
immunisa on schedule immunity to Measles, before 1966
Mumps and Rubella No vaccina on or
serology required
Dose 2 Signature: OR OR for students born
(4 weeks) Booster Vaccina on
(if required) before 1966.
Date ___/______/_____
Varicella (Chicken Pox) Dose 1 Signature: Date ___ /___ /_______ Date ___ /___ /___
Evidence of comple on of
immunisa on schedule ○ Serology confirms ○ Documented
immunity to Varicella history of physician‐
Dose 2 Signature: diagnosed chicken‐
OR OR
(4 weeks) pox or shingles
Two dose course only required if * See Point 5 (Page 1)
ini ated a er 14 years of age
Pertussis (Whooping Cough) Date: Signature: Not applicable
Evidence of one adult dose of dTpa within
the past ten (10) years.
Hepa s B Dose 1 Signature: Date ___ /___ /_______ Date ___ /___ /___
Documented history of two or
three doses for age appropriate
Please ck as applicable ○ Documented
OR
course (including any childhood ○ Serology confirms evidence that the
Individual is not
vaccina ons) of Hepa s B vac‐ Dose 2 (4 weeks) Signature: immunity to Hepa s B
cine suscep ble to
An ‐HBs greater than or
Hepa s B
equal to 10mIU/mL *See point 4 (Page 1)
* See Point 3 (Page 1)
Dose 3 (4‐6 months) Signature:
○ Nega ve
Please refer to sec on
1A for booster regime
Sec on 1A: Hepa s B Supplementary Doses (if required)
Hepa sB Dose 4 (challenge) Signature: Date ___ /___ /_____
○ Immune * See Point 3 (Page 1)
An ‐HBs greater than or
equal to 10mIU/mL
○ Nega ve
If HBsAb remains nega ve 4 to 8 Proceed to dose 5/6
weeks post supplementary dose Dose 5 (if required) Signature: Date ___ /___ /______
regime please complete (1 mth) ○ Immune * See Point 3 (Page 1)
Sec on 2: Non Responder to An ‐HBs greater than or
Hepa s B immunisa on Dose 6 (if required) Signature equal to 10mIU/mL
acknowledgement. (4‐6 months)
○ Nega ve
Sec on 2: NON‐Responder to Hepa s B Vaccine Acknowledgement:
ONLY complete if student has not responded to the Hepa s B Vaccina on booster regime.
The student does not have adequate post‐vaccina on Hepa s B an bodies detected and the student and I have discussed risk and preven on
required whilst on clinical placement.
The student is aware of the recommended management in the event of a poten al exposure to Hepa s B, including the recommenda ons for
administra on of Hepa s B immunoglobulin (HBIG) .
The student is aware that if they undertake exposure prone procedures throughout the course of their study that they have a responsibility to have
regular Hepa s B screening at least annually and a er any blood or body fluid exposure.
Doctor Name (PRINT) Doctor Signature Date
/ /
STUDENT NAME: Division of Tropical Health and Medicine, Version 3.6, June 2021
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Health Record and Immunisa on Form
Sec on 3: Exposure Prone Procedures : Only required for students studying the below listed courses.
This sec on can be completed and submi ed as a stand alone form.
Bachelor of Dental Surgery & Postgraduate Dental students will undertake exposure prone procedures throughout the course
of their study and are required to complete tes ng annually from the commencement of the program.
Bachelor of Nursing/Bachelor of Midwifery/Graduate Diploma of Midwifery may undertake exposure prone procedures
throughout the course of their study. Tes ng required at the commencement of the program.
Bachelor of Health Science (Physician Assistant) may undertake exposure prone procedures throughout the course of their
study. Tes ng required at the commencement of the program.
Bachelor of Medicine/Bachelor of Surgery may undertake exposure prone procedures from Year Level 4 of the course and are
required to complete tes ng by the start of 4th Year.
The current Communicable Diseases Network Australia (CDNA) guidelines define an exposure prone procedure as a procedure
where there is a risk of injury to the healthcare worker resul ng in exposure of the pa ent’s open ssues to the blood of the worker.
These procedures include those where the worker’s hands (whether gloved or not) may be in contact with sharp instruments,
needle ps or sharp ssues (spicules of bone or teeth) inside a pa ent’s open body cavity, wound or confined anatomical space
where the hands or finger ps may not be completely visible at all mes.
Student name: Student Number:
Course of Study Current Year Level
Please note:
This sec on must be completed by a registered General Prac oner.
The Doctor must not be a rela ve or someone with whom you have a close personal rela onship
Serology only accepted if done in the current calendar year.
Students must be aware of their status, however they are not required to provide evidence of their status.
Date of HIV / / Date of HCV / /
tes ng: tes ng:
This student is aware of their infec ous status with regards to HIV and HCV.
This student is aware of any consequent implica ons on their ability to perform exposure prone procedures.
This Student is able to par cipate in Exposure Prone Procedures: YES NO
Doctor Name:
Doctor Signature: Date:
/ /
STUDENT NAME: Division of Tropical Health and Medicine, Version 3.6, June 2021
3Health Record and Immunisa on Form
Sec on 4: Inherent Requirements
Inherent requirements are the fundamental abili es, a ributes, skills and behaviours necessary to complete the learning and prac ‐
cal outcomes of a course while preserving the academic integrity of JCU’s learning, assessment and accredita on processes. Stu‐
dents must be able to demonstrate that they have the ability to acquire the inherent requirements for the dura on of their course.
(All students who intend to par cipate in laboratory, workplace simula on environments and undertake professional experience
placements (PEP) are required to establish and maintain their medical, physical and psychological capacity to prac ce safely.
https://www.jcu.edu.au/learning-and-teaching/resources/inherent-requirements
Please list any known medical condi ons, physical condi ons, psychological issues or medica on requirements which may impair the
student’s capacity to safely par cipate in laboratory, workplace simula on environments and undertake professional experience
placements (PEP) in a variety of clinical se ngs.
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Sec on 5: Comple ng Doctor details
Doctor Name: Date:
/ /
Doctor Signature: Prac ce stamp or facility name and address:
Provider Number:
Sec on 6: Student Declara on
I declare that the informa on provided on this form is true and correct.
Student Name: Student Signature: Date:
/ /
STUDENT NAME: Division of Tropical Health and Medicine, Version 3.6, June 2021
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