Form

Radiological report on chest x-ray of an

applicant for an Australian visa 160
Department of Home Affairs

This form is for applicants who are required to undergo a Completing health examinations before you lodge your
chest x-ray as part of an application for an Australian visa.
For information on heath examinations see
visa application
https://immi.homeaffairs.gov.au/help-support/meeting- In some circumstances, the Department allows visa applicants
our-requirements/health to complete health examinations before they lodge their visa
application. The Department’s website provides information
The Department of Home Affairs (the Department) is
on where this is possible. For details see
authorised to collect and use the personal information on this
https://immi.homeaffairs.gov.au/help-support/meeting-our-
form under section 60 of the Migration Act 1958. When you
requirements/health/when-to-have-health-examinations
complete this form and give it to the panel physician or clinic,
the Commonwealth of Australia becomes the owner of the You must undertake the required health examinations, as
information on the form. The panel physician is required to requested by the panel physician.
send the form to the Department. Please be aware that if you do complete your health
examinations before lodging your visa application you may
Your responsibilities need to undertake additional health examinations if:
The costs of health examinations are paid by you directly to • you later lodge a visa application for a different visa
the panel physicians or clinics undertaking the examinations. subclass;
There may be additional costs if further tests or couriers are • you decide to stay in Australia for a longer period;
required.
• you do not complete all the required health examinations;
Outside Australia or
If outside Australia you must attend the same radiology clinic • your health examinations expire prior to a decision being
during the course of your health examinations. made on your visa application.
If you are an applicant for a visa under Australia’s Offshore If you have not lodged a visa application and a significant
Refugee and Special Humanitarian Programme the Australian health condition is identified which may impact on your ability
Government provides arrangements to cover the costs of your to meet the health requirement you will not be provided with
health examinations. an opinion of the Medical Officer of the Commonwealth until
after you lodge your visa application.
In Australia
If you are in Australia and you have applied for a protection How to make an appointment for your chest x-ray
visa, special arrangements may apply in regard to the costs of
health examinations. Outside Australia
If you only require a chest x-ray, please contact your closest
Visa subclass and visa name panel radiology clinic and if necessary, obtain a referral from a
panel physician. If you also require a medical examination,
To assist the Department to link your health examinations first contact a panel physician who will refer you to a panel
with your visa application you must write the visa subclass radiologist. For details see
number and the name of the visa you are applying for on https://immi.homeaffairs.gov.au/help-support/contact-
page 4 of this form. us/offices-and-locations/list
For example:
In Australia
• Subclass 405 – Investor Retirement
To make an online booking to undertake a chest x-ray in
• Subclass 600 – Sponsored Family Visitor stream
Australia you must contact the Migration Medical Services
• Subclass 890 – Business Owner (Residence). Provider. For information on how to contact the Migration
This information is required for the visa decision-maker to Medical Services Provider see
process your visa application. https://immi.homeaffairs.gov.au/help-support/meeting-our-
requirements/health/arrange-your-health-examinations
You can find the visa subclass number and the name of the
visa on the Department’s website
https://immi.homeaffairs.gov.au/visas/getting-a-visa/ Pregnant visa applicants and the chest x-ray
visa-listing requirement
A pregnant visa applicant who is required to complete a chest
x-ray needs to discuss her options with her own treating
doctors and/or the examining panel physician or radiologist.
A pregnant visa applicant may choose to either proceed with
the chest x-ray or defer until after the child’s birth.

If you decide to defer the chest x-ray until after the child’s birth
A pregnant visa applicant should advise the Department if she
decides to defer her chest x-ray until after the child’s birth.

© COMMONWEALTH OF AUSTRALIA, 2019 160 (Design date 08/19) - Page 1

 If you are prepared to undergo a chest x-ray while pregnant Important information about privacy
If a pregnant visa applicant is prepared to undergo a chest Your personal information is protected by law, including the
x-ray, it is recommended that she consults with her doctor Privacy Act 1988. Important information about the collection,
before arranging her appointment for a chest x-ray and that use and disclosure (to other agencies and third parties,
special precautions are taken (eg. using a double protective including overseas entities) of your personal information,
lead shield and waiting until at least the second trimester). including sensitive information, is contained in form 1442i
A pregnant visa applicant must sign the declaration on page 4 Privacy notice. Form 1442i is available from the Department’s
before undergoing a chest x-ray. website www.homeaffairs.gov.au/allforms/ You should
Undergoing a chest x-ray does not guarantee the grant of a ensure that you read and understand form 1442i before
visa. Where a chest x-ray shows abnormalities, the visa completing this form.
applicant may be asked to undergo more specific tests and a
course of treatment.

What to bring to the examination

Any previous chest x-ray films you have, particularly those
from the last 5 years. The radiologist may ask you to submit
these film(s) to the Department if they consider it necessary
to assess your health.

Identification
A valid original passport is the form of identity documentation
preferred by the Australian Government.
You must bring a valid original passport with you where
possible.
There are limited circumstances in which the Department will
accept alternative identity documentation. For details see
https://immi.homeaffairs.gov.au/help-support/meeting-our-
requirements/health/your-health-examinations-appointment
The radiology clinic is required to confirm the identity of
individuals who present at their clinic for Australian
immigration health examinations.
If you do not bring acceptable identification documentation
the processing of your visa application may be delayed or may
not proceed if the clinic is not satisfied with the identification
documentation.
Note: If you are a refugee, humanitarian or protection visa
applicant special arrangements regarding identification may
apply.

Medical information
Medical information such as a chest x-ray is used to assess an
applicant’s standard of health. After a decision has been made
on the visa application it is usual for the Department to retain
the medical information. The medical information is retained
by the Department for use when assessing the applicant’s
health in the future and for panel physician audits to ensure
the quality of work undertaken by the panel physician
network.

Please keep these information pages for your reference

160 (Design date 08/19) - Page 2 © COMMONWEALTH OF AUSTRALIA, 2019
 Form
Radiological report on chest x-ray of an
applicant for an Australian visa 160
Department of Home Affairs

How to complete this form YOUR PHOTOGRAPH

In Australia
Applicant • Complete Part A (with the exception of the ‘Pregnant visa applicant’s declaration’) If you need to bring a photo(s)
before attending the radiological examination. All questions must be answered. to the medical appointment at
• Complete Part B in the presence of the radiographer. the Migration Medical Services
Provider, they will advise you at
the time you make your
Radiographer • Certify in writing across the top of the photograph and on the form (without appointment.
obliterating the image) that it is a true likeness of the examinee. Date to be included.
• Sight valid passport/national identity card (if provided) and record
passport/national identity card number below.
Outside Australia
• You must ensure the applicant has provided answers to all the questions in Part A Please firmly attach a
before the applicant signs the declaration at Part B. recent passport size
• Complete Part C. photograph of yourself to
the form by staples or
other means. Another
Radiologist • Complete Part D. copy of the same photo
should be used for
form 26 (if required).

To be completed by RADIOGRAPHER (or staff)

Valid passport sighted? Part A – Applicant’s details

Yes Passport number To be completed by the applicant before attending the radiological
Country of passport examination.
Please open this form using Adobe Acrobat Reader.
Passport and photograph verified? Either type (in English) in the fields provided or print this form
No Yes and complete it (in English) using a pen and BLOCK LETTERS.
Please attach a copy of the bio-data page of the passport Tick where applicable 3
sighted to identify the applicant. The copy should be certified
by the radiographer. 1 Your HAP ID

No Reason not presented 2 Your full name (as it appears in your passport or national identity document)

Family name

Please attach a copy of the national identity card sighted to Given names
identify the applicant, if applicable. The copy should be certified DAY MONTH YEAR
by the radiographer. 3 Date of birth

Details of national identity card or identity number issued to the applicant by 4 Sex Male Female Indeterminate /
his/her government (if applicable). Intersex / Unspecified
Note: If the applicant is the holder of multiple identity numbers because he/ 5 Your telephone numbers
she is a citizen of more than one country, you need to enter the identity COUNTRY CODE AREA CODE NUMBER
number on the card from the country that the applicant lives in. Office hours (            ) (            )
National identity
card number After hours (            ) (            )

Country of issue
Office use only
Applicant’s full name (as it appears in passport or national identity card) File number/PRID/CID

Family name Date of application

Given names Visa class

DAY MONTH YEAR Name and address
Date of birth of office processing
Indeterminate / the application
Sex Male Female
Intersex / Unspecified

© COMMONWEALTH OF AUSTRALIA, 2019 160 (Design date 08/19) - Page 3

 6 Your residential address Pregnant visa applicant’s declaration
To be signed and dated by the pregnant visa applicant after
consultation with a doctor and/or radiologist.
I have read the information on pages 1–2 of this form and understand
POSTCODE that the Department of Home Affairs requires that a pregnant visa
applicant:
7 Intended occupation/activity in Australia • consults her doctor and/or the examining panel physician or
radiologist to discuss her options before undergoing a chest x-ray.
• is provided with a full explanation of the risks.
• takes special precautions (eg. using a double protective lead shield
8 How long do you intend staying in Australia? and waiting until at least the second trimester).
Permanently (including non-migrating family member of • makes a decision on this basis of whether to proceed with the chest
x-ray or defer until after the child’s birth.
an applicant)
YEARS MONTHS I understand that undergoing a chest x-ray does not guarantee the
Temporarily For how long? grant of the visa.
In full knowledge of the above, I wish to proceed with the required
chest x-ray while pregnant.
9 If you are in Australia: YEARS MONTHS

• how long have you been here? Applicant’s

• what visa subclass do you currently hold? : :

signature -
DAY MONTH YEAR
Date
10 What is the visa subclass number and the name of the visa that
you are applying for?
For more information please refer to page 1 of this form.
Part B – Applicant’s declaration
To be signed and dated by the applicant in the presence of the
radiographer.
11 Have you undertaken a health examination for an Before signing this declaration you must have completed all the
questions in Part A – Applicant’s details.
Australian visa in the last 12 months?
A parent or guardian should sign on behalf of a child under 16 years of age.
No In exceptional circumstances a child under 16 years of age may sign if he
Yes Give details (including HAP ID if available) or she is able to understand and verify the information given on the form.

13 • I declare the information I have provided on this form is correct and I

have answered all questions.
• I understand that if I have given false or misleading information, my
application may be refused, and any visa issued may be cancelled.
• I understand that the Commonwealth of Australia becomes the
owner of the information on this form and that the panel physician is
required to send the form to the Department.
12 For female applicants
• I have read the information on page 2 at ‘Medical information’ and I
Are you pregnant? consent to the Department retaining my medical information.
No Go to Part B • I consent to the Department passing on relevant sensitive
information (including about my health) to the radiologists/panel
Yes What is the expected date of birth? physicians who examined me, clinic administrative staff, Australian
DAY MONTH YEAR
law enforcement, health agencies and international agencies,
including overseas recipients with whom we have a Memorandum
of Understanding. The reasons for this release of information may
Note: Please read the information under ‘Pregnant visa include, but are not limited to, investigation and resolution of
applicants and the chest x-ray requirement’ on pages 1–2 inconsistencies, complaints or audit recommendations.
of this form. Then, after consultation with a doctor and/or • I consent to the Department destroying my personal data (including
radiologist, read and sign the declaration below. digital x-ray images and photographs) after a certain period of time
where consistent with the Department’s archiving obligations and
any current disposal authorities. Consequently if I do not request a
copy of this data from the clinic I attend when undergoing my
immigration health examinations, I understand it may not be
available for me to retrieve at a later date.

Applicant’s
signature -
DAY MONTH YEAR

Date
If signing on behalf of a child under 16 years of age –
Name of parent or guardian

Relationship to child
160 (Design date 08/19) - Page 4 © COMMONWEALTH OF AUSTRALIA, 2019
 Part C – Radiographer to complete
DAY MONTH YEAR
Please provide large (14 x 17 inch) posteroanterior (PA) film if possible.
1 Date of x-ray
The x-ray film must bear the date of the examination, the applicant’s
family and given names, the HAP ID (if available), and the name of the
clinic. This information is to be automatically inscribed during the 2 Is this person pregnant? No Yes
photographic process or written in white ink.
3 Radiographer’s certification
If the examinee is pregnant the film must be full sized, the field size
must be strictly limited and there must be double abdominal shielding. I certify that I have carried out the x-ray of the person whose
If the pregnant woman does not wish to be x-rayed, please comment photograph and signature are on this form.
and return this form.
Signature of
radiographer -
DAY MONTH YEAR

Date

Part D – Radiologist to complete

Please use a pen and write neatly in English. Illegible forms will be returned for clarification.
Comment is required on any and all aspects found not to be entirely normal.

1 Skeleton and soft tissue Give a full description of all abnormal findings.
Normal Abnormal

2 Cardiac shadow
Normal Abnormal

3 Hilar and lymphatic glands

Normal Abnormal

4 Hemidiaphragms and costophrenic angles

Normal Abnormal

5 Lung fields
Normal Abnormal

6 Evidence of Tuberculosis (TB)

Absent Present

7 Are there strong suspicions of active

Tuberculosis (TB)?
No Yes

8 Details of other abnormalities

If insufficient space, attach an additional statement

© COMMONWEALTH OF AUSTRALIA, 2019 160 (Design date 08/19) - Page 5

 9 Examination grading
Please consider the information that you have recorded regarding this client and provide a grading on their radiology
examination below. Supporting comments must be provided if you decide to provide a B grading.

A No evidence of active
Tuberculosis (TB), or changes
consistent with old or inactive TB,
or changes suggestive of other
significant diseases identified.

B Evidence of active Tuberculosis Please list significant history or abnormal findings

(TB), or changes consistent
with old or inactive TB, or
changes suggestive of other
significant diseases identified.

10 Radiologist’s declaration To the radiologist:

I declare that I have examined the x-ray and that this is a true Place the form and report(s) inside a secure envelope.
and correct record of my findings. If outside Australia:
• attach the envelope to the packaged x-ray;
Signature of • do not give the envelope containing the form and the report
radiologist - to the applicant. You may, however, provide the applicant with a
DAY MONTH YEAR copy of the form and your report for their records.
Date If you are in Australia, the x-ray does not need to be included.

Full name (please print) Return the package direct to:

• the officer of the Department specified in the attached covering
letter; and/or
Address • the return address specified in the ‘Office use only’ section on
page 3 of this form; or
• to the referring panel physician, if applicable; or
• as specified in the ‘Where to send Australian immigration medical
POSTCODE
forms, results and x-rays’ document; or
Contact telephone number • for cases examined in Australia, according to local arrangements
COUNTRY CODE AREA CODE NUMBER with the Migration Medical Services Provider.
(            ) (            )

Email address

160 (Design date 08/19) - Page 6 © COMMONWEALTH OF AUSTRALIA, 2019