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Section B – Program protocols
Protocol 1: Coordinator/Nurse - Roles and Responsibilities
Protocol 2: Develop an Advisory Group
Protocol 3: Implementation of the program
Protocol 4: Collating, reporting and analysing data
Protocol 5: Feedback of coverage
Protocol 6: Evaluation and reports
Section C – Attachments –
Required Resources
Attachment 1 Policy Document ‘Access to Influenza Vaccine for the Department of
Health Employee Vaccination Program’
Attachment 2 Policy Document ‘Management and Storage of Vaccines’
Attachment 3 Policy Document ‘Vaccine Safety in South Australia’
Attachment 4 Standing Drug Order (SDO) for Influenza Vaccine
Attachment 5 Standing Drug Order (SDO) for Adrenaline
Attachment 6 Model Endorsement for Standing Drug Orders (SDOs) Sign off Page
Attachment 7 Vaccine Order Form
Attachment 8 Comparison of the effects of disease with the possible side effects
of vaccination / Pre-vaccination checklist
Attachment 9 Employee Consent Form – Influenza Vaccine
Attachment 10 Employee Influenza Information Sheet
Attachment 11 Pre-Vaccination Assessment table
Attachment 12 Clinical features which may assist Differentiation between a Vasovagal episode and Anaphylaxis/ Management of Anaphylaxis
Attachment 13 Adverse Event Following Immunisation Reporting Form
Attachment 14 Flow Chart for Needle Stick Injury with Body Fluid Exposure
Attachment 15 Employee Influenza Vaccine Exemption Form
Attachment 16 Statistics: Employee Annual Influenza Vaccination Program
Section D – Attachments –
Sample Resources
Attachment 1 Example Policy Document ‘Organisation policy for the Immunisation
Requirements of Health Care Workers Annual Influenza Vaccination Program and
Endorsement of the Immunisation Guidelines for Health Care Workers in South
Australia – 2006’
Attachment 2 ‘DO NOT USE’ label
Attachment 3 Top Concerns Regarding Influenza Immunisation
Attachment 4 Pandemic Influenza Information for Health Care Workers
Attachment 5 ’Six reasons why you should receive the Annual flu vaccination to
assist in achieving a more effective level of protection in the event of a
Pandemic strain emerging’
Attachment 6 Relevant Influenza websites
Attachment 7 Suggested initial promotional support from Executive
Attachment 8 Sample photo promotion with Senior Staff
Attachment 9 Letter from Executive to Employees who have not had the Annual flu
Vaccine
Attachment 10 Recognition Award
Attachment 11 Reminder Memo template
Attachment 12 Example template for Timetable of Clinics
Attachment 13 Last chance to receive your free flu vaccination
Attachment 14 Differentiation between Cold and Influenza
Attachment 15 Fainting Information
Attachment 16 Daily running sheet
Attachment 17 Post Influenza Vaccination Program Employee Survey
Section E -
Attachments - Complete Human Resources Information
System (CHRIS) Instructions
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