Protocol for vaccine preventable disease screening for contractors, students and volunteers

Protocol number: QH-HSDPTL-047-1

Effective date: 14 November 2025

Review date: 14 November 2028

Supersedes: Version 4

On this page:

1. Purpose
2. Scope
3. Process for vaccine preventable disease screening for contractors, students and volunteers
4. Human Rights
5. Aboriginal and Torres Strait Islander considerations
6. Supporting and related documents
7. Authorising health service directive
8. Definition of terms
9. Approval and implementation
10. Version control

1. Purpose

This Protocol describes the mandatory steps for vaccine preventable disease screening for Contractors, Students, and Volunteers.

2. Scope

This Protocol applies to all Hospital and Health Services (HHSs).

3. Process for vaccine preventable disease screening for Contractors, Students, and Volunteers

Mandatory vaccine preventable disease (VPD) screening requirements

Evidence of vaccination against, OR proof that a Contractor, Student, or Volunteer is not susceptible to measles, mumps, rubella, and varicella (chicken pox), is required to be provided by a Contractor, Student, or Volunteer for roles in which:

• work requires face to face contact with patients, or
• normal work location is in a Clinical Area such as a ward, emergency department or outpatient clinic, or
• work requires them to attend Clinical Areas.

Evidence of pertussis (whooping cough) vaccination within the last 10 years is required to be provided by the Contractor, Student, or Volunteer for roles where:

• work requires face to face contact with patients, or
• normal work location is in a Clinical Area such as a ward, emergency department or outpatient clinic, or
• work requires them to attend Clinical Areas.

Evidence of vaccination against, OR proof that the Contractor, Student, or Volunteer is not susceptible to hepatitis B is required to be provided by the Contractor, Student, or Volunteer for roles where:

• there is direct physical contact with patients or the deceased, or
• where in the course of their work, there may be exposure to blood, body substances and/or equipment or surfaces contaminated with these.

Hospital and Health Service requirements

HHS must meet the following mandatory VPD screening requirements unless otherwise contractually obligated or agreed by Queensland Health:

• Ensure that where a Contractor or Volunteer is engaged by a Contract Provider, rather than directly by the HHS, the Contract Provider is required as part of their contract, to provide only Contractors or Volunteers who meet the VPD role requirements relevant to their role.
• Ensure that a Contractor, Student, or Volunteer with VPD screening requirements engaged directly by the HHS after 1 July 2016, provide:
  • acceptable documentary evidence of compliance with the VPD screening requirements applicable to prior to the execution of the contract or deed, or prior to commencing work; and
  • evidence of future vaccination for pertussis (whooping cough) as per their role requirement in accordance with recommendations in The Australian Immunisation Handbook (as updated from time to time) and
  • evidence of completion of any vaccine course, where VPD partial compliance allowed commencement, as per their role requirement.

This evidence may be provided by a third party on behalf of the Contractors, Students, or Volunteers.

Evidence

Acceptable documentary evidence of vaccination means the following:

• vaccine record book or vaccine record card with details of vaccine given and clinic attended; or
• Australian Immunisation Record (AIR) immunisation history statement; or
• letter or immunisation history statement from a medical/nurse practitioner, infection prevention and control professional or Vaccine Service Provider with details of vaccine given.

Acceptable documentary evidence of immunity/non-susceptibility means the following (not applicable for pertussis):

• pathology testing result; or
• letter from a medical/nurse practitioner stating diagnosis of varicella or shingles; or
• letter from a medical/nurse practitioner stating non-susceptibility to hepatitis B; or
• birth date before 1966 (for measles, mumps and rubella only).

The Vaccine preventable disease (VPD) evidence and certification form is recommended for use by a HHS in applying the protocol.

VPD specific recommendation information is contained in the Guideline for the vaccination of workers in healthcare settings.

Statutory declarations are not acceptable evidence of vaccination or non-susceptibility to the VPDs specified for the role.

Exemptions

An exemption may be granted from the VPD screening role requirements in the following circumstances:

• Verified supply shortage, or
• Exceptional circumstance (for a Contractor only).

For all exemptions granted, the HHS must provide information to the Contractor, Student, or Volunteer regarding:

• the risk of exposure to a VPD associated with the work proposed to be undertaken; and
• all policies and procedures relevant to avoiding/reducing the risk of exposure and/or injury from a VPD; and
• any required modification of duties to be undertaken, where relevant; and
• any lawful action or recommended action the HHS wants to be taken by the Contractor, Student, or Volunteer in the event of exposure and/or injury from the VPD.

Verified supply shortage of a vaccine

The Chief Health Officer will notify the Health Service Chief Executives of a verified supply shortage of a vaccine (the exemption period), during which the following applies:

• The HHS is not required to comply with the relevant mandatory VPD screening requirements of the protocol for the exemption period, provided that the following requirements are met:
  • a risk assessment is completed by local experts, for example, an infectious diseases physician, the infection prevention and control unit or the safety and quality unit, to determine the level of risk of the Contractor, Student, or Volunteer contracting or transmitting the VPD; and
  • the HHS manages staffing and other operational and clinical matters based on the completed risk assessment.
• In circumstances where a Contractor, Student, or Volunteer is to be engaged following the completion of the risk assessment, approval for an exemption to the required vaccine that is in a verified supply shortage must be obtained from the Health Service Chief Executive.
• The exemption period only applies to the vaccine affected by the verified supply shortage and ends when the Chief Health Officer declares to Health Service Chief Executives that vaccine supply is available. The exemption period must not extend beyond this time.

