Download Staff Immunisation Record Form

STAFF IMMUNISATION RECORD
(Read ‘Important Notice’ on next page before completing this form)
Name
Start Date
Position
Centre
Disease
Measles, Mumps, Rubella
(MMR)
Two doses normally given as a
child/ adolescent for those born
before 1/7/66. Those born after
1/7/66 received one dose only, so
2nd dose is required to ensure
immunity. Doses must be at least
4 weeks apart.
Year of vaccination and/or disease
Measles Infection? If yes, what year?_________
Mumps infection? If yes, what year?__________
Rubella (German measles) infection?
If yes, what year? __________


No/Unknown
No/Unknown

No/Unknown
If yes, what date(s)?
1st ___________
(Attach evidence)
2nd ___________
If born on or after 1/7/1966, have you had a second dose of MMR
vaccine?
If yes, what year? __________  No/Unknown
MMR vaccination
Chickenpox (varicella)
Infection gives immunity.
Vaccination highly recommended
for non-immune adults – two
doses required min.4 wks apart
Hepatitis A
Infection may give immunity –
blood test confirms. Vaccination
highly recommended for nonimmune adults – two doses
required
Hepatitis B
Not required but recommended
by C&K if having Hep. A
vaccination. (given as Twinrex)
Whooping Cough (pertussis)
3 in 1 vaccine which includes
diphtheria and tetanus. Usually
Chickenpox infection If yes, what age/year? _________  No/Unknown
(written evidence not required. History of infection acceptable)
Chickenpox vaccinated? If yes, enter dates: 1st ________ 2nd _________
(Attach evidence)
given in high school, a booster is
required every 10 years in child care
settings.
Whooping Cough Vaccination (attach evidence of most recent)
If yes, what date(s)? __________  No/Unknown
Hepatitis A infection in past? If yes, what year? ________  No/Unknown
Hepatitis A vaccinated? enter the dates below
Hep A only
Dose 1 date:
__________
Hep A only
Dose 2 date:
__________
(attach evidence)
(attach evidence)
Hep A/B
Hep A/B
Hep A/B
(attach evidence)
(attach evidence)
(attach evidence)
Dose 1 date:
Dose 2 date:
Dose 3 date:
__________
__________
__________
Whooping cough infection in past?
If yes, what year?__________

No/Unknown
 I consent to this information being made available to those persons at C&K who have an obligation to
protect my health and safety. I understand that this information will be kept confidential.
 I choose not to be tested/vaccinated for (name of diseases) _____________________________
I am aware that any time away from work that has resulted from not being vaccinated will be considered to be
unpaid leave unless I request deduction from my Personal or annual leave entitlements.
 I cannot be vaccinated for (name of disease) ________________________________________________
because (state reason)___________________________________________________ I have provided a
letter from my doctor stating the reasons why I cannot be vaccinated.(allows you to claim entitlements).
 I have been informed of the risks of contracting disease during my employment with C&K Services,
especially during pregnancy (see information over).
Note:
Further information is available from C&K Infectious Disease & Immunisation Procedure.
This form is to be submitted to your Director and retained at the Centre (not at C&K Central)
Signed:
___________________________________
© ALL RIGHTS RESERVED C&K 2012
Page 1 of 2
Date: ___ / ___ /___
S01.7.1 Version 2. Correct at time of printing 20/8/2012
S01.7 Procedure Infectious Diseases & Immunisation
Important Notice
1.
2.
3.
4.
5.
You must complete as much of this record as possible before employment commences. The aim is to have a fully complete record
of diseases you are immune to and diseases you are not immune to.
Read the C&K Staff Handbook section on Infectious & Vaccine-Preventable Diseases and Pregnancy and Infectious
Diseases in Early Childhood Centres
Gather any vaccination records you may have going right back to your childhood if possible. Talk to your family/parents about
your disease history. Once you have completed as much of the Staff Immunisation Record as you are able, and you decide to
proceed with updating your vaccinations, take the Staff Immunisation Record to your Doctor and discuss any further vaccinations
you may require. C&K will reimburse you for half of the costs if you keep receipts.
If you plan to have vaccinations done, and you have already started work, you will be considered non-immune in the event of a
vaccine-preventable disease outbreak if you have not yet received your vaccinations.
Further information is available from Public Health Units in Queensland or from C&K WH&S Officer Joanne Ellis on 07 3513 2863.
Frequently asked questions
Which vaccinations are recommended for C&K staff and how often should they be given?
Adult pertussis booster – once in a 10 year period; Measles, mumps and rubella – two doses, once in a lifetime; Varicella (chicken pox)
– two doses, once in a lifetime, unless you have had chicken pox; Hepatitis A – two doses, once in a lifetime, unless you have had
hepatitis A; Influenza – once a year in autumn
I have had a vaccination, but I still got the disease. Why didn’t the vaccination work?
Approximately 10% of vaccinations may not result in you not getting the infectious disease. However, it reduces the severity of the
disease and can prevent possible complications associated with the disease.
Why do I need to receive these vaccinations?
Immunisation of staff working for C&K not only helps to protect the young children you care for, but helps to protect yourself and your
family. Disease outbreaks in education and care services are more common due to groups of children playing closely together.
Exposure to disease for staff can mean illness, the risks of taking the disease home and time off work.
Why do I need to get a diphtheria, tetanus and pertussis booster in order to get pertussis protection?
The adult pertussis booster is only available as a 3-in-1 vaccination. Often, people are due for boosters for tetanus and diphtheria at
the same time they are having the pertussis booster. Even if you have had a tetanus or diphtheria vaccination recently, it is safe for you
to have the 3-in-1 vaccination.
Where can I get vaccinated?
At your GP or nearest Medical Centre. For more information contact your nearest Public Health Unit.
What will be the cost of vaccinations?
There is a cost to buy the vaccine and there may be a consultation fee charged by your doctor, unless they bulk bill. The measles,
mumps and rubella vaccine is free for one dose for anyone born after 1965. C&K will reimburse you 50% of the cost of the following
vaccines:

