Residential Aged Care COVID-19 Vaccination Clinic - Registration Form - Page 1 of 3 - Australian Government Department of Health

Registration Form

1. Please enter the name of the Residential Aged Care facility requesting a COVID-19 Vaccination Clinic:

Facility Name (Required)

2. Please enter the address of the Residential Aged Care facility:

Address Line 1 (Required)

Suburb/Town (Required)

State (Required)

Postcode (Required)

3. Please enter the NAPS Service ID and MACP Outlet ID of the Residential Aged Care facility:

NAPS Service ID is the unique National Approved Provider System reference code that easily idenfities a facility to the Department of Health.

MACP Outlet ID in the unique reference code used by a facility in the My Aged Care portal to record staff and resident vaccination numbers

The provision of this information will allow registrations to be processed faster.

If not known, please enter "Unknown"

NAPS Service ID (Required)

MACP Outlet ID

4. Please enter the details of the best point of contact for a Vaccine Provider to contact the facility in order to organise the COVID-19 Vaccine Clinic:

Name (Required)

Email Address (Required)

Phone Number (Required)

5. Please enter the details of an alternate point of contact:

Name

Email Address

Phone Number

6. Please enter the Vaccination status of the facility, and efforts to engage Primary Health settings:

Please outline the estimated number of residents who require a COVID-19 vaccination, and the number of staff who may take up the opportunity to get a vaccine at the same time.

Please confirm you have sought in-reach vaccine services from a primary care provider (GP, Pharmacy etc), and if unsuccessful have sought assistance from your Primary Health Network (PHN). Please provide detail, including contact with the PHN.

This information determines eligibility, and the registration will not be progressed unless this information is provided.

Number of Residents requiring a vaccination (Required)

Number of workers requiring a vaccination at the same time

Primary Health information (Required)

7. When would you like the vaccine clinic to be held?

Please specify an approximate date for when you would like a clinic held, and any other contextual information around preferred timing. Actual clinic dates are subject to scheduling processes.

If you would like the clinic ASAP, answer using todays date and reference ASAP as part of additional information.

Preferred date (estimate) (Required)

Day (dd)
-

Month (mm)
-

Year (yyyy)

Additional information