Form 3 - Student Undertaking/declaration printable pdf download

Occupational assessment, screening and vaccination

against specified infectious diseases

PROCEDURES

FORM 3. – Student Undertaking/Declaration

All students must complete each part of this Form 3: Student Undertaking/Declaration Form and the Form 2:

Tuberculosis (TB) Screening Assessment Tool and return these forms to their educational institution’s clinical

placement coordinator as soon as possible after enrolment. (Parent/guardian to sign if student is under 18 years

of age.)

Students will not be permitted to attend clinical placements if they have not submitted Form 3: Student

Undertaking/Declaration Form and Form 2: Tuberculosis Assessment Tool.

Failure to complete outstanding hepatitis B or TB requirements within the appropriate timeframe(s) will result in

suspension from further clinical placements and may jeopardise the student’s course of study.

The educational institution will:

ensure that all students whom they refer to a health service for clinical placement have submitted these

forms, and

forward the original or a copy of these forms to the health service for assessment.

The health service will:

assess these forms along with evidence of protection against the infectious diseases specified in this

policy directive.



Part 1

I have read and understand the requirements of the NSW Health Occupational Assessment,

Screening and Vaccination against Specified Infectious Diseases Policy Directive.



Part 2

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.



I undertake to participate in the assessment, screening and vaccination process, however I am

aware of medical contraindications that may prevent me from fully completing these

requirements and am able to provide documentation of these medical contraindications. I

request consideration of my circumstances.



Part 3

I have evidence of protection for:

pertussis

diphtheria

tetanus



varicella

measles

mumps

rubella



Part 4

I have evidence of protection for hepatitis B.



I have received at least the first dose of hepatitis B vaccine (documentation provided) and

undertake to complete the hepatitis B vaccine course (as recommended in the Australian

Immunisation Handbook, current edition) and provide a post-vaccination serology result within

six months of commencement of enrolment.



Part 5

I have been informed of, and understand, the risks of infection, the consequences of infection

and management in the event of exposure (refer Information Sheet 3: Specified Infectious

Diseases: Risks, consequences of exposure and protective measures) and agree to comply

with the protective measures required by the health service.

I declare that the information I have provided is correct

Name _____________________________________________________________________________________

Phone or Email _____________________________________________________________________________

Date of Birth or Student ID ____________________________________________________________________

Educational institution _______________________________________________________________________

Signature ________________________________________________ Date _____________________________

PD2011_005

Issue date: January 2011

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Form 3 - Student Undertaking/declaration

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