Vaccination Record Card forHealth Care Workers and Students

&,NSWGOVERNMENT

Personal Details ( ease Please refer to instructions on three

Dr Full MoonMilky Way General PracticeSouthern Cross DriveOuter Galaxy NSW 2099Provider No: 1234567A

Tpa vacclne)

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Dr Full MoonMilky Way General pracriceSouthern Cross DriveOuter Galaxy NSW 2099Provider No: 12345674Dr Full MoonMilky Wa1 Ceneral PracticeSouthern Cross DriveOuter Galaxy NSW 2099Provider No: 1234567.4

OR core antibody

Dr Full MoonMilky Way General PracticcSouthern Cross DriveOuter Galaxy NSW 2099Provider No: 1234567,4

Dr Full MoonMilky Way General Practice

Southern Cross DriveDr Full Moon

Outer Galaxy NSW 2099

Provider No: 1234-567,4 Milky Way General Practice

Southern Cross Drive

Outer Gal axy NSW 2099

ProviderNo: I234567A 7f z/t-r,/

Surname G Azr N c., Given names

Address C-lSiate:gg.; J p/cottJ: 'CCIO Date of BirthJ e)D\co \ o(^)c)

Staff/student lD

Email qA/r^q c;".-: gt .a e.Av. dr-r{Contact numbers Mo co aco iO Work i) d*)') doooMedicare Number € >1r1X) aOLpA{) Position on card: Cl Expiry date:q1 O/€!) - _

Adult formulation diphtheria, tetanus, acellular pertussis (wI

Dose l rlrl )iLl kc=;l-&'tL3lYt ) nY\Booster1O years after previous dose

Hepatitis B vaccine (age appropriate course of

C-\Dose I

Boosterdoseafterto

Dose 2\

Tick foradolescent ltr\a, I h+f>r c t ,=,u h I blz--i

Dose 3 t 2o. '-l hllfr,/-lt-r*N\

AND

2a4Resu/t mlU/mL

OR Sero ogy ant -HBc Positive Negative

2-e,2-/Measles, Mumps and Rubella (MMR) vaccine(2 doses [4MR vacctne at ieasf 1 month apart OR pasttive seroloa

Dose l \ I ll zou Ktgt(. \)z /+k(,"1?c- I tz/\Dose 2

Booster if required

OR

Serology Meas es lgG Result

Serology Mumps lgG ResultSerology Rubella (include numerical value and immunity status as per lab report: Positive,/ Negative /Low level / Equivocal/ Booster required)

lgG ResultVaricella vaccine (agetmmunitv to chtckenpox

approprlate course of vacclnatlon OP posrtlve serology OR AIR history statement that records natural

Dose Iif given

prior to l4vears

Dose 2

Booster if required

ORI

Serology Varicella 2ctL1 lgG Result

OR

Australian lmmunisation Register(AlR) History Statement that recordsnatural immunity to chickenpox

AIR Statement Slghted

YES NO

Dr Full MoonMilky WaY General Practice

Soulhern Crclss Drivc

Outer GalaxY NSW 2099

Provider No: 1234567A

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Batch No. (where possible)or Brand name

Off icia I Certif ication by Vacci nation Provid er (c I i n i c,/Vaccine Dateto each entry)

Revised February 2O21 1/z

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Serology: anti-HBs(NLrmerical rralr rc) I rlz-ozt Resu/) iO,Ajntu/mt

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Surname Caku rt)r,r Given

=r7\€Date of Birth frT: oclc&D StaffAtudent 1D

Contact Mobiie: O AO clJ3 Work: OC oOQ) C{x-D

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Vaccination Record Card forHealth Care Workers and Students

&;NSv[f

Personal Details (please print)

lnfluenza vaccine (strongly recommended for all health care workecare workers)

health

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Dr Full MoonMilky WaY General Practice

Southern Cross DriveOuter GalaxY NSW 2099

Provider No: 1234567A bt4

Requires TB screening? iltlzor r.ro (veslHistory of BCG No Yes

IGRA il4,*, oositive lndetermrrateKIilI\

TST Administration

]GRA Positive lndeterminate Negative

lnterferon Gamma Release

Tuberculin Skin Test (TST) - TB Service/Chest CIinic

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tbfp,Dr Full Moon

PractrceGeneralwayMilkYveDtiCrosSouthern

2099NSWGal axyOuterA6'l51 234N

(IGRA) - GP or TB Service/Chesl Dr Full MoonMilky Way General PracticeSouthern Cross DriveOuter Calaxy NSW 2099 JProvider No: 123.1567A

TST Reading nduration mm

TST Administration

TST Reading I nd u ratio n mmReferral to TB Service/Chest Clinic for TB ClinicalReview reouired?

No Yes

TB Clinical Review

Chest X-ray

Other

TB Compliance - TB Service/Chest CjjAic-oqQASV Assessor (circle ( KStfiT.IfiqqRIHB}

ltrTB ComplranceAssessment 7,J2-l Non-compliant

mplianceRsrtistered Nurse t{MW000 1 27 5249

Auii-roi"ised ir!u rse i mmuniseri lr.i, rar:i'ir,, ri -[h.r,fifenia

TB ComplianceAssessment

CompliantTemporary ComplianceNon-compliant

TB Screening Date Batch No. or Result

Vaccine Date Official Certification by Vaccination ProviderBatch No. (where possible) orBrand name

Revised February 2O2l 2/z

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