160 - Radiological report on chest x-ray of an …

1 160 (Design date 10/08) - Page 1 COMMONWEALTH OF AUSTRALIA, 2008 Forms 1071i Health requirement for permanent entry toAustralia and 1163i Health requirement for temporary entryto Australia provide information on Australia s Department of Immigration and Citizenship (thedepartment) is authorised to collect and use the personalinformation on this form under section 60 of the Migration Act1958. When you complete this form and give it to the doctor orclinic, the Commonwealth of Australia becomes the owner ofthe information on the form. The doctor is required to sendthe form to the responsibilitiesThe costs of medical examinations are paid by you directly tothe doctors or clinics undertaking the examinations. There maybe additional costs if further tests or couriers are AustraliaIf outside Australia you must attend the same radiology clinicduring the course of your health you are an applicant for a visa under Australia s OffshoreRefugee and Special Humanitarian Program the AustralianGovernment provides arrangements to cover the costs of yourmedical AustraliaIf you are in Australia and you have applied for a protectionvisa, special arrangements may apply in regard to the costs ofmedical to make an appointment for your chest x-rayOutside AustraliaIf you only require a chest x-ray , please contact your closestPanel radiology clinic and if necessary, obtain a referral from aPanel doctor or your local doctor.

2 If you also require a medicalexamination, first contact a Panel doctor who will refer you toa Panel radiologist. For details AustraliaFor a chest x-ray in Australia you must contact the nearestHealth Services Australia (HSA) office. You can make an onlinebooking at , see for contact numbersand address details or under HSA or Health Services Australiain the White Pages telephone : If you are in Australia and you have applied for aprotection visa, you must see a doctor at HSA city premises, notan Approved Medical Practitioner (AMP) in a regional report on chest x-ray of anapplicant for an Australian visaPregnant visa applicants and the chest x-rayrequirementThe department does not recommend that a pregnant visaapplicant undergoes a chest x-ray . This is because there is a riskthat a chest x-ray could harm the unborn child.

3 It isrecommended that a pregnant visa applicant defers her chestx-ray, and therefore the decision on her visa application, untilafter the child s pregnant visa applicant should firstly contact the departmentto discuss her options, including the possible deferral of hervisa you decide to defer the chest x-ray until after the child s birthA pregnant visa applicant should advise the department if shedecides to defer her chest x-ray until after the child s you are prepared to undergo a chest x-ray while pregnantIf a pregnant visa applicant is prepared to undergo a chestx-ray, it is recommended that she consults with her doctorbefore arranging her appointment for a chest x-ray and thatspecial precautions are taken (eg. using a protective lead shieldand waiting until at least the second trimester).

4 A pregnant visaapplicant must sign the declaration on page 4 beforeundergoing a chest a chest x-ray does not guarantee the grant of a result of the chest x-ray must be found to be normal. Wherea chest x-ray shows abnormalities, the visa applicant may beasked to undergo more specific tests and a course of to bring to the examinationAny previous chest x-ray films you have, particularly those fromthe last 5 years. The radiologist may ask you to submit thesefilm(s) to the department if they consider it necessary to assessyour valid passport is the mandatory , in exceptional circumstances such as: you are unable to obtain a passport without a visa due tolaws in your country of origin; your passport is at the department for processing of yourvisa application; your passport is at the United Nations High Commissionerfor Refugees (UNHCR) or the International Organization forMigration (IOM) for processing in relation to a refugeeapplication or other Australian visa;Continued on the next page160 (Design date 10/08) - Page 2 COMMONWEALTH OF AUSTRALIA, 2008 you are unable to obtain a passport due to political or othercircumstances in your country of origin.

5 Or your passport is not suitable for identification purposes ( photograph is of a baby and with passage of timethe photograph is no longer satisfactory);the following may be acceptable: a verified copy of the front page of the passportendorsed by the Australian Consulate; national identity document (incorporating a photograph,name, date of birth and signature); alternative identification documents otheridentification documentation requested by the departmentor the department s contracted service you do not bring acceptable identification documentation tothe medical examination the processing of your visa applicationmay be : If you are a refugee, humanitarian or protection visaapplicant special arrangements regarding identification happens after the health examination?You may be required to undergo further tests.

