COVID-19 Vaccination Policy and Procedures
Policies and procedures
This policy contains links to organisations overseeing and supporting the rollout of the COVID-19 Vaccination.
You can link this policy to other relevant policies in your PracticeHub site, e.g. cold chain management, Personal Protective Equipment. Suggestions are highlighted in blue.
You should customise the content to reflect the actual procedures in your practice. Sections where you should do this are highlighted in yellow.
The Australian government has developed the ‘Australian COVID-19 vaccination policy’. The policy includes the strategy for immunisation administration and monitoring. Whilst this policy document is updated by the government from time to time, it should not be solely relied on as changes may be made after updates are released.
All vaccines must be administered in accordance with the relevant legislation, best practice, and the guidelines and recommendations in the Australian Immunisation Handbook
For general practices participating in the COVID-19 rollout, there are requirements that must be met and specific procedures the practice should implement to meet those requirements.
The key areas are:
- Training and certification of immunisers
- Stock Management
- Patient Management
- Administering the Vaccine
- Dept of Health: COVID-19 vaccine - Information for Vaccine Providers
- Dept of Health: Phase 1B COVID-19 Vaccine Roll-out through Primary Care Providers – Onboarding Pack (this should be checked regularly for updates)
- Dept of Health: Phase 1B COVID-19 Vaccine Roll-out - General Practice Guidance
- Dept of Health: COVID-19 vaccination – Easy Read resources (a series of fact sheets about COVID-19 vaccines in Easy Read format)
1. Training and certification of immunisers
The Australian government has developed training that is compulsory for all staff intending to be involved in the COVID-19 vaccine program.
The training is mandatory for COVID-19 vaccination providers and includes clinical, non-clinical and administration staff. The training can be accessed on the COVID-19 vaccination training website.
The practice ensures that there is a copy of the completed training certificate for all immunisers participating in the immunisation program.
The person responsible for collating certificates from immunisers is [insert name].
A record of each provider’s certification is kept [location of certification, e.g. PracticeHub personnel page].
The practice monitors the COVID-19 Vaccination Training Program for updates and ensures that all vaccination providers log in and view the new information.
2. Stock Management
The practices orders vaccines using the Online Stock Management Portal.
The person/s responsible for ordering the COVID-19 vaccines is: [insert name/s]
The practice has a weekly allocation of [no.] doses.
Orders are placed using the Dept of Health COVID-19 VACCINE ADMINISTRATION SYSTEM (CVAS). [insert link to CVAS log in]
Practices are emailed when the window/days to order open and close.
The practice completes an online Stock Acceptance Form via the online portal when taking delivery of the AZ vaccine. Forms must be submitted by 9pm on the day of delivery.
The Vaccine Operations Centre (VOC) (ph: 1800 318 208) is the central point of contact within the Department of Health to assist with operational components of the COVID-19 vaccine roll-out.
According to the Dept of Health, the practice does not need to reserve the second dose for patients.
The practice completes the Vaccine Stock Management Form weekly with:
- details of stock on-hand
- the number of doses administered to patients during the day; and
- any wastage of doses from the stock.
A Vaccine Wastage Report has been developed to capture any wastage incident that exceeds 5 or more vials at one time (wastage threshold). In the event of a potential or actual wastage incident that exceeds the threshold (5 or more vials at a time), the practice needs to contact the VOC as soon as possible, and complete the Vaccine Wastage Report within 2 hours of the incident.
The Commonwealth will provide 3mL syringes, 25mm needles and sharps waste disposal bins. These will be shown with our vaccine order in the portal.
All other consumables should be sourced from our usual supplier. [insert name and any item codes if of preferred supplier].
Storage, including cold chain management
The person/s responsible for cold chain management of COVID-19 vaccines is [insert name].
We review and update our cold chain policy in line with the manufacturer’s recommendations and in line with the Commonwealth Department of Health and TGA guidelines for each of the COVID-19 vaccine brands that we administer.
Vaccines are allocated to specific clinics. Vaccines cannot be shared or transported between clinics as it may influence the vaccine potency through a potential cold-chain breach.
A cold chain breach could occur before or during stock acceptance, during stock management or on-site day-to-day.
Any stock believed to be affected by a cold chain breach should be immediately quarantined in 2-8°C refrigeration and clearly marked “do not use”, and the VOC should be notified. The VOC will provide advice on the use of the stock following receipt of the incident details. A cold chain breach protocol poster is displayed near the vaccine refrigerator.
