COVID Vaccination - Third Dose

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You are receiving this survey as Western Health’s records currently indicate that you have yet to provide evidence of having received the mandatory third (booster) dose of a COVID vaccine, or a medical exemption.

First Name:

* must provide value

Last Name:

* must provide value

Date of Birth:

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D-M-Y

WH Employee No:

Have you received the third dose (booster) of a COVID vaccine?

* must provide value

Yes

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Western Health can access your Australian Immunisation Record (AIR) to record your COVID-19 vaccination details.

Do you consent to Western Health accessing your AIR?

* must provide value

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:

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Please download a copy of your Immunisation Record or COVID-19 Vaccination Certificate from Medicare Online (myGOV) and upload it here:

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Upload file

Have you been diagnosed as having COVID-19 in the past 4 months?

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Yes

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What date were you diagnosed with COVID-19?

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D-M-Y

Are you seeking an exemption for up to 4 months for your third dose of a COVID vaccine?

* must provide value

Yes

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I make the following statutory declaration that I have received a positive COVID-19 result via either a PCR or Rapid Antigen Test on this date:

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D-M-Y

Please upload evidence of medical exemption

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Upload file

Are you seeking a medical exemption for a condition other than a COVID diagnosis?

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Yes

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Please upload evidence of your medical exemption.

* must provide value

Upload file

Are you intending to receive the third dose of a COVID vaccine?

* must provide value

Yes

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Are you able and intending to receive the third dose of the COVID-19 vaccine prior to the mandatory third dose deadline of 29 March 2022?

* must provide value

Yes

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Thank you for completing the survey. You can walk in to any Western Health vaccination centre to receive the vaccine. Western Health urges you to get your third dose as a priority. Under the requirements of the Pandemic Order, failure to receive the mandatory third dose of the COVID vaccine may result in you being stood down without pay and a disciplinary process commencing.

Western Health urges you to reconsider and get your mandatory third dose. Under the requirements of the Pandemic Order, failure to receive the mandatory third dose of the COVID vaccine may result in you being stood down without pay and a disciplinary process commencing.

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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.