Exceptional circumstances for a Contractor only

An exceptional circumstance, for the purpose of this protocol, is an event, or combination of events, that requires the appointment of a Contractor to meet a need of the HHS or a facility where:

• not appointing the Contractor may create a risk that is unacceptable to the HHS, that may lead to injury or death of a patient(s) or worker(s); and
• this risk cannot be mitigated in any other practicable way.

Approval for an exceptional circumstance exemption must be sought from a Health Service Chief Executive for a specified VPD vaccine for a specific Contractor, and the following requirements must be met:

• a risk assessment is completed by local experts, for example, a safety and quality unit, an infectious diseases physician or an infection prevention and control unit, to determine the level of risk of the prospective Contractor contracting/transmitting the VPD; and
• the Health Service Chief Executive is satisfied there is no other suitably qualified person who meets the VPD requirements that is able to perform the required duties under the contract; and
• the Contractor must provide documentary evidence from a medical practitioner to support the decision to enter the contract with the Contractor. The documentary evidence must include:
  • the reason for vaccine contraindication relevant to the Contractor; and
  • the timeframe of the vaccine contraindication; and
• any exemption must only be granted for a specified timeframe, not exceeding 12 months and Contractors must re-submit their request with supporting evidence for an extension of the exemption.

The HHS may seek their own advice regarding managing any risks identified in exceptional circumstances, including epidemiological, medical, clinical or legal advice.

Record keeping

The HHS must meet the following mandatory VPD recording requirements:

• In circumstances where the Contractor(s), Student(s) and Volunteer(s) vaccination history, or evidence that they are not susceptible to the specified VPDs, is provided directly to the HHS, this documentation must be stored in a secure database that is accessible to authorised personnel only and maintained in accordance with the Information Privacy Act 2009 (Qld) and the Public Records Act 2023 (Qld). The HHS must ensure the management of these records is in accordance with the local HHS clinical records management policy and procedure. This should include the keeping and disposal of records at the appropriate times.
• The HHS is not responsible for keeping a record of the vaccination history for individual Contractors or Volunteers where a Contract Provider is required as part of their contract, to provide only Contractors or Volunteers who meet the VPD requirements relevant to their role.
• The HHS is not responsible for keeping a record of a Student’s vaccination history. However, a HHS may request this information from the Education Provider, and any information received must be stored in a secure database that is accessible to authorised personnel only and maintained in accordance with the Information Privacy Act 2009 (Qld) and the Public Records Act 2002 (Qld).

Additional VPDs

• The HHS should apply a risk-based approach to include pre-engagement/pre-commencement VPD screening for Contractors, Students, and Volunteers for additional VPDs which are outlined in The Australian Immunisation Handbook (as updated from time to time), only where this pre-engagement/pre-commencement VPD screening has a lawful basis.

Tuberculosis

Mandatory requirements for assessment and screening for tuberculosis are described, and shall be undertaken, in accordance with the Tuberculosis control health service directive and Tuberculosis control protocol.

Monitoring VPD requirements

The HHS must meet the following VPD monitoring requirements:

• Monitor compliance by all relevant Contractor(s) or Volunteer(s) with the VPD screening conditions of their engagement.
• Provide Queensland Health with a report about the use of the verified supply shortage exemption, including the reliance of an exemption period for a verified supply shortage, if requested.
• Provide Queensland Health with a report regarding the number of, and the reason for, exceptional circumstances exemptions sought and/or approved, if requested.
• Provide Queensland Health with a report regarding compliance by Volunteer(s) or Contractor(s) with the VPD screening conditions of engagement, if requested.

4. Human Rights

This protocol may limit the following rights of Contractors, Students, and Volunteers:

• Recognition and equality before the law (s 15)
• Protection from torture and cruel, inhuman or degrading treatment (including the right not to be subjected to medical treatment without consent) (s 17)
• Freedom of thought, conscience, religion and belief (s 20)
• Taking part in public life (s 23)
• Privacy and reputation (s 25)
• Right to education (s 36)

However, any limitation of rights is demonstrably justifiable as the mandatory steps of this protocol are appropriate to minimise risk of the transmission of VPDs to persons in a HHS, which includes vulnerable cohorts.

5. Aboriginal and Torres Strait Islander considerations

Some vaccines have different recommendations for Aboriginal and Torres Strait Islander people. There are additional vaccination recommendations for healthcare workers who work in remote Aboriginal and Torres Strait Islander communities. Please refer to detailed information detailed in The Australian Immunisation Handbook.

6. Supporting and related documents

Legislation

• Hospital and Health Boards Act 2011 (Qld)
• Human Rights Act 2019 (Qld)
• Information Privacy Act 2009 (Qld)
• Public Health Act 2005 (Qld)
• Public Records Act 2023 (Qld)
• Right to Information Act 2009 (Qld)
• Work Health and Safety Act 2011 (Qld)

Guideline

• Guideline for the vaccination of workers in healthcare settings (PDF 930 kB) as updated from time to time

Related documents

• Vaccine preventable disease (VPD) evidence and certification form
• The Australian Immunisation Handbook—as updated from time to time
• Tuberculosis control health service directive
• Tuberculosis control health service directive protocol
• Student deed poll
• Vaccination of workers in healthcare settings

For VPD screening and reporting requirements for health service employees refer to:

• Health employment directive No. 01/16: Vaccine preventable diseases (VPD) requirements (PDF 243 kB)
• Human resources policy B1: Recruitment and selection (PDF 495 kB)

7. Authorising health service directive

• Vaccine preventable disease screening for Contractors, Students and Volunteers Health Service Directive (QH-HSD-047)

8. Definition of terms

9. Approval and implementation

Protocol custodian

Dr Heidi Carroll

Executive Director, Communicable Diseases Branch

Approving officer:

Director-General, Queensland Health

Approval date: 14 November 2025

Effective from: 14 November 2025

10. Version control

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