Pre Employment Immunisation and Screening
INFORMATION FOR APPLICANTS
NON-CLINICAL CONTACT CAREGIVERS DO NOT NEED TO COMPLETE THIS FORM
Please read this information carefully
1. It is a requirement of your employment at St John of God Hospital Subiaco that you complete
a pre-employment screening and immunisation assessment. This is to ensure that
compliance with current Australian Infection Control and Occupational Health requirements
is met in order to protect you and our patients from exposure to vaccine preventable
diseases.
2. Caregivers are classified according to the degree of clinical contact they will have with patients and
the risk of exposure to infectious agents in the work place. Each caregiver is assessed individually;
however the following are general guidelines:
Clinical Contact: generally this is caregivers who will provide direct clinical care to patients,
and have potential exposure to blood / body fluids. It also includes caregivers that have
less direct patient contact but may be exposed to infection spread through the air. This
category includes all nursing, midwifery, medical, allied health, patient care assistants, some
patient service assistants, administrative assistants (e.g. ward clerks) and caregivers
employed in SSD, environmental services, pastoral care, maintenance and waste
management.
Non-Clinical Contact: Many caregivers work in areas of the hospital where they have no
greater risk of exposure to infectious diseases than in the general community. This includes
caregivers in departments such as medical records, accounts, catering, admissions and
administration etc. Non Clinical Contact caregivers are not required to complete the
Immunisation Screening Form.
3. Caregivers in the Clinical Contact category above must complete the Immunisation Screening
Form and return it with your application along with written evidence of immunisations. All details
must be completed to enable an informed decision to be made when reviewing your status and
making any recommendations for attendance at the staff immunisation clinic.
Tuberculosis testing (Mantoux) – All direct Clinical Contact caregivers are required to provide a
baseline mantoux result. If you have never had a mantoux test, or are unable to provide evidence of
a previous one you will be required to attend the staff immunisation clinic for a mantoux test.
Alternatively, a recent Quantiferon test result will be accepted. Please note, it may be necessary for
some indirect clinical contact caregivers to attend for Mantoux testing. This will be determined when
your immunisation screening form is reviewed.
If you require any blood tests to check your immune status or further vaccinations these will be
identified when your immunisation status form is reviewed. You will be advised where to attend for
these. You will not be charged for the cost of any testing performed or vaccines provided.
Please note – failure to attend for recommended tests or vaccinations within
the required period may impact on your ongoing employment at St John of
God Hospital Subiaco.
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INFECTION CONTROL – IMMUNISATION REQUIREMENTS
PLEASE PRINT CLEARLY
Family Name Date of Birth / / Sex M F
Given Names Country of Birth
Address Suburb Postcode
Position Applied for Tel No
Dept/Ward
Declaration
I declare that the information I have provided is accurate and I have not withheld any relevant information.
Applicant’s Signature:
Date:
Attach copies of previous tests and vaccination records to this form.
Complete both sides of form.
The Staff Health Screening and Immunisation Clinical Nurse will determine what vaccinations or tests are
required.
If you suffer from any infectious disease, you must discuss your work practices with the Staff Health
Screening and Immunisation Clinical Nurse or your medical practitioner.
Yes No
1. Does your new position involve direct patient contact? (refer point 2 on front page)
2. Are you likely to have contact with blood or body fluids?
1. MRSA Yes No
1.1 Have you worked, or been a patient in a hospital outside WA in the past 12 months?
1.2 Have you worked in a residential care facility in WA in the past 12 months?
1.3 Have you been screened for MRSA in Western Australia within the last 12 months?
2. TUBERCULOSIS (TB) Yes No
Have you had TB? Date:
Have you had a mantoux / Quantiferon test? Date: Result: mm
Have you had a BCG vaccination? Date:
Have you had a chest Xray for TB? Date: Result:
Have you had the following Vaccinations? (Please complete in full)
3. HEPATITIS B Yes No
Have you had at least three (3) doses of Hepatitis B vaccine?
Have you had a blood test to confirm immunity?
4. HEPATITIS A Yes No
Have you been vaccinated against Hepatitis A?
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INFECTION CONTROL – IMMUNISATION REQUIREMENTS
5. VARICELLA (VZV) (Chickenpox) Yes No
Have you ever had chickenpox or shingles?
If NO – have you had at least two (2) doses of Varicella vaccine?
If YES – have you had a blood test to confirm immunity?
6. MEASLES (MMR) Yes No
Have you had at least two (2) doses of Measles (MMR) vaccine?
If YES – have you had a blood test to confirm immunity?
Have you had Mumps?
Have you had Measles?
Have you had Rubella (German Measles)?
Have you had a blood test to confirm immunity to Rubella? Result:
7. PERTUSSIS (WHOOPING COUGH) Yes No
Have you had at least one (1) dose of Pertussis (dTPa) vaccine?
OFFICE USE ONLY
Yes No
Date of Commencement………………………………. International Recruit:
INVESTIGATION REQUEST
DATE RESULT COMMENT
ACTIONED
Hepatitis A Vaccination Yes No
Hepatitis B Vaccination Yes No
Mantoux Yes No
Measles Immunity Yes No
Mumps Yes No
Rubella Yes No
MRSA Screen Yes No
Pertussis Vaccination Yes No
Varicella Immunity Yes No
Pathology letter Yes No
Vaccination letter Yes No
Alesco entry Yes No
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