Immunisation Compliance Form - Faculty of Health Work-Integrated Learning (WIL) - Placements - Charles Darwin University

Sep 15, 2026

This immunisation compliance form for Charles Darwin University (CDU) Faculty of Health Work-Integrated Learning placements sets out the mandatory evidence required from Australian immunisation provider students. It specifies when serology results and vaccination records must be provided, highlights requirements for staff and students in healthcare organisations, and explains actions if a student is a non-responder or has contraindications. It includes sections for student information and mandatory immunity details with disease-by-disease acceptance criteria, dates, and signatures.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages5

Reading Time13 min

AccessFree to download

Student Information

Mandatory Immunity Information

Disease acceptance evidence and compliance checks

Vaccine dates and serology evidence requirements

Important notes

Faculty of Health Work-Integrated Learning (WIL) -Placements Immunisation Compliance Form THIS FORM IS TO BE COMPLETED BY AN AUSTRALIAN IMMUNISATION PROVIDER STUDENTS NEED TO BE PROVIDED WITH THE SEROLOGY EVIDENCE IN SUPPORT Evidence of immunity to specific diseases is mandatory for both staff and students in government, private practice, and healthcare organisations. Charles Darwin University (CDU) students undertaking a placement within these organisations must provide evidence of their immune status to specified vaccine-preventable diseases. This ensures that students are protected from these diseases, and CDU meets the State and Territory requirements and its contractual obligations. Different States/Territories have differing requirements; this document outlines the pre-placement vaccinations required by the Faculty of Health at CDU. The university requires the following: • A record of vaccination(s) signed by the medical practitioner/immunisation provider confirming the student’s immunity. • Copies of the serology results detailing immunity. Please provide the student with a copy of theirserology to provide as evidence. • Please complete this form after the first dose has been administered and ensure the student has follow-up appointments to complete the vaccination schedule. If a student is a non-responder or has a contraindication to a vaccine (allergies, pregnancy, or breastfeeding), SECTION 3: Inability to Comply needs to be completed by their medical practitioner. Please provide vaccination dates and ensure the implications have been explained to the student. Please complete SECTION 1 and SECTION 5 and ask your medical practitioner to complete SECTION 2, SECTION 3 (if required), and SECTION 4 IF STUDENTS HAVE THE REQUIRED SEROLOGICAL EVIDENCE TO SUPPORT THEIR IMMUNISATION COMPLIANCE, THEY CAN UPLOAD THE FORM TO INPLACE WITHOUT A MEDICAL PRACTITIONER'S SIGNATURE | SECTION ONE: Student Information | | --- | | Student Name: | | Date of Birth: | | SECTION TWO: Mandatory Immunity Information | | | | | | --- | --- | --- | --- | --- | | DISEASE | ACCEPTED EVIDENCE OF IMMUNITY | COMPLIANT
(Medical Practitioner only – please indicate) | DATE(S) OF VACCINE
(Medical Practitioner to complete) | SEROLOGY EVIDENCE
(Medical Practitioner to provide) | | Hepatitis B *
Standard 3-dose
schedule is
recommended
(0-1- & 6-month
intervals) | Documented history of ageappropriate course of HBV containing vaccines of either three (3) doses (booster if required)
AND | 􀂅 Yes
􀂅 Nos | Dose 1: / /
Dose 2: / /
Dose 3: / /
Booster: / / (if required) | Sign:
Sign:
Sign:
Sign: | | | Documented seroconversion of HBsAb (≥10mLU/mL) | | Serology confirms Anti-HBs immunity with levels greater than 10mLU/mL. Evidence attached.
􀂅 Yes 􀂅 No | | | Chickenpox (Varicella zoster
virus) ^+ both doses need tobe given | Documented history of chickenpox or Shingles infection
OR
Documented evidence of age-appropriate doses of varicella vaccine (2 doses need to be at least four weeks apart) | 􀂅 Yes
􀂅 No | Serology confirms immunity. Evidence attached.
􀂅 Yes 􀂅 No | | | | | | Dose 1: / /
Dose 2\# : / /
\# If initiated after 14 years | Sign:
Sign: | | Diphtheria,
Tetanus,
Pertussis^
Not ADT | One documented dose of adult dTpa within the last
10 years
(serology is not accepted) | 􀂅 Yes
􀂅 No | Dose 1: / / | Sign: | | Measles, Mumps, Rubella (MMR)^
Must have a positive IgG for all three diseases or receive 2 doses of MMR vaccine | Documented evidence of positive IgG for Measles AND Mumps AND Rubella
OR | 􀂅 Yes
􀂅 No | Serology confirms IgG immunity. Evidence attached.
􀂅 Yes 􀂅 No | | | | Documented two (2) doses of MMR vaccine at least one month apart | | Dose 1: / /
Dose 2: / / | Sign:
Sign: | | Influenza
Required yearly | One documented dose of vaccine during influenza season | 􀂅

FAQs

Who must complete and submit the Immunisation Compliance Form for CDU WIL placements?

Australian immunisation provider students undertaking placements within relevant government, private practice, or healthcare organisations must complete the form and upload it when serological evidence supports immunisation compliance.

When is a medical practitioner required to complete parts of the form?

The form instructions require a medical practitioner to complete specified sections (including immunity confirmation and evidence provision). If a student is a non-responder or has contraindications such as allergies, pregnancy, or breastfeeding, SECTION 3 must be completed by the medical practitioner.

What evidence is required for mandatory immunity to vaccine-preventable diseases?

The form requires either documented vaccination records and/or accepted serology results showing immunity for each listed disease, along with the relevant dates, evidence attachment, and medical practitioner indications for compliance.

Sep 15, 2026

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