APPLICATION FOR REAUTHORISATION OF VACCINATOR
where the previous authorisation expired more than 1 month ago but less than 5 years ago

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)
Copy of expired Vaccinator Authorisation Certificate
Vaccinator Update Course certificate dated within the last two 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)
Clinical Assessment by an Immunisation Facilitator or approved assessor within the last 3 months (see Immunisation Handbook 2020, A4.1.6)

Current Clinical setting (please select)	Choose an item.
Details (if Other selected):

Summary of clinical practice over the last 12 months:	Signature of 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