Immunisation forms

The following frequently used forms are available for downloading to assist your immunisation service.

For more information and resources about the Australian Swine flu vaccine program visit the Health Emergency website or call 180 2007.

Form	MS Word version	PDF version
Swine Flu vaccine order form	Swine Flu vaccine order form (163kb, MS Word)	Swine Flu vaccine order form (114kb, pdf)
Pertussis Prevention for New Parents: Free time limited program	Pertussis Prevention for New Parents: Free Time Limited Program (193kb, MS Word)	Pertussis Prevention for New Parents: Free Time Limited Program (152kb, pdf)
Government funded vaccine order form	Government funded vaccine order form (143kb, MS Word)	Government funded vaccine order form (159kb, pdf)
Refugee program vaccine order form	Refugee program vaccine order form (116kb, MS Word)	Refugee program vaccine order form (135kb, pdf)
Immunisation resource order form (these resources can also be ordered online)	Immunisation resource order form (145kb, MS Word)	Immunisation resource order form (45kb, pdf)
Local Government resource order form Kindergarten and Secondary School resources (these resources can also be ordered online)	Local Government resource order form Kindergarten and Secondary School resources (134kb, MS Word)	Local Government resource order form Kindergarten and Secondary School resources (139kb, pdf)
Hepatitis B vaccine order form for Clinics with Injecting Drug User Clients	Hepatitis B vaccine order form for Clinics with Injecting Drug User Clients (123kb, MS Word)	Hepatitis B vaccine order form for Clinics with Injecting Drug User Clients (192kb, pdf)
Rabies vaccine order form for post-exposure treatment	Rabies vaccine order form for post-exposure treatment (120kb, MS Word)	Rabies vaccine order form for post-exposure treatment (65kb, pdf)
PPD Test and BCG Vaccine Order Form	PPD Test and BCG Vaccine Order Form (121kb, MS Word)	PPD Test and BCG Vaccine Order Form (201kb, pdf)
Infant Hepatitis B Consent Form		Infant Hepatitis B Consent Form (21kb, pdf)
Starting primary school brochure order form	Starting primary school? brochure order form (180kb, MS Word)	Starting primary school? brochure order form (68kb, pdf)
SAEFVIC reporting form (see SAEFVIC for further information)	SAEFVIC reporting form (166kb, MS Word)	SAEFVIC - Form for reporting an adverse event following immunisation (44kb, pdf)

Forms should be sent to:

Immunisation Program
Department of Human Services
GPO Box 4057 Melbourne 3001

Fax: 1300 768 088

Email: immunisation@dhs.vic.gov.au

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