PRE EMPLOYMENT IMMUNISATION SCREENING

INFORMATION FOR APPLICANTS Please read carefully

1. It is a requirement of employment at Mercy Hospital Mount Lawley that all healthcare employees who have clinical contact (see below) and work in clinical areas have a preemployment assessment which includes a review of their immunisation status to ensure that it is current and appropriate for their category of employment. 2. Healthcare employees are classified according to the degree of clinical contact they have with patients and the risk of exposure to infectious agents in the work place. The following are general guidelines. Clinical Contact: Generally this is healthcare employees who provide direct clinical care to patients and/or who have potential exposure to blood/body fluids. This also includes Healthcare employees that have less direct patient contact but may work in areas where they will be exposed to infections spread through the air. Non-Clinical Contact: This includes health care employees in departments such as medical records, accounts, catering and administration who have no greater risk of exposure to infectious diseases than in the general community. 3. Please complete the Immunisation/Screening Form (next page) and return it with your application for employment. All details must be completed and returned with application to enable an informed decision to be made when reviewing your status and making any recommendations. 4. Methicillin Resistant Staphylococcus Aureus (MRSA) All Healthcare employees who have worked in or have been hospitalised in a health care facility outside WA or who have worked in a residential care facility within WA in the past 12 months will require MRSA screening prior to commencement of employment. 5. Mantoux All nursing/medical health care employees and some Patient Care Assistants are required to provide baseline Mantoux results. If you have never had a baseline mantoux before or do not have evidence please contact the Infection Control Manager on 0437 884 322 or attend the Perth Chest Clinic for testing. They can be contacted on 9325 3922. 6. Please provide proof of evidence of immunity if you have these documents. If you require any blood tests to check immunity or further vaccinations required this will be done once your paperwork is reviewed by the Infection Control Manager. 7. If you have any concerns in relation to your immunisation/screening requirements please contact the Infection Control Manager at Mercy Hospital on 0437 884 322 8. This paperwork must be completed and submitted with application form and supporting documents with proof of immunity attached.

IMMUNISATION/SCREENING FORM
Applicant Name (print): ....................................................................................DOB:../../ Position Applied for: ....................................................................................Dept:.. Clinical Contact Non-Clinical Contact (circle) Interviewing Manager: ....................................................................................Date:./../... Category of Employment:

Section 1: Communicable Diseases (Vaccine Preventable) Have you either been immunised against or suffered from the following diseases? Diphtheria. Tetanus Polio Mumps Varicella(chicken pox)... Rubella(German Measles). Measles.. If born after 1966 have you received a measles booster?...................... Have you had an Adult Pertussis (Whooping Cough) booster?............. Section 2: Hepatitis B Vaccination Have you completed a full course of 3 injections Did you develop immunity post vaccination Section 3: MRSA(if yes to either, MRSA screening is required) Have you worked in or been a patient in a hospital outside WA in the past 12 months Have you worked in a Residential Care facility in WA in the past 12 months

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No

Unsure Unsure Unsure Unsure Unsure Unsure Unsure Unsure Unsure Unsure Unsure

Yes No Yes No

Section 4: Tuberculosis (Nursing, Medical, PCA only) Have you ever had a BCG(vaccination against TB) Yes No If you have had a Mantoux please give the date obtained/../.. and the result .mm Copy of the Mantoux result is required Office Use Only Investigation Rubella IgG Varicella IgG Measles IgG Mumps IgG Hepatitis BsAb MRSA Screen MMR vaccination Hep B vaccination Hep A vaccination Pertussis vaccination Mantoux Lab Test Date Result Comments Yes No .. Yes No .. Yes No .. Yes No .. Yes No .. Yes No .. Yes No .. Yes No .. Yes No .. Yes No .. Yes No ..

I declare the above information to be true in all respects. Signature: ........................................................................................................Date:../../