OFFICE USE ONLY Client no.: Date received: / / Application no.

December 2020 INZ 1096

Chest X-ray
Certificate

Applicant’s notes
Who should use this form?
The information in this section will help you complete this
Applicants for entry to New Zealand are required to have chest X-ray certificate. Please read the information in this
an acceptable standard of health (Health Requirements section before you start to complete this certificate.
(INZ 1121) has more details). This chest X-ray certificate
records information about your health that Immigration
When do I use this chest X-ray certificate?
New Zealand requires to assess whether you meet this You must use this chest X-ray certificate if:
standard. • you are applying for residence, or
Most people can submit health information electronically • you are applying for a temporary entry class visa and
via their panel physician. To find out if you can you intend to stay longer than 12 months, unless you are
submit your health information electronically, go to applying for a military visa, diplomatic, consular or official
www.immigration.govt.nz/paneldoctors. If you are visa, or a visa related to the Antarctic Treaty, or
not able to submit electronically, the medical clinic
completing the form should send it directly to the • you are applying for a temporary entry class visa and
following address: you intend to stay between six to 12 months and you are
from, or have visited, a place that is not on Immigration
Health Assessment Team
C/O Immigration New Zealand
New Zealand’s list of countries, areas and territories with
PO Box 76895 a low incidence of tuberculosis (TB). The guide Health
Manukau City Requirements (INZ 1121) has more details and includes
Auckland 2241 the full list.
New Zealand Children under 11 years of age and women who are pregnant
Courier costs may be charged for sending medical are not required to undergo a chest X-ray examination
certificates. These costs must be disclosed to the client unless requested by INZ.
prior to the examination taking place.
What if I submitted a chest X-ray certificate with my
Deciding whether you are eligible for a visa last application?
Immigration New Zealand collects the information about
You may not need a new chest X-ray certificate if you have
you on this form to decide whether you are eligible for
submitted a chest X-ray certificate completed and dated by
a visa.
a radiologist or a radiographer within the last 36 months
Collecting the information is authorised by the with a previous application, and that information has been
Immigration Act 2009 and the Immigration Regulations
retained by Immigration New Zealand*. Your immigration
made under that Act. You do not have to provide the
officer will let you know if a new chest X-ray certificate is
information, but if you do not we are likely to decline
required. If a new certificate is required you are responsible
your application.
for any fees.
Immigration New Zealand may also share the information
you have provided with other government agencies that Note: You will need to provide a new chest X-ray certificate
are entitled to it by law, or with other agencies (as you if you have spent six consecutive months in a place that is
have agreed in the declaration). not on Immigration New Zealand’s list of countries, areas
You are able to ask for the information we hold about and territories with a low incidence of TB since any previous
you and request to have any of it corrected if you think chest X-ray certificate was completed and dated by a
it is necessary. The address of Immigration New Zealand radiologist or radiographer. The guide Health Requirements
is PO Box 1473, Wellington 6140, New Zealand. This is not (INZ 1121) has more details and includes the full list.
where your application should be sent.
* Immigration New Zealand does not necessarily retain medical
information about applicants.

immigration.govt.nz
 When filling in this form, please write clearly using CAPITAL LETTERS.

Where do I get my immigration chest X-ray? • if the person has been identified with active TB in
New Zealand, please ensure the Medical Officer of
This chest X-ray certificate must be completed by Health at the local Public Health Unit has been advised
a radiologist. This certificate is not to be completed in accordance with the Tuberculosis Act 1948.
by a radiologist or radiographer who is related to the
person having the chest X-ray examination. Person having chest X-ray examination
Please note you may require a referral from a When you have your chest X-ray examination you must:
registered medical practitioner for a chest X-ray.
In most countries Immigration New Zealand has • attach one recent passport-size colour photograph of
approved lists of panel physicians who must be used yourself in the space provided. The photograph must be
for the examination. If you require information on the no more than six months old
panel physicians list, please visit the INZ website at • bring your valid passport (or other photographic
www.immigration.govt.nz/healthinfo. If you live in identification, for example national identity card where
a country which does not have any panel physicians, passport unavailable). The examining physician will not
a registered radiologist can complete this certificate. proceed with the examination without photographic
identification
Your responsibilities • complete section A before attending the examination
• You must pay the fees for the chest X-ray, any • complete Section B: Declaration of person having chest
tests required and all postage and courier fees. X-ray examination in the presence of the radiographer.
• You must tell the truth. False statements on a medical If you have evidence of past or present TB you may be
certificate may result in your application being declined, asked to provide a respiratory physician’s report. This
any visa granted being cancelled, and if you are in must include:
New Zealand, you may be required to leave the country.
• the date of diagnosis
Completing the certificate • documentation of treatment given
• compliance with treatment confirmed, and
This certificate must be completed in English.
• results of 3x3 sputum cultures. Smears alone will not
If any accompanying specialist report cannot be provided be accepted.
in English, a certified translation must be provided along
with the original specialist report. What happens after the examination?
Radiographer The radiologist that completes your chest X-ray
The radiographer must: certificate must submit it to INZ, along with any other
medical certificates required. The chest X-ray certificate
• certify the identity of the person being examined, by
must be submitted within three months from the
signing and dating the front of the photograph at A1 date the radiologist signed the completed chest X-ray
(without obliterating the image). These details must certificate.
extend beyond the photograph’s edge, and
• check passport details and record the passport number Your application will be assessed by Immigration
New Zealand and may be referred to an Immigration
(or other form of identification) at A1 and on every
New Zealand medical assessor or New Zealand health
following page in the top right-hand corner.
authorities. You may be required to get further specialist
Radiologist reports or tests. You are responsible for paying for these.
If a radiographer is not involved in this process, the Your medical information may be retained by Immigration
radiologist must complete the steps outlined above, and: New Zealand.

