Immunisation Declaration – Lakeview Private Hospital

All staff at Lakeview Private Hospital (LPH) have to meet certain immunisation requirements. For this, all roles at LPH are separated into categories. Please read the following policy document which outlines LPH’s immunisation policy, and indicate below once you have done this Staff Immunisation Policy.
Name of Position Applied For*
Name of Hiring Manager or NUM*
Your (candidate) Email address*
Contact Number*
Identification - 100 points of evidence required (passport, drivers licence, medicare card)
Drop files here or

Max. file size: 128 MB.
ID - Provide reason if no evidence given
National Criminal Record Check - Evidence Required
Drop files here or

Max. file size: 128 MB.
Provide reason if no evidence provided
Criminal Check - Provide reason if no evidence given
Working with Children Check - Evidence Required
Drop files here or

Max. file size: 128 MB.
WWC Check - Provide reason if no evidence given
For registered nurses or allied health staff only - Provide copy of AHPRA Certificate
Drop files here or

Max. file size: 128 MB.
Please upload your latest resume.
Max. file size: 128 MB.
Who is your hiring manager?
The next section requires evidence regarding your current compliance with our immunisation requirements.
I*
have read and understand the requirements of LPH’s occupation vaccination program as outlined in the above attachment. Accordingly (please check boxes to indicate your agreement):
check-option*
- 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.
check-option*
- I understand Tuberculosis screening may be required dependant on my place of birth and/or residence in a country with a high incidence of TB.

Evidence of vaccinations/immunisation
Do you have a vaccination card from previous employment?*
- Yes
- No
If no, you must provide evidence at the questions below.
If you have a vaccination card (eg. NSW Health) please upload here.
Drop files here or

Max. file size: 128 MB.
Refer to our immunisation policy for more details at https://hssaustralia.sharepoint.com/:b:/g/EXAAdKKYl3xFs0Ir3klu5qMBWYKP5bYSXfXtCPisiI6wTA?e=yyM8TY
Hepatitis B - Provide serology showing anti-HBs ≥ 10mIU/mL
Drop files here or

Max. file size: 128 MB.
Provide reason if no evidence given
Diptheria, Tetanus and Pertussis - Evidence is a medical certificate showing you had your booster shot and the batch number of the vaccines need to be on the certificate.
Drop files here or

Max. file size: 128 MB.
Provide reason if no evidence given
Measles, Mumps, Rubella - Serology showing positive 1gG for measles, mumps and rubella
Drop files here or

Max. file size: 128 MB.
Provide reason if no evidence given
Varicella (chickenpox) - Serology showing positive 1gG for varicella
Drop files here or

Max. file size: 128 MB.
Provide reason if no evidence given
If you have not provided evidence for any of the immunisations above do you provide agreement to undertake the necessary vaccinations.*
- Yes
Have you had a current influenza vaccine. This is optional, but highly recommended for Category A roles.*
- Yes
- No
Upload evidence*
Max. file size: 128 MB.
If no, please provide reason*
Optional – upload additional documents (eg NSW Health Record)
* Please refer back to Staff Immunisation Policy if you need clarification on what evidence LPH accepts in regards to immunity status

Tuberculosis assessment
Were you born in Australia?*
- Yes
- No
Where were you born?*
Have you ever lived or travelled overseas. Please indicate yes if you have travelled to another country and stayed there for more than 2 weeks?*
- Yes
- No
Please provide details below:*
Country Year Duration in months

Click the "+" icon to add a new row.
Have you ever had contact with a person known to have TB?*
- Yes
- No
Have you ever had TB screening?*
- Yes
- No
Please attach evidence of the screening and result
Max. file size: 128 MB.

Declaration
I declare that the information I have provided is true and correct to the best of my knowledge. I understand that providing false or misleading information may impact on my prospects of employment at Lakeview Private Hospital.
Name:*
Date:*
DD slash MM slash YYYY

Lakeview Private Hospital Immunisation Declaration

Step 1 of 4

Evidence of vaccinations/immunisation

Tuberculosis assessment

Declaration

Country	Year	Duration in months