Adverse event following immunisation form
Part A of this form should be filled out if there is an unexpected reaction following immunisation. The definitions of adverse events following immunisation are listed in the Australian Immunisation Handbook pge 360-363. Providers should fill in as much detail about the vaccines administered and the reaction as possible.
Fax the completed form to the Centre for Disease Control Darwin on 8922 8310.
Part B of this form should be completed 60 days after the reaction and forwarded to Centre for Disease Control Darwin on 8922 8310.
Ring your Regional Centre for Disease Control for any further advice.
Download: Adverse event following immunisation form (Adobe PDF document - 63KB)
Vaccine usage and wastage form
A biannual audit of vaccine usage and wastage occurs throughout the NT in Jan - Feb and again in Jul - Aug each year. Forms are sent to all immunisation service providers via the Centre for Disease Control in their region prior to the audit months. All immunisation providers are encouraged to participate in the audit by recording vaccine deliveries and losses during the audit months. Vaccine usage can be determined by a simple mathematical formula. This form should also be used if there is a large unexpected vaccine loss at other times outside of the audit period.
Fax all forms back to Centre for Disease Control Darwin on 8922 8310.
Download: Vaccine usage and wastage form (Adobe PDF document - 27KB)
Vaccination ordering form
Please use this form when ordering any seasonal infulenza vaccine and all National Immunisation Program vaccines.
Download: Vaccine order form (Adobe PDF document - 55KB)
Childhood vaccination recording form
Use this form to record immunisations given to children <7 years of age who are not on routine recall lists.
Fax all forms back to Centre for Disease Control Darwin on 8922 8897
It is not necessary to fill out this form if you are providing the immunisation database with a monthly electronic record of immunisation data from your community.
Download: Childhood vaccination recording form (Adobe PDF document - 19KB)
The following information sheet from the General Practice Network NT with advice about common side effects after vaccination can be given to parents after vaccination
Download: Common immunisation side effects
Adult vaccination recording form
Use this form to record immunisations given to anyone >7 years of age who are not on routine recall lists.
Fax all forms back to Centre for Disease Control Darwin on 8922 8897
It is not necessary to fill out this form if you are providing the immunisation database with a monthly electronic record of immunisation data from your community.
Download: Adult vaccination recording form (Adobe PDF document - 23KB)
Lyssavirus post-exposure prophylaxis recording form
Please contact Centre for Disease Control if you have a petient with a potential exposure to lyssavirus or rabies. Post-exposure vaccination can be provided by Centre for Disease Control during regular working hours and NT public hospital Emergency departments after hours.
Download: Lyssavirus post-exposure prophylaxis questionnaire (Adobe PDF document - 23KB)
