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It guides workers to read their role requirements, complete Section 1 by signing consent, then supply VPD evidence via either direct completion of Section 2 or submission of Section 3 completed by an approved vaccine service provider. The form specifies required documentation copies, translation responsibilities, and that statutory declarations are not acceptable evidence. Consent for passing screening information to relevant Queensland Health recruitment, line manager, staff health, and infection control units is included.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/vaccine-preventable-disease-vpd-evidence-and-certification-form-instructions-for-workers-section-1-to-section-3/270688/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/vaccine-preventable-disease-vpd-evidence-and-certification-form-instructions-for-workers-section-1-to-section-3/270688.png","ImageObject",300,407,{"name":92,"@type":93},"Genevieve","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-23","2026-09-15",true,{"@type":102,"interactionType":103,"userInteractionCount":52},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What steps must workers follow to provide VPD evidence?","Question",{"text":112,"@type":113},"Workers first review their role instructions for required VPDs, complete Section 1 by reading and signing consent, then choose either completing Section 2 themselves or having a vaccine service provider complete Section 3. The completed Section 1 and Section 2 or Section 3 must be returned, including copies of the VPD evidence.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What are the important requirements for acceptable evidence?",{"text":117,"@type":113},"Certified translations are required if evidence is not in English. Statutory declarations are not accepted as valid evidence, and failure to provide required evidence can affect meeting employment engagement conditions, with the right for Queensland Health to withdraw an employment offer. Costs for medical consultations, vaccinations, or testing are the worker’s responsibility.",{"name":119,"@type":110,"acceptedAnswer":120},"What does the consent section allow Queensland Health to do?",{"text":121,"@type":113},"Consent authorises passing personal and VPD screening information to relevant Queensland Health or Hospital and Health Service recruitment units, line managers, and staff health and infection control units for VPD assessment purposes only. Information will not be disclosed to other third parties without additional consent unless permitted or required by law.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},270688,1789456343,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":52,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":34,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":129,"read_time":143},1374391974585,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","Vaccine preventable disease (VPD) evidence and certification form  \nInstructions for workers*:  \n| Step 1 | Read your role description or work instructions for vaccine preventable disease (VPD) evidence requirements, and check those that apply here:\u003Cbr>☐ Hepatitis B\u003Cbr>☐ Varicella (chicken pox)\u003Cbr>☐ Measles, mumps, rubella\u003Cbr>☐ Pertussis (whooping cough)\u003Cbr>Additional vaccines: ONLY REQUIRED FOR AT-RISK ROLES (see page 5)\u003Cbr>☐ Hepatitis A\u003Cbr>☐ Japanese encephalitis virus |\n| --- | --- |\n| Step 2 | Complete Section 1. Read and sign the consent. |\n| Step 3 | Select one of the following options for supplying your VPD evidence. |\n|  | Section 2: Complete Section 2 yourself. Do not complete Section 3. |\n|  | Section 3: Visit your vaccine service provider\\# and have them complete Section 3 for you. |\n| Step 4 | Return Section 1 and Section 2 OR Section 3.\u003Cbr>Your completed form must include copies of your VPD evidence. |\n\nImportant requirements:  \n• If your evidence is not in English, it is your responsibility to provide a certified translation.  \n• Please note that statutory declarations will not be accepted as valid evidence.  \n• Failure to provide the required evidence will result in not meeting the conditions of employment engagement, where Queensland Health retains the right to withdraw the offer of employment.  \n• Any costs associated with medical consultations, vaccinations, or testing are the responsibility of the worker.  \n* “Worker” refers to any of the following: employment candidate, prospective volunteer, student, or contractor.  \n\\#A vaccine service provider is a qualified health professional, such as a medical or nurse practitioner, pharmacist, midwife, registered nurse, or Aboriginal and Torres Strait Islander health practitioner with the appropriate qualifications and authorisation, under an extended practice authority (EPA), to administer immunisation medicines.  \n| Full name |  |  |  |\n| --- | --- | --- | --- |\n| Date of birth |  | Phone no.\\# |  |\n| Email\\# |  |  |  |\n| Signature |  | Date |  |\n| \\# A VPD assessor may contact you regarding the evidence that you have supplied. Please do not provide contact details on this form if you do not consent to this contact. |  |  |  |\n\nConsent to pass on your information:  \nYour consent is requested to pass your personal and vaccine preventable disease screening information to relevant Queensland Health and/or Hospital and Health Service recruitment units, relevant line managers, staff health and infection control units for vaccine preventable disease assessment purposes only. Your personal information will not be disclosed to other third parties without additional consent unless the disclosure is authorised or required by or under law.  \nIf you choose not to allow your information to be passed on, please discuss with the recruitment panel chair or email [at](at dohrecruitment@health.qld.gov.au)[ ](at dohrecruitment@health.qld.gov.au)[dohrecruitment@health.qld.gov.au](at dohrecruitment@health.qld.gov.au).  \nI consent ☐  \nI do not consent ☐  \n\n| Signature |  | Date |  |\n| --- | --- | --- | --- |\n\nSection 2 – Vaccine preventable disease evidence  \nCopies of vaccination and/or non-susceptibility evidence must be attached to this form  \n\n| Full name |  |\n| --- | --- |\n| Pertussis (Whooping cough) | Brand names of pertussis-containing vaccines: Boostrix, Boostrix-IPV, Adacel, Adacel Polio, Infanrix and Tripacel. This list is not exhaustive. |\n| Vaccine record | ☐ Documented history of one adult dose of pertussis-containing vaccine within the past 10 years1\u003Cbr>Dose date: |\n| Worker acknowledgement | ☐ Pertussis vaccination every 10 years as a healthcare worker. |\n| Explanatory notes:\u003Cbr>1. Evidence of vaccination with a pertussis-containing vaccine within the last ten years is the only acceptable evidence for pertussis. |  |\n| Hepatitis B | Brand names of hepatitis B-containing vaccines: H-B-Vax II, Engerix-B, Infanrix hexa, Twinrix/Twinrix Junior, ComVax and Vaxelis. This list ","cbCairH28uW0wcJd","https://ap.wps.com/l/cbCairH28uW0wcJd","pdf",562685,"English","# Instructions for workers\n## Step-by-step evidence submission\n# Consent to pass on information\n## Worker decision and signature\n# Section 2 – Vaccine preventable disease evidence\n## Pertussis (Whooping cough)\n## Hepatitis B","[{\"question\":\"What steps must workers follow to provide VPD evidence?\",\"answer\":\"Workers first review their role instructions for required VPDs, complete Section 1 by reading and signing consent, then choose either completing Section 2 themselves or having a vaccine service provider complete Section 3. The completed Section 1 and Section 2 or Section 3 must be returned, including copies of the VPD evidence.\"},{\"question\":\"What are the important requirements for acceptable evidence?\",\"answer\":\"Certified translations are required if evidence is not in English. Statutory declarations are not accepted as valid evidence, and failure to provide required evidence can affect meeting employment engagement conditions, with the right for Queensland Health to withdraw an employment offer. Costs for medical consultations, vaccinations, or testing are the worker’s responsibility.\"},{\"question\":\"What does the consent section allow Queensland Health to do?\",\"answer\":\"Consent authorises passing personal and VPD screening information to relevant Queensland Health or Hospital and Health Service recruitment units, line managers, and staff health and infection control units for VPD assessment purposes only. Information will not be disclosed to other third parties without additional consent unless permitted or required by law.\"}]","Vaccine preventable disease（VPD）evidence and certification form - Instructions for workers - Section 1 to Section 3 | PDF",18]