Historical immunisation records request Historical Immunisation Records Request 1Introduction2Request details3Contact details You can use this form to: Request historical immunisation records from prior to 1996 Before you begin: Tell us your name, email address and phone number Read the City of Boroondara Privacy Statement After you complete this form we will: Send you an email confirming we have received your immunisation historical records request We may contact you about your request, if required. What happens with your information? We record your information on our customer databases and make it available to relevant Council staff in line with our Privacy Policy Your personal and health information is being collected by the City of Boroondara for the request of an Immunisation history statement. The information will be used by Council and its contracted service providers for that primary purpose or a directly related purpose and shall be disclosed to relevant Council staff. It will not otherwise be used or disclosed unless that use or disclosure is permitted or required by law. You may apply for access and/or amendment of the information by writing to Council’s Privacy Officer. Consent * Required I consent to the collection/use of my information on this form. This immunisation request is for * Required(as appears on Birth Certificate, passport or Medicare card) First name Maiden name (if applicable) Last name Your date of birth * Required DD slash MM slash YYYY Your gender * Required Male Female Other Please provide the Medicare card number Medicare card individual reference numberThe number that appears beside the person’s name on the card Email * Required(Correspondence will be sent to this email within 10 business days) Enter email Confirm email Phone number * RequiredAustralian Residential Address * Required Address line 1 Address line 2 Suburb / City State Post code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Previous known address in Boroondara Council * Required Address line 1 Address line 2 Suburb / City State Australian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia Post code What Primary and/or Secondary School did you attend within Boroondara Council I have read and accept Council's Privacy Policy and understand how my information will be used. * Required Yes PhoneThis field is for validation purposes and should be left unchanged.
