The Information Privacy Act 20
09 sets out ways in which a health agency can collect personal information for the purpose of reporting Adverse Events Following
Immunisation (AEFI). The Public Health Act 2005 requires the AEFI to be reported to Queensland Health for inclusion on the Notiable Conditions Register (NoCS).
If further follow up is required following an adverse event, the information stored on the Notiable Conditions Register will be used. AEFI reports and collects
details such as the vaccinated person’s name, contact information and relevent health information. Details pertaining to the adverse event, important medical
history relevant for follow up following the adverse event, details of the provider who administered the vaccine, reporter details and vaccination details are
requested and recorded for each AEFI report. Authorised Queensland Health sta may access the information for the purpose of clinical follow up and monitoring.
Personal information will not be accessed by or given to any other person or organisation without permission unless permitted or required by law. For information
about how Queensland Health protects personal information, or to learn about the right to access your own personal information, please see our website at
www.health.qld.gov.au/system-governance/records-privacy
All reports are provided to the Therapeutic Goods Administration (TGA) to be entered into the TGA’s Australian Adverse Drugs Reactions System (the ADRS).
Information about how the TGA uses adverse event information that is reported is available at www.tga.gov.au/safety/problem.htm
Date
Signature
Management of event: (tick as many as apply)
Details:
Nurse assessment Medical assessment GP assessment
Pharmacist
Hospital emergency department
Hospital admission
Self
Unknown None Other, please specify
Please specify the treatment/care provided (e.g. antibiotics, adrenaline, advice, counselling, etc.):
.
Click ‘Save As’ button to save the form for your records. Attach to an email for sending to
[email protected] . Click the ‘Print’ button, scan the form and then attach it to an email for sending to CDIS-NOCS-Support @health.qld.gov.au
.
Open the form in Acrobat desktop and click ‘Email’ button to send
to
[email protected](Note: This requires the latest version of Adobe Acrobat and does not save the form for your records)
. Fax the form to ()
Privacy statement
Clicking the ‘Reset Partial’ button will maintain the data entered in
the Vaccination Provider Details and Reporter Details sections.
However, all the other information in the form will be removed.
Clicking the ‘Reset All’ button will
remove all the information from this
form.
Save As Print Email
Reset Partial
END OF FORM
OR
OR
OR
Reset All
Once you have completed this form, you can either:
Oce use only - Public Health Unit
Is follow-up of the person required?
No Yes —Timeframe for follow up
Same day Next working day Next 60 days
Date of admission Date of discharge