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Au Pair Vaccination Checklist

This document is a vaccination record form for an au pair applicant. It requires the applicant's doctor to confirm the applicant has been immunized against tetanus, measles, mumps, rubella, and tuberculosis. For tuberculosis, the doctor must confirm the applicant received the BCG immunization, a Mantoux test, or a clear chest x-ray. The form also requests dates for other recommended immunizations like the flu vaccine, smallpox, typhoid, and hepatitis B. Finally, it asks if the applicant has been immunized against whooping cough if they will be placed with a family caring for an infant under 6 months old.

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180 views1 page

Au Pair Vaccination Checklist

This document is a vaccination record form for an au pair applicant. It requires the applicant's doctor to confirm the applicant has been immunized against tetanus, measles, mumps, rubella, and tuberculosis. For tuberculosis, the doctor must confirm the applicant received the BCG immunization, a Mantoux test, or a clear chest x-ray. The form also requests dates for other recommended immunizations like the flu vaccine, smallpox, typhoid, and hepatitis B. Finally, it asks if the applicant has been immunized against whooping cough if they will be placed with a family caring for an infant under 6 months old.

Uploaded by

cidaparecida141977
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Applicant Name

___________________ Vaccination Record


___________________ To be completed by your Doctor - Relatives may not complete this report
__

It is an Au Pair in America program requirement for the applicant to be immunized against certain diseases. Please provide the
vaccination history for this applicant below.

Please confirm the applicant is immunized against the following:

Tetanus  Yes Date _________________


Measles  Yes Date _________________
Mumps  Yes Date _________________
Rubella (German Measles)  Yes Date _________________

Tuberculosis
• This is mandatory for applicants from Brazil, China, South Africa, Russia and Thailand.
• Highly recommended for applicants from other countries.

BCG immunization OR  Yes Date _________________  No


Mantoux test OR  Yes Date _________________  No Result:  Positive  Negative
Chest X Ray  Yes Date _________________  No Result:  Clear  Not clear

Please note: positive test results (unless the applicant was immunized against TB) will require a copy of a recent chest x-ray

The following immunizations are highly recommended but not required:

Flu vaccine  Yes Date _________________  No


Small Pox  Yes Date _________________  No
Typhoid  Yes Date _________________  No
Hepatitis B  Yes Date _________________  No
Diphtheria  Yes Date _________________  No
Polio  Yes Date _________________  No
Meningitis  Yes Date _________________  No
Chickenpox – if not previously suffered from  Yes Date _________________  No

Whooping Cough
If the applicant is placed with a Host Family that requires the care of a baby under the age of 6 months, the applicant will be required to
be immunized against Whooping Cough. Please confirm if the applicant is immunized:

Whooping Cough  Yes Date _________________  No

Name of Doctor _______________________________________ Please add your Doctor’s or Medical Practice stamp below
Address _____________________________________________
____________________________________________________
____________________________________________________
Telephone ___________________________________________
____________________________________________________

Do you speak English?  Yes  No If no, did you fully understand all the questions asked on this form?  Yes  No

Doctor’s Signature: ________________________________________ Date: _________________________________


Signature ______________________________________________________________
Au Pair in America, 37 Queen’s Gate, London SW7 5HR, UK Date __________________________
v. September 2017

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