APPLICATION FOR REAUTHORISATION OF VACCINATOR
NB: Please complete this form digitally to ensure legibility,
and insert a digital signature if you have one, or print and sign

Application is being sought by:

Name
Employer
Town/City (working in)
Sub region (working in)	Choose an item.
Email Address
Phone Number (mobile preferred)
Ethnicity	Please indicate which ethnic group(s) you identify with.
Choose an item.

Please attach: (We must receive ALL the above documentation to complete this application)

Proof of Current Annual Practicing Certificate (must include name, NCNZ registration number and expiry date)
Proof of dated Indemnity Insurance Cover (this can be requested by ringing the NZNO on 0800 283848, or Nurses Society of NZ on 09 360 3990, or your insurance provider)
Attendance certificate from your most recent Vaccinator Update Course (must be within the last 2 years) To find out about these courses please visit: www.immune.org.nz/health-professionals/education-training
Current CPR Certificate – Core Immediate – CPR including management of choking, anaphylaxis and collapse management (see the Immunisation Handbook 2020 Section A4.2 for full details)
Evidence of Peer Review within the last 3 months

Current Clinical setting (please select)	Choose an item.
Details (if Other selected):
Summary of immunisation practice over previous 12 months eg. Types of vaccinations given (intramuscular, subcutaneous, intradermal), and other responsibilities related to immunisation (eg. Cold chain-designated person, etc)

Signed by Applicant	Date Click or tap to enter a date.

Please email all documents to: enquiries@toiteora.govt.nz

Toi Te Ora Office use only
Date received	Checked by
Date Approved	Approved by