PEER REVIEW CLINICAL ASSESSMENT

This form is to be used for authorised Vaccinators seeking reauthorisation from the Medical Officers of Health.

The Reviewer must be a current authorised Independent Vaccinator.

Name of Vaccinator	Name of Peer Reviewer
Location	Date

Vaccinator

Holds current CPR certificate (level 4 equivalent + Anaphylaxis), practicing certificate

and indemnity insurance	YES/NO

Attended appropriate update (four hours every two years)	YES/NO

Venue

Allows for safe management and delivery of immunisation	YES/NO

Private	YES/NO

Resting space/waiting space	YES/NO

Safety – sharps containers/spillages	YES/NO

Equipment

Check oxygen and masks (adult and paediatric)	YES/NO

Check adrenaline and expiry date	YES/NO

Emergency equipment airways (all sizes) ambubag, needles, syringes, etc	YES/NO

Emergency plan for dealing with anaphylaxis and other reactions	YES/NO

Cold Chain

Daily temperature readings and documentation	YES/NO

Vaccines stored correctly	YES/NO

Knows what to do in case of cold chain failure	YES/NO

Pre-vaccination

Meet and greet parents/caregivers and child	YES/NO

Checks vaccinations to be given/nil recent vaccines	YES/NO

Checks history/contraindications/current health status/on any treatment/medical warnings

YES/NO

Explain what vaccines are to be given	YES/NO

Discuss what side effects there may be	YES/NO

Discuss risks versus benefits	YES/NO

Discuss post immunisation advice and give contact numbers for aftercare	YES/NO

Inform must stay in clinic for 20 minutes post vaccination	YES/NO

Allows time to answer any questions	YES/NO

If happy to proceed obtains consent – verbal or written	YES/NO

5.	Administration

Washes hands	YES/NO

Check:

correct vaccine	YES/NO

expiry date and appearance	YES/NO

draws up vaccine using aseptic technique	YES/NO

checks mixes and diluents	YES/NO

changes needles	YES/NO

uses correct needle size and length	YES/NO

Prepares child:

good access	YES/NO

held securely	YES/NO

Administer vaccine in appropriate site/s	YES/NO

Disposes of needles and syringes in sharps container	YES/NO

Washes hands	YES/NO

6. Post Vaccination

Completes documentation in files and/or computer	YES/NO

Put on recall for next vaccinations	YES/NO

Completes Well Child Tamariki Ora Book	YES/NO

Completes Immunisation Certificate as required	YES/NO

Informs caregiver of next vaccination date	YES/NO

Repeats aftercare advice	YES/NO

Keeps vaccinee in clinic for 20 minutes and inspects site/s before leaving	YES/NO

PASS	YES/NO

Comments
Peer Reviewer’s Signature
Contact Details Phone Number
Vaccinator’s Signature
Contact Details Phone Number