Interim Vaccination Objection Form For Enrolment In Nsw Child Care

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Interim* vaccination objection
form for enrolment in NSW child
care centres
GP declaration
How to complete this form
This form must be completed and signed by:
5. I declare that:
the parent/guardian of the child who has an
I have explained the benefits and risks of
objection to vaccination, and
immunisation and disease signs and symptoms
a General Practitioner (GP).
to the parent or guardian of the child named,
and have informed him/her of the potential
Checklist for GP
dangers now and later in life if a child is not
 explain the benefits and risks of immunisation
immunised, and of the wider consequences of
 provide advice on disease signs and symptoms and
not complying with the NSW Immunisation
when to seek medical advice
Schedule
 discuss the wider consequences of not complying
the information provided in this form is
with the NSW Immunisation Schedule (e.g. exclusion
complete and correct.
from school during disease outbreaks)
GP name & address details
 offer a referral to the AEFI clinic (if the basis for the
objection is a previous suspected AEFI)
 offer a follow-up appointment to review decision
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What to do with the completed form
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The parent/guardian must provide a copy of the
Postcode
completed and signed form to the child care centre when
Medicare provider number
enrolling their child.
For more information
For more information about the vaccination
Signature
Date
requirements for enrolment in child care:
/
/
visit
call your local Public Health Unit on 1300 066 055
Parent/guardian declaration
Child’s details
6. I declare that:
1. Family Name
I have discussed the benefits and risks of
immunisation with the provider named above
and have considered the information given
I have been advised about disease signs and
2. First given name
symptoms and when to seek medical advice
I have been advised that my child can be
excluded from child care during disease
3. Postal address
outbreaks
I have been given the opportunity to discuss any
concerns about immunisation with the provider
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I have an objection to immunisation and have
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chosen not to have my child vaccinated.
Parent/guardian name (please print)
Postcode
4. Date of birth
/
/
Signature
Date
/
/
* Valid from 1 January 2017 to 31 December 2017

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