Influenza Immunisation Survey

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Required format:

VsHPu3JnGzD7ZdAB3zWQtPXccoBNBbLZjP8oDsWWNL8jzUp96rTCeDCbSVGcb8sLhofDPDhgzZRBR3mpMRGE8m3CpwHRpGhuuopSGmCh3

Western Health are mandated to record a copy of your influenza vaccination.

Please complete this survey if you have a medical exemption, you have received your vaccination external to Western Health or you have been directed to by your manager.

First Name:

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Last Name:

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Date of Birth:

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D-M-Y

WH Employee No (if known or applicable):

We may need to get in contact with you for further information. What is your preferred contact method?

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Phone

Email Address:

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Mobile Phone Number:

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Staff are categorised depending on the risk of work activities.

Category A and B are defined as:

Healthcare workers who have direct physical contact with patients, clients, deceased persons or body parts, blood, body substances, infectious materia or surfaces or equipment that might contain these OR
Contact that might allow respiratory infections to be acquired or transmitted, which includes workers with prolonged face-to-face contact with patients or clients or where their normal work is in a clinical area

What health care risk category do you fall into?

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Category A

Category B

Category C

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Please confirm your staff group from Category A:

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allied health practitioners

biomedical engineering staff

central sterile supply staff

dentists

medical practitioners

mortuary technicians

nurses and midwives

patient care attendants

patient service attendants

cleaning staff responsible for cleaning, decontamination and disposal of contaminated materials

other staff member who works in patient areas who rarely have direct contact with blood or body substances who may be exposed to infections spread by droplets

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Please confirm your staff group from Category B:

food delivery kitchen staff

menu monitors

ward clerks

other

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Please confirm your staff group from Category C:

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gardening Staff

kitchen Staff

clerical staff who do not visit clinical areas (such as Finance, EMR, People Services, Health Information and Administration)

other staff that have no greater exposure to infectious disease than do the general public

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Please select which applies to you:

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I received my flu vaccination elsewhere

I have a medical exemption

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Please select which applies to you:

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I received my flu vaccination elsewhere

I have a medical exemption

I choose to decline the vaccination

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Please provide a copy of your medical exemption.

Valid documentation is a download of your Immunisation Statement or a copy of the Australian Immunisation Register Immunisation Medical Exemption Form (IM011)

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Upload file

You have chosen to decline the 2023 influenza vaccination - please tick which applies to you:

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I 'm strong and healthy so I don't need a flu vaccine

I believe the flu vaccine isn't safe and can give me the flu

I felt faint or fainted after previous vaccinations

Other

With your consent, Western Health can access your Australian Immunisation Record (AIR) to view or record your immunisation details.

Do you consent to Western Health accessing your AIR record?

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Yes

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Please provide your medicare number (including the IRN).

If you don't have a medicare number, please provide your IHI number.

Medicare Card

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Please provide your residential suburb postcode:

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Please download a copy of your Immunisation Statement from Medicare Online (myGOV) and upload it here:

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Upload file

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.