The student must scan and submit this Student Immunisation Record via upload into InPlace. 1/2

Tasmanian STUDENT IMMUNISATION RECORD

STUDENT DETAILS (This is the ONLY section of the Immunisation Record to be completed by the student)

Surname: Given Names:

Address: State: Post Code:

Mobile: Date of Birth: Student ID:

Student Declaration: I agree to have my immunisation records documented in this UTas Tasmanian Immunisation Record and will produce this Immunisation Record for sighting by PEP agencies if/when required.

Signature: ……………………………………………………… Date: …………………………….

Vaccines (Mandatory)

DATE of all doses and/or serologies required

Results Vaccination provided/evidence sighted Signature AND practice stamp required

dTpa - Adult formulation: diphtheria, tetanus, acellular pertussis (whooping cough) vaccine

Booster (every 10 years)

Batch Number/Vaccine Brand Name Mandatory

SIGNATURE Place Practice stamp here

Hepatitis B Vaccine (age appropriate course of vaccinations AND Hepatitis B surface antibody ≥ 10mlIU/mL OR Hepatitis B core

antibody positive)

DATES SIGNATURES

Place Practice stamp here

Dose 1

Dose 2

Dose 3

AND

Serology: HBsAb

Result: IU/mL

Place Practice stamp here

Result: IU/mL

OR Serology: Hepatitis B Core Antibody

Positive (please circle)

Place Practice stamp here

Measles, Mumps, Rubella (MMR) vaccine (2 doses MMR vaccine at least 1 month apart OR positive serology for measles

and mumps AND numerical titre level for rubella only OR born before 1966); Rubella serology report MUST be included

DATES SIGNATURES Place Practice stamp here Dose 1

Dose 2

OR Serology Measles IgG result: Place Practice stamp here

Serology Mumps IgG result:

Serology Rubella IU/mL result:

Varicella vaccine (age appropriate course of vaccination OR positive serology)

DATES SIGNATURES Place Practice stamp here Dose 1

Dose 2

OR

Serology Varicella

IgG result:

Place Practice stamp here

The student must scan and submit this Student Immunisation Record via upload into InPlace. 2/2

TB QUESTIONNAIRE (Mandatory)

CIRCLE YES OR NO ON ALL QUESTIONS

DATE Signature AND practice stamp required

What is the student’s country of birth?

Has the student had a BCG vaccination in the past? YES NO (please circle)

Has the student ever lived in or travelled to a country with a high incidence of TB for a total period of 3 months? Refer: www.health.nsw.gov.au/infectious/tuberculosis

YES NO (please circle)

Has the student ever been in contact with a person known to have active TB?

YES NO (please circle)

Has the student previously been a health care worker or student in an environment where contact with TB was likely?

YES NO (please circle)

If the answer to any of the above questions is YES, then the student DOES require referral to either LGH or RHH Respiratory (TB) clinic

Refer the student to the Respiratory Clinic at the RHH or LGH for review

TB SCREENING only to be completed at RHH or LGH

RESULT DATE

Signature AND RHH/LGH Hospital stamp required

Mantoux test/TST injection

Reading Induration mm

Mantoux test/TST injection (if 2 step required)

Reading Induration mm

OR IGRA

BLOOD BORNE VIRUS TESTING To determine infectivity status ONLY

DO NOT RECORD RESULTS

DATE of Serology (Performed no earlier than October prior to the first year of study)

Results sighted by Health Care Provider Signature AND Practice stamp required

Human Immunodeficiency Virus (HIV)

HIV antibody test

Hepatitis B Virus (HBV)

HBsAg Test If positive further testing to determine the degree of infectivity: HBeAg & HBV DNA

Hepatitis C Virus (HCV)

HCV antibody test If HCV antibody positive, further testing for HCV RNA

HEALTH CARE PROVIDER DECLARATION (if applicable)

Please tick and sign box below (if applicable) • If the student has had a positive result for a blood borne virus or TB, I have arranged further testing, advice and treatment.

• If the student has a blood-borne virus or has/had tuberculosis or has a medical contraindication to a vaccination or is a documented non-responder to a vaccination, a Safety in Practice Immunisation Variation form must be completed. The Safety in Practice Immunisation Variation form can be accessed at: http://www.utas.edu.au/__data/assets/pdf_file/0008/782342/Safety-in-Practice-Immunisation-Variation-Form.pdf

I have completed and returned the Safety in Practice Immunisation Variation Form to the student to submit to their Program PEP Coordinator/Administrator.

Health Care Provider:

Name: ………………………………………………………………………………… Provider Number: …………………………………………………

Signature: …………………………………………………………………………….. Date: ……………………………………………………………………

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TASMANIAN STUDENT IMMUNISATION RECORD – COMPLETION GUIDE

The University of Tasmania is required to comply with Commonwealth and State legislation and regulations to ensure the safety of students and healthcare consumers. The College of Health and Medicine has a duty of care towards both students and healthcare consumers to prevent or minimise the risk of transmission of infectious or blood-borne diseases.

This completion guide accompanies the Tasmanian Student Immunisation Record. All vaccinations, screening and serology results MUST be documented on the Tasmanian Student Immunisation Record to ensure you comply with the University of Tasmania College of Health and Medicine Infectious Diseases Guidelines and Procedures requirements.

