DOCTOR’S CERTIFICATE(* all fields to be filled out)

Purpose of examination: presentation for studies at the bachelor’s degree program Radiology Technology at the UAS „FH Campus Wien“

First name and family name: / Date of birth:
Current address:

Presented reports / anamnestic data (please cross where applicable):

*IGRA(Interferon-Gamma-Release-Assay) / dated: / ______IU/ml / pos. / neg.
Test-conducting facility: AGES - Agentur für Gesundheit und Ernährung / Institut für medizinische Mikrobiologie und Hygiene, 1090 Vienna, Währingerstraße 25a, TEL: 050-555-37111
orMendel-Mantoux-Test / dated: / ______mm / pos. / neg.
If IGRA or Mendel-Mantoux-Test showspositive result,
Lung radiography is required / dated: / negative results / pathologicalresult see below
*Diphtheria/Tetanus /Pertussis/Polio / Booster injection not longer than 10 years ago proven / yes
no / Date of latest vaccination / Date of previous vaccination
*Measles/Mumps / Two-time vaccination proven / yes
no / Date of second vaccination / Date of first vaccination
*Measles
titer determination / dated: / Vaccination recommendation:
Titer: / yes / no
*Rubella
IgG- antibody titer / dated: / Vaccination recommendation:
Titer: / yes / no
*Varicella / Two-time vaccination proven / yes
no / Date of second vaccination / Date of first vaccination
*Varicella IgG-AB / dated: / pos. / borderline / neg.
Vaccination recommendation: / yes / no
*Hepatitis B
*Hepatitis A / Previous vaccine administration: / If yes, please state previous vaccinations here:
Date of latest vaccination / Date of previous vaccination / Date of previous vaccination
no / yes / Date of previous vaccination / Date of previous vaccination / Date of previous vaccination
Determination of quantitative antibody titer available / no / yes / Date and level of latest or current determination: / Antibody titer is too low / vaccination at GP is recommended:
If NO
determination of antibody titer required / Date: / Date:
Level in ImE / Level in ImE
*Hepatitis C anamnesis / pos. neg.
*Hepatitis-C
IgG-AB-Determination / dated: / pos. / borderline / neg.
*Meningococci / Vaccination proven / yes no / Date of latest vaccination
*Pneumococci
Influenza / Advice and information regarding vaccination recommendation of the Federal Ministry of Health have been given. / yes no

Other results / remarks / recommendations:

Report:

Herewith we confirm that at the time of the examination on ……………………….. Ms. / Mr. …………………………………………………………………..showed an appropriate state of health to be trained as a radio technologist and to exercise the profession.

Signature and stamp of General Practitioner / Date

VACCINATION RECOMMENDATION OF THE FEDERAL MINISTRY OF HEALTH  Medical professionals and vaccine indications according to vaccination and areas

Standard vaccinations
Group of people / Diphtheria/Tetanus /Pertussis/Polio / MMR / Varicella / Influenza / Hepatitis B / Hepatitis A / Meningococci / Pneumococci
Close contact with patient / Doctors / +++ / +++ / +++ / +++ / +++ a / ++ / +++ (pediatrics, isolation ward, ICU, laboratory e) / +++ (geriatrics, pediatrics, ICU, laboratory)
Nursing and auxiliary personnel, midwives, doctor’s assistant / +++ / +++ / +++ / +++ / +++ b / ++ / +++ (pediatrics, isolation ward, ICU, laboratory e) / +++ (geriatrics, pediatrics, ICU, laboratory)
Ambulance service and community service personnel in the medical field / +++ / +++ / +++ / +++ / +++ a / ++ / +++ (pediatrics, isolation ward, ICU, laboratory e) / +++ (geriatrics, pediatrics, ICU, laboratory)
Therapeutic personnel (speech therapists, occupational therapists, physiotherapists etc.) radiographers, pharmacists / +++ / +++ / +++ / +++ / +++ c / + / +++ (pediatrics, isolation ward, ICU, laboratory e) / +++ (geriatrics, pediatrics, ICU, laboratory)
Trainees (students, pupils) / +++ / +++ / +++ / +++ / +++ a / ++ / +++ (pediatrics, isolation ward, ICU, laboratory e) / +++ (geriatrics, pediatrics, ICU, laboratory)
Non-medical patient service (home care providers, hairdressers et. al) and health care professions not regulated by law / +++ / +++ / +++ / +++ / +++ d / - / - / ++ 1
Welfare staff and care providers (in the hospital sector) / +++ / +++ / +++ / +++ / +++ b / - / - / ++ 1
No patient contact / Laboratory staff including MTA, CTA / +++ / +++ / +++ / +++ / +++ b / ++ (in case of treatment of feces) / +++ a / +++
Cleaning personnel and maintenance workers in medical institutions / +++ / +++ / +++ / +++ / +++ b / +(+) / - / -
Service staff in the medical field / +++ / +++ / +++ / +++ / +++ b / - / - / -
Orthopedic technology / +++ / +++ / +++ / +++ / +++ b / - / - / -
Pharmacist / +++ / +++ / +++ / +++ / - / - / - / -
1 / Patient protection
+++ / High risk, vaccination required urgently
++ / Intermediate risk, vaccination is advised
+ / Low risk, vaccination worth considering
a / High risk group according to AUVA (General Accident Insurance Institution)
b / High risk group according to AUVA, if workplace evaluation shows significant risk of infection
c / High risk group in hospitals and nursing homes according to AUVA, if workplace evaluation shows significant risk of infection
d / High risk group according to AUVA (pedicure) or high risk group to AUVA, if workplace evaluation shows significant risk of infection (home care providers)
e / Only in microbiological laboratories which examine samples of patients with meningococci infection

Dateiname: Test_FO_Ärztliches Attest FH 2015_DEP_V6_e - Kopie.docx

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