Undertaking Declaration PD2022 - 030

NSW Health
Undertaking/Declaration Form
Occupational Assessment, Screening
and Vaccination Against Specified Infectious Diseases
1. This form must be completed by all new workers, students and existing staff applying for new positions or undergoing
vaccination and screening requirements outlined in the NSW Health Occupational Assessment, Screening and Vaccination
against Specified Infectious Diseases Policy Directive (the “policy directive”). This includes volunteers/facilitators/
contractors (including visiting medical officers and agency staff) who provide services for or on behalf of NSW Health.
2. Category A workers as defined in the policy directive must complete:
• each part of this document; and

• each part of the Tuberculosis (TB) Assessment Tool; and
• provide evidence of protection which may include a NSW Health Vaccination Record Card for Category A Workers
and Students; and
• provide evidence of protection for COVID-19 as specified in Appendix 1 of the policy directive Evidence of
protection; and
• provide evidence of protection (serological and/or vaccination) for other requirements as specified in Appendix 1
Evidence of protection; and
• return these forms to the health facility with their application/enrolment or before attending their first clinical
placement. (Parent/guardian to sign if student is under 18 years of age).
Category A workers will only be permitted to commence employment/attend clinical placements if they have submitted
this form, have evidence of protection as specified in Appendix 1 Evidence of protection and submitted the Tuberculosis
(TB) Assessment Tool.
Failure to complete outstanding hepatitis B, TB or COVID-19 vaccination requirements within the appropriate timeframe(s)
will result in suspension from further clinical placements/duties and may jeopardise their course of study/ work/
employment.
3. Category B workers as defined in the policy directive must complete:
• each part of this document; and

• provide evidence of protection for COVID-19 as specified in Appendix 1 of the policy directive Evidence of
protection; and
• return this form to the health facility with your application/enrolment. (Parent/guardian to sign if student is under
18 years of age).
Category B workers will only be permitted to commence employment/attend placements if they have submitted this form
and have evidence of COVID-19 protection as specified in Appendix 1 of the policy directive Evidence of protection.
Failure to complete outstanding COVID-19 vaccination requirements within the appropriate timeframe(s) will result in
suspension from further placements/duties and may jeopardise their course of study/ work/ employment.
4. The recruitment agency/education provider must ensure that all persons whom they refer to a NSW Health agency
for employment/clinical placement have completed these forms, and forward the original or a copy of these forms to
the NSW Health agency for assessment.
5. The NSW Health agency must assess these forms along with evidence of protection specified in this policy directive.
1
Undertaking/Declaration Form
Occupational Assessment, Screening and
Vaccination Against Specified Infectious Diseases
Part Undertaking/Declaration (tick the applicable option)

I have read, understand and agree to abide by the requirements of the NSW Health Occupational Assessment, Screening and
1
Vaccination against Specified Infectious Diseases Policy
a. I consent to assessment and I undertake to participate in the assessment, screening and vaccination process and I am not
aware of any personal circumstances that would prevent me from completing these requirements, (OR)
b. (For existing workers only) I consent to assessment and I undertake to participate in the assessment, screening and
2
vaccination process; however I am aware of medical contraindications that may prevent me from fully completing these
requirements and am able to provide documentation of these medical contraindications. I request consideration of my
circumstances.
I have provided evidence of protection for hepatitis B as follows (Category A workers only):
a. history of an age-appropriate vaccination course, and serology result Anti-HBs ≥10mIU/mL OR
b. history of an age-appropriate vaccination course and additional hepatitis B vaccine doses, however my serology result Anti-
HBs is <10mIU/mL (non-responder to hepatitis B vaccination) OR
c. documented evidence of anti-HBc (indicating past hepatitis B infection) or HBsAg+ OR
d. I have received at least the first dose of hepatitis B vaccine (documentation provided) and undertake to complete the
3 hepatitis B vaccine course (as recommended in The Australian Immunisation Handbook, current edition) and provide a post-
vaccination serology result within six months of my initial verification process OR.
e. I have provided evidence of a medical contraindication to hepatitis B vaccine (e.g. letter from a doctor); AND.
f. I have been informed of, and understand, the risks of infection, the consequences of infection and management in the event
of exposure (refer Appendix 6 Specified Infectious Diseases: Risks and Consequences of Exposure) and agree to comply
with the protective measures required by the health service and as defined by PD2017_013 Infection Prevention and Control
Policy.
I have provided COVID-19 vaccination evidence as follows (Category A workers only):
a. Evidence of 3 doses of a Therapeutic Goods Administration (TGA) approved or recognised COVID-19 vaccine (in accordance
with ATAGI minimum intervals); OR
b. Evidence that I have received at least two doses of a TGA approved or a recognised COVID-19 vaccine and will complete the
required 3 dose schedule with a TGA approved COVID-19 vaccine, within the dosing time frame stipulated by the Australian
4 Technical Advisory Group on Immunisation (ATAGI) and will provide evidence of completed vaccines within 6 weeks of the
dose 3 due date; OR
c. I have provided evidence of a temporary or permanent medical contraindication to all the available TGA approved COVID-19
vaccines, in the form of an Australian Immunisation Register (AIR) - immunisation medical exemption form (IM011). I
understand that if the medical contraindication is temporary, I must be reviewed by the date specified on the Medical
Contraindication Form; OR
I have provided COVID-19 vaccination evidence as follows (Category B workers only):
a. Evidence of 2 doses of a Therapeutic Goods Administration (TGA) approved or recognised COVID-19 vaccine (in accordance
with ATAGI minimum intervals); OR
5 b. I have provided evidence of a temporary or permanent medical contraindication to all the available TGA approved COVID-19
vaccines, in the form of an Australian Immunisation Register (AIR) - immunisation medical exemption form (IM011). I
understand that if the medical contraindication is temporary, I must be reviewed by the date specified on the Medical
Contraindication Form.
Declaration: I, declare that the information provided is correct
Full name Worker cost centre (if available)
Parent/guardian name Parent/guardian signature

(for workers/students under 18 years)
D.O.B Worker/Student ID (if available):
Medicare number Position on card Expiry date
Email
NSW Health agency / Education provider
Signature Date

Undertaking Declaration PD2022 - 030

Uploaded by

Copyright:

Available Formats

Undertaking Declaration PD2022 - 030

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Undertaking Declaration PD2022 - 030

Uploaded by

Copyright:

Available Formats

NSW Health

2. Category A workers as defined in the policy directive must complete:

• each part of this document; and

3. Category B workers as defined in the policy directive must complete:

• each part of this document; and

Part Undertaking/Declaration (tick the applicable option)

Declaration: I, declare that the information provided is correct

Full name Worker cost centre (if available)

Parent/guardian name Parent/guardian signature

D.O.B Worker/Student ID (if available):

Medicare number Position on card Expiry date

NSW Health agency / Education provider

You might also like