• complete sections C, D and E

• complete one form only for each person having For more information
the examination
If you have questions about completing the form:
• ensure the radiologist’s report is attached to
this certificate • see our website www.immigration.govt.nz/contactus
• where abnormalities are present or indicated, • telephone our call centre on 0508 558 855 (within
ensure the X-ray film accompanies this certificate New Zealand).
• ensure the complete certificate and radiologist’s report,
(and X-ray film if abnormalities have been noted) are
returned to the applicant
• provide a copy of the radiologist’s report to the
referring examining physician, and

2 – Chest X-ray Certificate – December 2020 This form has been approved under section 381 of the Immigration Act 2009
 Passport/identification number Radiologist/radiographer initials

Section A Personal details

Attach one passport-size colour photograph here. The photograph must be no more than
six months old. Write your full name on the back of the photograph.

Question A1 must be completed by the radiographer or radiologist. All other questions in

this section must be completed by the applicant before the examination.

A1 Radiographer or radiologist: certify identity by placing signature and date across 4.5cm
photograph without obscuring the likeness of the person.
Valid photographic identification sighted?
Type of identity document 3.5cm
Original Passport Certificate of identity Refugee travel document
National ID card with photo

Identity document number

Issuing country

Date of issue D D M M Y Y Y Y Date of expiry D D M M Y Y Y Y

A2 Applicant: name as shown in identity document

Family name

Given name

Title Mr Mrs Ms Miss Dr Other (specify)

A3 Gender Male Female

A4 Date of birth D D M M Y Y Y Y

A5 Country of birth

A6 Contact address

and/or personal email address

A7 Which visa category are you applying for a visa under?
Temporary
Visitor
Student
Worker with job offer
Worker without job offer
Residence

Skilled/Business
Pacific Categories
Family
Humanitarian (UNHCR)
Humanitarian other

Chest X-ray Certificate – December 2020 – 3

 When filling in this form, please write clearly using CAPITAL LETTERS.

Passport/identification number Radiologist/radiographer initials

Work to Residence


Worker

Family of a Worker

A8 If you are applying under the Temporary – Worker with a job offer, Residence – Skilled/Business or Work to
Residence – Worker categories detail your intended occupation:

A9 How long do you intend to stay in New Zealand?

Less than 6 months 6 – 12 months 12 – 24 months More than 24 months

Section B Declaration of person having chest X-ray examination

This declaration must be signed and dated by the person having the chest X-ray examination, in the presence
of the radiographer or radiologist.

A parent or guardian must sign on behalf of a child under 18 years of age.

Please read carefully before signing.
I declare that the information that I have provided in terms of my medical history and during my immigration health
examinations is true, complete and correct.
I understand that:
• my personal details and health information are being collected to enable Immigration New Zealand (“INZ”),
Ministry of Business, Innovation and Employment (“MBIE”) to determine whether or not they are satisfied that
I meet the health criteria for a New Zealand visa(s);
• INZ may enter and store my personal details and health information into the eMedical system;
• INZ is authorised to collect and use my personal information under the Immigration Act 2009, regulations made
under that Act and in accordance with the Privacy Act 2020; further information about the purposes for which
INZ requires my information is included in my visa application form which can be found on the INZ website at
www.immigration.govt.nz;
• if I have provided any false or misleading information as part of my immigration health examination, my visa
application(s) may be declined, and I may become liable for deportation. I may also be committing an offence and
I may be imprisoned;
• I must inform INZ of any relevant fact or any change of circumstance that may affect the decision on my application
for a visa due to my health circumstances;
• INZ will retain my personal information for use in assessing my health in the future as necessary, or for audit reasons.
I also understand that my personal information (including medical results, bio details and photographs) may be
disclosed to:
• New Zealand Government health agencies, health and settlement service providers and examining physician(s);
• New Zealand Government agencies entitled to receive this information by law, to the extent necessary to make
decisions about my immigration status; and
• New Zealand law enforcement, health agencies and international agencies, including overseas recipients in the
United Kingdom, the United States of America, Canada and Australia. [Note: if I am applying for a visa as a refugee
or protected person, INZ will only disclose this information to another country, if it is satisfied that this information
will not be disclosed to the country from which I have sought refugee or protection status and the disclosure is
otherwise permitted under the Immigration Act 2009].
I consent to:
• INZ retaining my medical information, including any x-ray images, beyond the determination of my visa application,
for the purposes of considering future applications I may make for a visa to New Zealand;
• my medical information being temporarily stored on the eMedical system owned and operated by the Australian
Department of Home Affairs;