Note: The Victorian Department of Health has additional cold chain breach information which must be followed if in Victoria.
The practice follows the National Vaccine Storage Guidelines ‘Strive for 5’ 3rd edition which provides up-to-date information and key recommendations about safe vaccine storage.
The practice has a process in place to safely dispose of unused vaccines, in accordance with TGA and other regulatory requirements.
Link to: Cold chain management policies and procedures
3. Patient Management
The practice can vaccinate eligible to be vaccinated.
The Dept of Health has a Vaccine Eligibility Checker. The practice uses the Checker if they are unsure if a patient is eligible for the COVD-19 vaccine.
Informed consent is required before administering each COVID-19 vaccine dose and providers are required to document it in a patient’s medical record.
Verbal or written consent is acceptable. The Dept of Health has a template for the COVID-19 vaccination -Consent form (includes Astra Zeneca update).
The practices should check that consent has been obtained in accordance with the ATAGI recommendations at the time each vaccine is given (rather than when any consent was provided).
Patients should see the doctor in circumstances where the consent conversation is not simple.
Patients are to be advised that their vaccination details must be reported to the Australian Immunisation Register (AIR). This will include some personal information, including their date of birth and Medicare number.
The Australian Government Department of Health published information about the AstraZeneca vaccine to help patients make informed decisions. The document provides guidance on weighing up the potential benefits against the risk of harm from the AstraZeneca COVID-19 vaccine.
The practice uses [select relevant option: our existing clinical and booking software/Healthdirect].
If two doses are required, the practice books the second dose [at time of initial booking/at time of the first dose] complying with the required interval between doses.
The practice books appointments for [length of appointment] on [days/times].
Patients are provided with [consent form/other information] via the online booking software.
- Existing practice patients
Patients of the practice are booked for COVID-19 vaccination appointments separate to other types of appointments.
- New patients
Patients new to the practice [select relevant option: need to provide a health summary from their usual practice/takes a patient history].
- Patients without a Medicare card
Everyone in Australia will be offered a safe and effective COVID-19 vaccine. Patients who are not Medicare-eligible can be referred to a GP-led Respiratory Clinics or a state/territory vaccination clinic.
Advertising and communication
The practice complies with the Therapeutic Goods Administration regulations relating to advertising COVID-19 vaccines to the Australian public.
The practice also complies with the laws and guidelines for advertising a regulated health services, including social media.
Information in the ‘Providers Kit’ distributed to providers by the Dept of Health contains compliant resources that can be used to promote the availability of the vaccine.
The National Centre for Immunisation Research and Surveillance has developed ‘A guide for developing COVID-19 vaccine communication materials’. The guide assists organisations in creating targeted communications and to address questions and concerns that people may have.
All COVID-19 vaccination services must be bulk-billed. Patients’ Medicare payments are processed at the time of consultation.
Vaccination providers cannot charge to administer the COVID-19 vaccine. The vaccine is free and the consult appointment for patients to receive their vaccinations is also free. Charging a patient any costs associated with the administration of the COVID-19 vaccination (including booking fees) is a breach of the requirements under the program.
DVA patients can use their Veteran Card as per usual DVA arrangements for:
- using a Veteran Gold Card
- using a Veteran White Card if it relates to an accepted condition. Services Australia will accept the clinical judgement of the general practitioner to determine what accepted condition requires the administration of the COVID-19 vaccine.
For the purposes of claiming an MBS item, it is the responsibility of treating practitioners to use their professional judgment to determine the most clinically appropriate services to provide, and to ensure that any services billed to Medicare fully meet the eligibility requirements outlined in the legislation.
Standard MBS multiple same-day attendance rules apply to the COVID-19 vaccination suitability assessment services. Co-claiming is only permitted where another GP service is provided that is unrelated to the vaccine suitability assessment item. More information can be found at Medicare Benefits Schedule - Note AN.44.1 and in the Medicare Support for COVID-19 Vaccinations – FAQ
4. Administering the Vaccine
Prior to administering the COVID-19 vaccine, the practice checks that:
- the patient has not already received their first dose of the COVID-19 vaccine at another location
- the patient has not received a any other vaccination within the last fourteen days. The practice cannot administer the COVID-19 vaccine to the patient if they have had any other vaccination in the two weeks prior to the scheduled COVID-19 vaccination. The period between the influenza and the COVID-19 vaccine may be shorter only in the circumstances where any delay may result in either of the vaccines not being administered.
- that the appropriate time has passed between first and second doses.
