MOH-HP-BCG-VAC

Answer these questions so we can review and route your request.

Select the option that best describes why the vaccination is being requested.

Reason for vaccination request *

1. Planned overseas travel to a country where tuberculosis (TB) is common2. Occupational requirement overseas (e.g. healthcare or high risk work)3. Contact with person from a high tuberculosis (TB) incidence country4. Other

Specify other reason *

Travel details

When do you plan to travel? *Use the format DD/MM/YYYY. If not yet booked, please select the closest expected travel date.

What is the intended length of stay for this trip?

Primary country of intended travel *Type name above for country lookup

Are you travelling to more than one country?

YesNo

How many countries will you travel to on this trip?

234+

Country 2 *Select an additional country

Country 3 *Select an additional country

Country 4 *Select an additional country

Add any additional countries not already listed above

Beyond this trip, do you have future additional overseas travel planned?

YesNo

Details of person requiring vaccination

First name *

Last name *

Date of birth *Use the format DD/MM/YYYY

Sex

Country of birth *Type name for auto country lookup

Medicare number (if available)A Medicare card is an Australian government-issued document provided to citizens enabling access to subsidised health services

Has the person had close contact with someone with tuberculosis (TB) that you know of? *

YesNo

Provide details to assist us assess your exposure

When was the TB exposure?

Has the person to be vaccinated lived in or travelled overseas? *

YesNo

Please provide details on countries visited and time spent in each country *

Person to be contacted

First name *

Last name *

Email *

Phone *

Residential address *

Street address *

Street address line 2

Suburb

State

Postcode

Country

Only available for NSW residents

Acknowledgement

I have read the NSW recommendations and fact sheet regarding BCG vaccination and agree for my local TB service to contact me. *

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