4 – Chest X-ray Certificate – December 2020

 Passport/identification number Radiologist/radiographer initials

• INZ disclosing my personal information, including information about my health, to the radiologists or panel
physicians who have examined me. The reason(s) for this disclosure will be to investigate inconsistencies between
the radiologist and/or panel physician’s examination and a previous/subsequent health assessment, to investigate
a complaint against the radiologist or panel physician, or to follow up adverse results with the radiologist or panel
physician to ensure the quality of the work undertaken by New Zealand’s panel physician network;
• INZ storing my photograph(s) digitally and using them for client identification purposes in addition to the health
examination process where INZ deems it necessary;
• INZ making any enquiries it deems necessary in respect of health information I have provided and to share this
information with other Government agencies (including overseas agencies), and for these agencies to provide
information about my health to INZ, to the extent necessary to make decisions about my immigration status;
• any New Zealand health service agency providing information about my state of health to INZ; and
• INZ disclosing my medical information in accordance with the provisions above.

I undertake to pay the fees for this medical examination including laboratory tests and I also agree that I or my
child will undergo, at my expense, any further medical examination(s) that may be required by INZ in respect of the
immigration application.

Signature of person having chest X-ray Date D D M M Y Y Y Y

Signature of parent or guardian if person having chest x-ray is under 18 years of age

Date D D M M Y Y Y Y

Full name of parent or guardian

Relationship to person having chest X-ray

Signature of radiographer or radiologist Date D D M M Y Y Y Y

Name of radiographer or radiologist

Chest X-ray Certificate – December 2020 – 5

 When filling in this form, please write clearly using CAPITAL LETTERS.

Passport/identification number Radiologist/radiographer initials

Section C Results of chest X-ray examination

This section must be completed in full by the radiologist.

Where abnormalities are present, the radiologist must provide details and comments in the space provided and the
X-ray film must accompany this certificate. The radiologist’s report must be attached to this certificate and both
returned to the examining physician or applicant.

C1 Notes to radiologist from examining physician (if applicable).

C2 Skeleton and soft Normal Abnormal Give details

tissue

C3 Cardiac shadow Normal Abnormal Give details

C4 Hilar and lympathic Normal Abnormal Give details

glands

C5 Hemidiaphragms Normal Abnormal Give details

and costophrenic
angles

C6 Lung fields Normal Abnormal Give details

C7 Evidence of TB Absent Present Give details

C8 Evidence suspicious No Yes Give details

of active TB

If abnormalities/evidence are noted in C1 to C8 , then include all X-ray films/plates/scans to show recent and past
history of diagnosis and treatment. X-ray films/plates/scans must have a corresponding report attached.

C9 Radiologist’s comments (if any).

6 – Chest X-ray Certificate – December 2020

 Passport/identification number Radiologist/radiographer initials

Section D Examination Grading

Please consider the information you have recorded regarding this applicant, and provide a grading on their radiology
examination below. Supporting comments are mandatory if you provide a B grading. If you provide an A grading,
comments are optional.
A No evidence of active TB, or changes consistent with old or inactive TB, or changes suggestive of other
significant diseases identified
B Evidence of active TB, or changes consistent with old or inactive TB, or changes suggestive of other
significant diseases identified
Please list abnormal findings

this is not an assessment of whether or not the applicant has an acceptable standard of health in relation to the

Immigration New Zealand standard.

General supporting comments (if applicable)

Section E Radiologist’s declaration

This declaration must be signed and dated by the radiologist who examined the chest X-ray.

I certify that the statements made by me in answer to all the questions are true to the best of my knowledge
and belief.

Signature of radiologist Date D D M M Y Y Y Y

Radiologist’s details (please write)

Full name

MCNZ number for New Zealand practitioners

Place of examination (city/state and country)

Postal address

Telephone (daytime) Email

Chest X-ray Certificate – December 2020 – 7

 When filling in this form, please write clearly using CAPITAL LETTERS.

8 – Chest X-ray Certificate – December 2020