Global

New vaccine ordering Account

New vaccine ordering Account

For completion by the principal



This form is to be used by all providers requesting access to National Immunisation Program and state funded vaccines.

Approval of a new vaccine account is reliant on the information supplied by each provider and mandatory attachments submitted to the PHU.

Approval of a new vaccine account (and site visit) is at the discretion of local public health unit.

Facility Details
Name of Facility:
Provider type:
Other Provider type:
Number of GPs/pharmacist immunisers providing vaccination in your facility:
Nominated AHPRA principal practitioner (as registered on AHPRA Web site):
AHPRA number of principal practitioner:
AHPRA expiry date of principal practitioner:
Type of medical/pharmacist software used e.g., Best Practice, Communicare, etc.:

Facility Address
Address 1:
Address 2:
Suburb:
Postcode:
Telephone:
Fax:
Main email (to receive vaccine correspondence):
Please ensure generic email addresses are used where possible. e.g., reception@gpfacility.com or practice manager@RACF.com.
Secondary Email:
Opening hours for delivery (specify days and hours):
LHD:
PHU:
Medicare provider number/AIR provider number:

Provider Equipment Details
Does the facility have a purpose built vaccine specific fridge? Yes No
Fridge Type (specify brand of refrigerator and volume capacity):
Year vaccine fridge was purchased:
Has your vaccine fridge been serviced in the last twelve months? Yes No NA
Is there a permanent data logger for each fridge? Yes No
Data logger brand name:
Data logger date of purchase:
Does your fridge have an inbuilt min/max thermometer? Yes No
Do you have battery operated min/max thermometers for both the vaccine fridge and eskies? Yes No
Battery operated thermometer brand name:
Battery operated thermometer date of purchase:

Provider Details
Is there a designated person and back up person responsible for vaccine storage? Yes No
Primary person name:
Primary person email address:
Primary person position:
Back up person name:
Back up person email address:
Back up person position:
Is there a designated person and back up person responsible for implementation of protocols? Yes No Same as above
Primary person name:
Primary person email address:
Primary person position:
Back up person name:
Back up person email address:
Back up person position:
Have all persons that manage vaccine storage completed the NSW Health online vaccine storage and cold chain management online training module?
A minimum of 2 completed HETI certificates are required to be be submitted to your Local Public Health Unit prior to approval.
It is recommended that ALL reception staff, nursing, pharmacist and medical staff complete the HETI cold chain training module. 		Yes No

New VAN checklist
Facility
Is there Adequate space and facilities to ensure patient privacy? Yes No NA
Are hand hygiene facilities available? Yes No NA
Equipment
Have all battery operated min/max thermometers been ice slush tested (as per Strive for 5) and had their battery changed in past 12 months? Yes No
Fridge alarm and parameters set (+2°C to +8°C)? Yes No
Door lock/fridge front tilted back slightly to ensure door closes easily? Yes No
Is there a separate power circuit? Yes No
Is the plug labelled "Do not unplug"? Yes No
Cooler (as per salvage plan)? Yes No
Ice bricks (as per salvage plan)? Yes No
Anaphylaxis kit to manage adverse events? Yes No
Key documents
The facility must have access to the current version of the following documents readily available (These documents are available online. Please download them using the links below).
National Vaccine Storage Guidelines "Strive for 5" Yes No
The Australian Immunisation Handbook Yes No
NSW Health Immunisation website Yes No
NSW Health Cold Chain Toolkit for Immunisation Providers Yes No
NSW Health Influenza Vaccination Provider Toolkit Yes No
NSW Health Pharmacy standards Yes No NA
Reporting requirements
Each authorised immuniser has access to AIR to review and submit vaccination records Yes No
Each authorised immuniser knows how to manage and report Adverse Events Following Immunisation Yes No
PHARMACIST ONLY have you completed the NSW pharmacist declaration form? Yes No NA
Cold Chain Management
Only vaccines and medications stored in the fridge (i.e. no food or drink) Yes No
There is a specific salvage plan (e.g. during power outages) available Yes No
Staff responsibilities
All staff must be are aware of their responsibility in regard to:
ordering vaccines Yes No
receiving vaccine orders Yes No
logging wastage of vaccines Yes No
performing twice daily checking of the fridge/staff ability to read and reset min/max and actions required to be taken in the event of a breach Yes No
weekly downloading the data logger and actions required in the event of a breach Yes No
managing power outages (planned and unplanned) Yes No
equipment maintenance plan (fridge maintenance, data logger calibration, data logger battery change, min/max battery change, and ice slurry test) Yes No
reporting and managing cold chain breaches Yes No
patient eligibility criteria for funded vaccines Yes No

Declaration

By ticking below you confirm the above details and you agree to reporting any changes.
I declare that:
  • all providers who will be administering vaccines have completed an accredited vaccination training course (not applicable for GPs), and;
  • all vaccination clinics will be conducted in line with all relevant National and State protocols/standards, and;
  • each vaccination administered will be reported to the Australian Immunisation Register.
I also declare that the above information is true and accurate at the time of completion and agree to notify the State Vaccine Centre (1300 656 132) of any changes to these details as soon as possible. 		Yes
Name of person making this declaration:
AHPRA number of person making this declaration:
Phone number of person making this declaration:
Following submission of this form your local Public health Unit will be in contact to verify your application. To expedite this process please ensure you have the below documentation ready to provide to your local Public Health Unit: Your local public health unit may request further documentation to those listed above.