Australian Childhood Immunisation Register Immunisation Exemption Conscientious Objection Form
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1Australian Childhood Immunisation Register
Immunisation exemption conscientious
objection form
3
When to use this form
Postal address
This form must be completed by a recognised immunisation provider
and the parent/guardian of the child.
For more information
Postcode
For more information about the Australian Childhood Immunisation
/
/
Register or for assistance completing this form go to our website
4
Date of birth
humanservices.gov.au/healthprofessionals >Other programs
5
>Australian Childhood Immunisation Register or call
Sex
Male
Female
1800 653 809 Monday to Friday, between 8.00 am and 5.00 pm,
Australian Eastern Standard Time.
Provider declaration
Note: Call charges apply from mobile phones.
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I declare that:
Filling in this form
• I have explained the benefits and risks associated with
immunisation to the parent or guardian of the child named,
Please use black or blue pen
•
and have informed him/her of the potential dangers if a child
•
Print in BLOCK LETTERS
is not immunised.
✓
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•
Mark boxes like this
with a
or
• the information provided in this form is complete and correct.
I understand that:
Returning your form
• giving false or misleading information is a serious offence.
Send the completed and signed form to:
Medicare provider/ACIR registration number
Department of Human Services
GPO Box 295
Hobart TAS 7001
Signature
or fax: 03 6281 0555
Date
-
/
/
Privacy notice
Your personal information is protected by law, including the
Parent/guardian declaration
Privacy Act 1988, and is collected for a Social Security, Family
Assistance, Medicare, Child Support and CRS purpose, depending
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I declare that:
on the service or payment concerned. This information may be
required by law or collected voluntarily when you apply for services or
• I have discussed the benefits and risks of immunisation
payments.
with the provider named above and have considered the
information given.
Your information is used for the assessment and administration of
payments and services and may also be used within Human Services,
• I have also been given the opportunity to discuss any concerns
about immunisation with the provider.
or disclosed to other parties or agencies, where you have provided
consent or it is required or authorised by law.
• I have a personal, philosophical, religious or medical belief
involving a conviction that vaccination under the National
You can get more information about privacy by going to our website
Immunisation Program should not take place. On this basis, I
humanservices.gov.au/privacy or requesting a copy of the full
choose not to have my child immunised.
privacy policy at one of our Service Centres.
• the information provided in this form is complete and correct.
Child’s details
I understand that:
• Giving false or misleading information is a serious offence.
1
Medicare card number
Parent/guardian name (please print)
Ref no.
2
Family name
Signature
Date
-
/
/
First given name
Initial
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IMMU12.1302
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