HPV VACCINATION NOTIFICATION

1 NHVPR-F-3 v5 February 2013To return this form FAX: (03) 8360 8699 or MAIL: reply Paid 725, Sunshine VIC 3020 For assistance or enquiries please call 1800 478 734 (1800 HPV REG) or visit DETAILSSCHOOL DETAILSS urname:School Name:First Name: Middle Name(s):School Postcode:Year Level:CONSENTER DETAILSP revious Surname (if applicable):Consenter Name (if applicable):Date of Birth: / /Gender: Female MaleRelationship to Consumer:Medicare Number: Person Number on Card:Consenter Address: (tick if same as consumer s address)Is the consumer of Aboriginal or Torres Strait Islander origin?Suburb:State: No Aboriginal Torres Strait Islander Both Aboriginal and Torres Strait Islander Postcode:Consenter Contact Number:Address:Suburb:State:Postcode:Pho ne Number: Postal Address (if applicable): VACCINATION DETAILSV accine Brand: Gardasil Cervarix VACCINATION Date: / /Dose Number:Batch Number.

2 PRACTITIONER DETAILSM edicare Provider Number:Practice Name:Provider Name:Phone Number:Signature: Date: / /--HPV VACCINATION NOTIFICATIONFor NOTIFICATION of a single administered NOTIFICATION of multiple doses, please see over for options. The National HPV VACCINATION Program Register (NHVPR) is fully funded by the Australian Government (Department of Health and Ageing) and operated by VCS Inc. Information is held securely and confidentially by the Register under specific National HPV VACCINATION Program Register (HPV Register) supports the National HPV VACCINATION Program by collecting information about HPV vaccine doses given across Australia. With the extension of the HPV VACCINATION Program to boys, the HPV Register will collect HPV VACCINATION notifications for both boys and the program is now mainly delivered by schools, there may be circumstances where HPV vaccines are given in general practice or other healthcare settings (eg.)

3 Absence from school, personal preference).Why notify?Notifying the HPV Register helps providers and patients to ensure HPV vaccine courses are completed. The HPV Register can help by: sending completion statements to those who have received all 3 vaccinations sending history statement reminders to those with an incomplete course within the schools program providing online overdue dose reports to providers, listing patients who have incomplete courses enabling providers to check the VACCINATION status of their patients (by phone or online)If HPV doses are not notified to the HPV Register, this may increase the risk of too many doses being administered, or VACCINATION courses not being in the HPV Register is also very important for monitoring how the HPV VACCINATION Program is working and measuring the effect of the vaccine on HPV-related disease, including cervical cancer. Who can notify?All medical practitioners and immunisation providers can notify HPV vaccine doses.

4 Medical practitioners can set up access to their online account for practice managers and nurses, to facilitate submission of notifications within the can opt-off at any time by contacting the HPV v5 February 2013 How can I notify?Methods for notifying HPV vaccine dosesONLINEHPV Register Secure Site DOCUMENT-bASED faxed or posted to the HPV RegisterSingle Dose HPV VACCINATION NOTIFICATION form Multiple Doses HPV VACCINATION NOTIFICATION form template (multiple doses) Reports generated from practice softwareRequirements for notificationConsumer consent (written or verbal)Minimum fields completed:> Patient - Name, DOB, Gender, Address, Medicare Number> VACCINATION - Date, Dose Number, Vaccine Brand> Practitioner - Provider NumberNote: Entering HPV VACCINATION details into practice software does not automatically result in NOTIFICATION to the HPV online portal, forms and templates are all accessible at can I get more information?National HPV VACCINATION Program Tel: 1800 478 734 Fax: 03 8360 8699 Posted notifications: reply Paid 725, Sunshine Vic 3020 Immunise 671 811 Australian Medicare Local : 02 6228 0800 HPV VACCINATION NOTIFICATIONHas your practice notified HPV vaccinations to the Register?