Hepatitis A

Flu

Whooping Cough

Hepatitis B

Chicken Pox

Measles Mumps Rubella (MMR)

Hepatitis A and B
Reimbursement is for the cost of the vaccines only. Any costs incurred for the doctor’s visit are at your own expense.
Can I claim the cost of vaccinations recommended for my occupation as a tax deduction?
The current advice (May 2012) from the Australian Taxation Office is that the cost of vaccinations may be claimed by education and
care service staff as a tax deduction if the following criteria are met:

You have a written letter from C&K stating that specific vaccinations are required for your occupation.

You keep receipts for the costs associated with vaccination. Request an itemised receipt from your doctor/chemist.
Claim the vaccinations as an expense incurred in earning your income. There is not a direct ruling from the Australian Taxation Office
for education and care service staff and tax deductions are worked out on an individual basis. For further information see
www.ato.gov.au/individuals/
What if I am planning a family?
Early childhood staff who are pregnant and unimmunised may be more at risk of complications for themselves and their baby when
exposed to disease. All female staff of childbearing age should check their immunity to rubella and staff who are planning a family
should ensure they are up to date with the vaccinations listed on this fact sheet before becoming pregnant. As a guide, some vaccines
should be administered at least one month before becoming pregnant. Discuss with your doctor or immunisation nurse.
If I am pregnant, should I get vaccinated?
The influenza vaccine is normally the only vaccination recommended while you are pregnant. Pregnant women are at increased risk of
severe disease from influenza and are eligible for free seasonal influenza vaccine, which is safe to have at any time during pregnancy.
The diphtheria, tetanus and pertussis booster can be given in certain circumstances, but is highly recommended before pregnancy or
as soon as possible after delivery in order to protect your newborn from whooping cough. Discuss with your doctor or immunisation
nurse.
What if I choose not to be immunised?
Immunisation is a personal responsibility. If you are unimmunised and exposed to disease you will need to be treated and/or be
excluded from the workplace for a set period of time. This varies depending on the disease. There have been many outbreaks in
education and care services requiring staff to take multiple courses of antibiotics and repeated periods of time off work. Staff who are
immunised and well can continue to work. You need to let C&K know if you choose not to be immunised.
Where can I obtain more information?
Contact
your
GP,
immunisation
nurse
or
your
local
Public
www.health.qld.gov.au/cdcg/contacts.asp for your nearest Public Health Unit
© ALL RIGHTS RESERVED C&K 2012
Page 2 of 2
Health
Unit
for
more
information.
S01.7.1 Version 2. Correct at time of printing 20/8/2012
S01.7 Procedure Infectious Diseases & Immunisation
See: