Complete the immunisation history request form below. Please allow 10 working days for your request to be processed. Request Details Name of the person immunised If different, name of the person requesting the records Yes, I am a legal guardian of the person Date of Birth Address Address Suburb State - None -Australian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia Postal Code Previous Address Phone Number Email Address Name of Primary School Years attended the primary school Name of Secondary School Years attended the secondary school Request for the following service: Email me a copy of the records Post me a copy of the records Disclaimer The personal information requested above is for the purpose of administrating the Public Health and Wellbeing Act 2008 and will be used solely by Council for that primary purpose or directly related purposes. The intended recipients of the information are Council officers. Council may disclose the information to law enforcement agencies, courts and other organisations authorised to collect it. Individuals have a right to seek access to their personal information and make corrections by contacting Council’s Environmental Health Unit on 9262 6197. You may view Council’s Privacy Policy or obtain a copy from any of the Council offices. Select the checkbox to confirm this is a valid submission. Leave this field blank