The practice encourages patients test for COVID-19 symptoms and to continue COVIDSafe behaviours.
Minimising vaccine wastage
The practice takes necessary steps to minimise stock wastage. Wastage could occur through multiple situations:
- doses left over at the end of the day (note – bookings should be planned to maximise full use of multi-dose vials);
- damaged vials; or a
- potential/actual cold chain breach
- inaccurate drawing up of the required volume for each dose
Administration and waiting areas
Patients awaiting vaccination observe social distancing requirements and are sheltered from weather elements.
[Note where patients for vaccination need to wait if not in normal waiting room]
There is a private and sound-proof space for the consultation with patients and the vaccinator.
[Note where vaccinations are administered]
There is a dedicated area, separate from areas that provide other clinical services at the same time and where the vaccines are delivered, where vaccines from multi-dose vials are be drawn up, labelled, and prepared for administration.
[Note where vaccines from multi-dose vials are be drawn up, labelled, and prepared for administration.]
Hand hygiene will be performed before and after each episode of clinical care and as recommended by Hand Hygiene Australia, the COVID-19 Vaccination Training Program and in line with our hand hygiene policy.
Link to: Hand hygiene policy
The practice has adequate space for patients to wait and be monitored post-vaccination that observes physical distancing requirements (note this may be the same as the waiting area) and is in accordance with jurisdictional requirements and guidance.
[Note where patients need to wait and be observed post-vaccination]
[Note length of time patients need to be observed post vaccination and process for discharging the patient.]
Observers are those members of the practice team that:
- can recognise an acutely unwell person
- must always be in the room during the observation
- must be able to summons help immediately when required
Routine environmental cleaning
Frequently touched surfaces will be cleaned and disinfected between each episode of patient care, taking particular care with surfaces that may have been exposed to respiratory droplets.
Communal areas for staff and public are routinely cleaned.
Link to: Managing the practice physical environment – Cleaning policy and procedure
Personal Protective Equipment and sharps management
Appropriate PPE is used, as per requirements in the Australian Immunisation Handbook and jurisdictional requirements.
The practice disposes of clinical waste, including sharps and vaccine vials, at the point of use.
Link to: Personal Protective Equipment and Sharps management policies and procedures
Australian Immunisation Register (AIR)
It is mandatory under the Australian Immunisation Register Act 2015 to report all COVID-vaccine encounters to the Australian Immunisation Register (AIR)
COVID-19 vaccine encounters should be uploaded into AIR at the time of administration (including the patient’s individual Medicare reference number), or as soon as possible, to ensure consumer immunisation information is up to date.
The practice reports vaccinations to the AIR using [select relevant option/s]:
- Practice management or clinical software integrated with AIR;
- The Australian Digital Health Agency’s Clinician Vaccine Integrated Platform (CVIP) free app;
- AIR site accessed via Health Professional Online Services (HPOS)
- Manual, paper-based form (should only be used when there is lack of access to AIR due to an outage of power or the internet)
Adverse event following immunisation (AEFI)
Where a patient experiences an adverse event following the administration of the COVID-19 vaccine, the practice reports these following standard adverse event reporting practices and processes. Adverse events are reported to relevant state/territory contacts.
If the practice reports AEFIs to state/territory contacts, they do not need to also report the event to the Therapeutic Goods Administration (TGA). However, if the practices reports the event to the TGA, it will also make a second report to the state/territory entity.
Vaccination providers can report an AEFI or a defect with a vaccine by contacting the TGA on 1800 020 653.
The practice also reports AEFIs to State and Territory contacts:
ACT Health Protection Services – Immunisation Team (02) 5124 9800
1300 066 055 (to connect to your local public health unit)
NT Department of Health 08 8922 8044
Queensland Health 07 3328 9888, or complete an AEFI initial report form on the Queensland Health website
Immunisation Section, Department of Health 1300 232 272
submit a AEFI form to firstname.lastname@example.org or call 1800 671 738
SAEFVIC 03 9345 4143 or the SAEFVIC website
WAVSSS 08 9321 1312
Link to: Adverse events and anaphylaxis policies and procedures
- Dept of Health: COVID-19 Vaccine FAQs for vaccine providers
- RACGP: COVID-19 vaccine information for GPs
- Ahpra and National Boards: Position statement – Registered health practitioners and students and COVID-19 vaccination
- Dept of Health: Information for patients: Australia’s vaccine rollout
- Avant Mutual Group: COVID-19: Vaccinations: FAQs
- Avant Mutual Group: COVID-19: Indemnity: FAQs
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