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Immunisation recording and reporting forms

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Vaccine order form

Please use this form when ordering any seasonal influenza vaccine and  all National Immunisation Program vaccines.

Download: Vaccine order form (Adobe PDF document - 40KB) | DOCX (42KB)

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 - 20KB) | DOCX (53KB)

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)

Adverse event following immunisation form

Adverse events following immunisation refer to any untoward medical occurrence that follows immunisation whether it is expected or unexpected and regardless of whether it is triggered by the vaccine or coincidentally occurs following its' administration. AEFIs can be reported by any health professional, vaccine provider, patient or their families.

Part A of this form should be filled out in as much detail as possible about the vaccines administered and the reaction which occurred. Please forward completed forms to the Centre for Disease on fax 8922 8310.   Please refer to the current Australian Immunisation Handbook for specific definitions and advice on adverse events following immunisation

Part B of this form should be completed 60 days after the reported reaction and forwarded to Centre for Disease Control Darwin on fax 8922 8310

Ring your Regional Centre for Disease Control for any further advice.

Download: Adverse event following immunisation form (Adobe PDF document - 66KB) | DOCX (74KB)

BCG incident and side effects reporting form

This form should be used to report both incidents relating to administration as well as BCG side effects. An Adverse Event Following Immunisation form (AEFI) should also be completed. Fax both forms to the Centre for Disease Control Darwin on 8922 8310.

Download: BCG incident and side effects reporting form (Adobe PDF document - 24KB) | RTF (39KB)

Cold chain graph

Keep all vaccines between 2-8°C. Strive for 5°C as this gives greater leeway for temperature fluctuations.

Daily or twice daily recordings of the minimum and maximum temperature of the vaccine storage fridge should be recorded on the cold chain graph.

Download: Cold chain graph (Adobe PDF document - 169KB)

Wastage report

Centre for Disease Control (CDC) has changed the biannual usage/wastage reports. Vaccine usage will no longer be collected and wastage will be reported throughout the year rather than biannually.

Please complete the attached form to record all vaccine wastage from your clinic at the time the vaccine is discarded. Vaccine providers are only required to complete this form when wastage occurs. Vaccine providers should still continue to report any cold chain breaches prior to discarding vaccines by calling CDC.

Fax all forms back to Centre for Disease Control Darwin on 8922 8310.

Download: Wastage report (Adobe PDF document - 35KB) I DOCX (28KB)

Lyssavirus post-exposure prophylaxis recording form

Please contact Centre for Disease Control if you have a patient 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) | RTF (43KB)