The Tasmanian Student Immunisation Record must be completed by a health care provider. The only section of the record to be completed by the student is the personal details section. Every entry on the Tasmanian Student Immunisation Record must include the date of vaccination administration/screening/serology, the health care provider’s signature and the health care provider’s stamp/clinic stamp. All entries on the Tasmanian Student Immunisation Record must be legible and in English.

Prior to visiting your health care provider, you should gather evidence of all past vaccinations you may have received. See ‘Guide to Meeting Immunisation & Screening Requirements’ which can be found on the PEP website.

Students are responsible for all costs associated with completing vaccination/screening requirements.

Once you have commenced your Tasmanian Student Immunisation Record you should:

• Scan your Tasmanian Student Immunisation Record into a single PDF and upload to InPlace for review/verification by the Tasmanian Senior Immunisation Advisor after each vaccination. You should regularly check InPlace for comments/instructions relating to your vaccinations.

• Once you have completed all vaccinations/serology/screening requirements, your Tasmanian Student Immunisation Record needs to be scanned into a single PDF and uploaded to InPlace for final verification.

• Take your Tasmanian Student Immunisation Record Card with you on your 1st day of PEP.

If you do not upload your Tasmanian Student Immunisation Record to InPlace and/or submit all other compliance documents to your PEP Coordinator/Tasmanian Senior Immunisation Advisor by census date, you may not be eligible to undertake PEP as scheduled.

Further information regarding Vaccine Preventable Diseases is available from the College of Health and Medicine Compliance webpage.

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Instructions for Health Care Provider:

Disease Tasmanian Student Immunisation Record entry must include

Diptheria, Tetanus & Pertussis

• One adult dose of dTpa vaccine administered within the last 10 years

• Documentation on the Immunisation Record must include:

• Date of administration

• Vaccine batch number or brand name AND

• Health care provider signature AND

• Health care provider practice stamp

• No serology results are accepted

• DO NOT use ADT vaccine

Hepatitis B • History of a completed age appropriate course of Hepatitis B vaccinations OR if a student has been vaccinated but cannot locate the Hepatitis B vaccination records, a verbal history of Hepatitis B vaccinations must be recorded on the Immunisation Record AND

• Hepatitis B serology demonstrating a hepatitis B surface antibody (anti-HBs) result of ≥10 IU/mL (note: positive, immune or detected are not accepted) OR

• Documented evidence of a positive results for hepatitis B core antibody (anti-HBc), indicating past Hepatitis B infection

• All Hepatitis B vaccinations/serology documented on the Immunisation Record must include:

• Date of administration/serology

• Health care provider signature AND

• Health care provider practice stamp

• If, after a primary course of Hepatitis B vaccinations (2 or 3 doses depending on age at administration) the Hepatitis B surface antibody level is <10 IU/mL please contact the Tasmanian Senior Immunisation Advisor for further advice

Measles, Mumps & Rubella

• Evidence of two (2) MMR vaccinations, administered at least one month apart. Documentation on the Immunisation Record must include

• Date of administration

• Health care provider signature AND

• Health care provider practice stamp OR

• Serology result indicating positive IgG result for Measles and Mumps and Rubella AND

• Rubella serology result must be recorded on the Immunisation Record as a numerical value ONLY (note: positive, immune or detected are not accepted). Rubella serology report must be attached to Immunisation Record

• Measles, Mumps, Rubella serology results must include:

• Date of serology

• Health care provider signature AND

• Health care provider practice stamp OR

• Born prior to 1966

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Varicella • Evidence of an age-appropriate course of vaccination:

• If vaccinated at under 14 years of age evidence of one (1) varicellavaccination

• If vaccinated at over 14 years of age, evidence of two (2) varicellavaccinations administered at least 1 month apart

OR

• Positive Varicella IgG serology

• Documentation on Immunisation Record must include:

• Date of administration of vaccination/serology

• Health care provider signature AND

• Health care provider practice stamp

Tuberculosis If, after completion of the mandatory TB Questionnaire the student is identified as requiring TB screening, they should be referred to the Respiratory Clinic at either the Royal Hobart Hospital or Launceston General Hospital

Blood Borne Virus Testing

Mandatory blood borne virus (BBV) testing (HIV, Hepatitis B and Hepatitis C) is required. Testing must have been completed no longer than 6 months prior to census date in their first year of study of the currently enrolled course. Results SHOULD NOT be recorded on the Immunisation Record, rather screening is to ensure students and their health care providers are aware of the student’ s BBV status and appropriate action can be taken. Documentation on Immunisation Record must include:

• Date of serology

• Health care provider signature AND

• Health care provider stamp

Influenza For all students undertaking PEP, annual influenza vaccination is mandatory. The vaccination must occur, and evidence of vaccination be submitted, prior to 1st June.

• Influenza vaccination should be documented on a Safety in PracticeInfluenza Vaccination Form OR

• Another form of evidence (e.g. pharmacy/hospital consent form, GPimmunisation summary/list/statement). These must include student name,student date of birth, influenza vaccine name, vaccine batch number,vaccine expiry date, date of administration, vaccinator name, vaccinatorsignature, practice stamp/letterhead.