Table. Pre-vaccination screening checklist

This checklist helps decide about vaccinating you or your child today. Please fill in the following information for your immunisation provider.

Where appropriate, the Zostavax screening tool and/or the special COVID-19 checklist may also need to be used in conjunction with this screening checklist.

Name of person to be vaccinated:   

Date of birth:   

Age today:       

Name of person completing this form:

Please indicate if the person to be vaccinated:

• ▢ is unwell today
• ▢ has a disease that lowers immunity (eg leukaemia, cancer, HIV)
• ▢ is having treatment that lowers immunity (eg oral steroid medicines such as cortisone and prednisone, DMARDs [disease-modifying anti-rheumatic drugs], other biologics/monoclonal antibodies, radiotherapy, chemotherapy)
• ▢ is an infant of a mother who received highly immunosuppressive therapy (eg bDMARDs [biologic disease-modifying anti-rheumatic drugs]) during pregnancy
• ▢ has had a severe reaction following any vaccine
• ▢ has any severe allergies (to anything)
• ▢ has had any vaccine in the past month
• ▢ has had an injection of immunoglobulin, or received any blood products or a whole-blood transfusion within the past year
• ▢ is pregnant
• ▢ has a history of Guillain–Barré syndrome
• ▢ was a preterm infant
• ▢ has a severe or chronic illness
• ▢ has a bleeding disorder
• ▢ identifies as an Aboriginal or Torres Strait Islander person
• ▢ does not have a functioning spleen
• ▢ is planning a pregnancy or anticipating parenthood
• ▢ is a parent, grandparent or carer of an infant ≤6 months of age
• ▢ lives with someone who has a disease that lowers immunity (eg leukaemia, cancer, HIV) or lives with someone who is having treatment that lowers immunity (eg oral steroid medicines such as cortisone and prednisone, DMARDs [disease-modifying anti-rheumatic drugs], radiotherapy, chemotherapy)
• ▢ is planning travel
• ▢ has an occupation or lifestyle factor(s) for which vaccination may be needed (discuss with immunisation provider)

Please specify: 

Note: Please discuss this information or any questions you have about vaccination with your immunisation provider before the vaccines are given.

Before any vaccination takes place, your immunisation provider should ask you:

• ▢ Did you understand the information provided to you about vaccination?
• ▢ Do you need more information to decide whether to proceed?
• ▢ Did you bring your/your child’s vaccination record card with you?

It is important for you to receive a personal record of your vaccinations or your child’s vaccinations. If you do not have a record, ask your immunisation provider to give you one. Bring this record with you every time you or your child visit for vaccination. Make sure your immunisation provider records all vaccinations on it. An AIR record is an acceptable example of personal record.