6 The reports willbe sent to the department by the doctor. However, if the doctorgives you the envelope containing the x-ray film and the reportplease do not open the envelope. Contact your case officerto determine where to send the medical : If envelopes or reports are tampered with you may berequired to repeat tests at your own the information you giveThe department is authorised to collect information on thisform under the Migration Act 1958. The information providedon this form, will be used to assess your health for an Australianvisa. Test results will not necessarily lead to a visa being result(s) may be disclosed to the relevant Commonwealth,state and territory health agencies and chest x-ray information provided might also be disclosed to agencieswho are authorised to receive information relating to adoption,border control, business skills, citizenship, education, healthassessment, health insurance, health services, law enforcement,payment of pensions and benefits, taxation, review of decisions,child protection and registration of migration information forms 993i Safeguarding your personalinformation and 1243i Your personal identifying information,available from offices of the department, give details of agenciesto which your information might be of birth2 MaleFemale( ) ( )

7 160 (Design date 10/08) - Page 3 COMMONWEALTH OF AUSTRALIA, 2008 Part A Applicant s detailsYour full name (as it appears in your passport or nationalidentity document)Family nameGiven namesTo be completed by the applicant before attending the radiologicalexamination. Please use a pen, and write neatly in English usingBLOCK telephone numbersOffice use onlyFile number/PRID/CIDDate of applicationVisa className and addressof office processingthe applicationForm160 Radiological report on chest x-ray of anapplicant for an Australian visaCOUNTRY CODEAREA CODENUMBER14 YesNoPassport numberValid passport sighted?Reason not presentedTo be completed by RADIOGRAPHER (or staff)YesNoPassport and photograph verified?Country of passportOffice hours( ) ( )After hoursHow to complete this form Complete Part A before attending the Radiological examination.

8 Complete Part B in the presence of the radiographer. Certify in writing across the top of the photograph and on the form (withoutobliterating the image) that it is a true likeness of the examinee. Date to be included. Sight valid passport/national identity document (if provided) and recordpassport/national identity document number below. Assist the applicant with Part B. Complete Part C. Complete Part PHOTOGRAPHIn AustraliaIf you need to bring a photo(s)with you to the medicalappointment at Health ServicesAustralia (HSA), HSA will adviseyou at the time you make AustraliaPlease firmly attach arecent passport sizephotograph of yourself tothe form by staples orother means. Another copyof the same photo shouldbe used for form 26(if required).Please attach a copy of the national identity document sighted toidentify the applicant, if applicable.

9 The copy should be certified bythe attach a copy of the bio-data page of the passportsighted to identify the applicant. The copy should be certifiedby the namesDate of birthDAYMONTHYEARSex: MaleFemaleApplicant s full name (as it appears in passport or national identity document)Family nameDetails of identity card or identity number issued to the applicant by his/hergovernment (if applicable) eg. National identity : If the applicant is the holder of multiple identity numbers because he/sheis a citizen of more than one country, you need to enter the identity number onthe card from the country that the applicant lives numberCountry of issueContinued on the next pageHow long do you intend staying in Australia?7 TemporarilyFor how long?Permanently(including non-migrating applicant)YesNoHave you lodged a visa application?

10 10 Which office?At which office do you intend to lodge an application?160 (Design date 10/08) - Page 4 COMMONWEALTH OF AUSTRALIA, 2008 MONTHSYEARSYesNoIf you are in Australia, are you applying for a protection visa?8If you are outside Australia, which visa are you applying for?9 Which visa are you applying for?Go to Question 10 For female applicantsAre you pregnant?12 YesNoGo to Part BDAYMONTHYEARWhat is the expected date of birth?Note: Please read the information under Pregnant visaapplicants and the chest x-ray requirement on page 1 ofthis form. Please then read and sign the declaration visa applicant s declarationI have read the information on page 1 of this form and understand thatthe Department of Immigration and Citizenship recommends that: a pregnant visa applicant does not undergo a chest x-ray ; a pregnant visa applicant defers her chest x-ray , and therefore thedecision on her visa application, until after the child s birth; and if a pregnant visa applicant is prepared to undergo a chest x-ray , sheconsults her doctor before undergoing the x-ray and that specialprecautions are taken (eg.)