Please enable JavaScript in your browser to complete this form.Vaccinator/Immuniser Full Name *FirstLastAre you assessingCovid-19Flu______________Part 1. KnowledgeCompetency assessment tool for health care workers administering the COVID-19 vaccines.1a. Can provide evidence of completion of the COVID-19 vaccine e-learning Core Knowledge session or attendance at a specific, comprehensive COVID-19 vaccine training course, in line with the UKHSA COVID-19 vaccinator training requirements.Not applicable to role assigned (NA)Supervisor review. Record: met (M) or needs to improve (NI) (initial and date)Met (M) or needs to improve (NI) Please chooseMet (M) Needs to improve (NI) 1b. With reference to 1a, has successfully completed and passed an assessment which assesses core COVID-19 vaccine knowledge: either the e-learning COVID-19 vaccine Core Knowledge assessment or an end-of-course test.Not applicable to role assigned (NA)Supervisor review. Record: met (M) or needs to improve (NI) (initial and date)Met (M) or needs to improve (NI) Please chooseMet (M) Needs to improve (NI) 1c. Name of vaccine assessed for (where separate assessment for each vaccine is recommended) Please choosePfizer BioNTech Comirnaty 30 ConcentratePfizer BioNTech Comirnaty 10 ConcentratePfizer BioNTech Comirnaty BivalentModerna Spikevax OriginalModerna Spikevax BivalentSanofi1c. Can provide evidence of completion of the COVID-19 vaccine specific e-learning sessions or attendance at a comprehensive COVID-19 vaccine training course where specific training about the individual COVID-19 vaccine(s) was provided.Not applicable to role assigned (NA)Supervisor review. Record: met (M) or needs to improve (NI) (initial and date)Met (M) or needs to improve (NI) Please chooseMet (M) Needs to improve (NI) ______________Competency assessment tool for health care workers administering the COVID-19 vaccines1d. Name of vaccine assessed for (where separate assessment for each vaccine is recommended) Please choosePfizer BioNTech Comirnaty 30 ConcentratePfizer BioNTech Comirnaty 10 ConcentratePfizer BioNTech Comirnaty BivalentModerna Spikevax OriginalModerna Spikevax BivalentSanofi1d. Has successfully completed and passed a knowledge assessment of the vaccine(s) they will be giving – either the vaccine-specific e-learning course assessment(s) or an end-of-course test.Not applicable to role assigned (NA)Supervisor review. Record: met (M) or needs to improve (NI) (initial and date)Met (M) or needs to improve (NI) Please chooseMet (M) Needs to improve (NI) 1e. Able to access the online Green Book and other relevant COVID-19 vaccine guidance, for example, DHSC/UKHSA/NHSE letters (or Scotland, Wales and Northern Ireland equivalents), JCVI statements, Vaccine Update, UKHSA Information for Healthcare Practitioners on the COVID-19 vaccine programme document, COVID-19 vaccine PGD and Protocol, and so on.Not applicable to role assigned (NA)Supervisor review. Record: met (M) or needs to improve (NI) (initial and date)Met (M) or needs to improve (NI) Please chooseMet (M) Needs to improve (NI) 1f. Knows who to contact for advice if unsure about issues such as eligibility for vaccination or action to take if a vaccine error occurs.Not applicable to role assigned (NA)Supervisor review. Record: met (M) or needs to improve (NI) (initial and date)Met (M) or needs to improve (NI)Please chooseMet (M) Needs to improve (NI) 1g. Name of vaccine assessed for (where separate assessment for each vaccine is recommended) Please choosePfizer BioNTech Comirnaty 30 ConcentratePfizer BioNTech Comirnaty 10 ConcentratePfizer BioNTech Comirnaty BivalentModerna Spikevax OriginalModerna Spikevax BivalentSanofi1g. Able to explain the basics of how the vaccine works, what it contains and why, how it has been trialled, any contraindications or precautions and possible side effects and how to treat them.Not applicable to role assigned (NA)Supervisor review. Record: met (M) or needs to improve (NI) (initial and date)Met (M) or needs to improve (NI)Please chooseMet (M) Needs to improve (NI) ______________Part 2. Core skills for vaccinationCompetency assessment tool for health care workers administering the COVID-19 vaccines2a. Is up to date with requirements for anaphylaxis and basic life support (BLS) training (has undertaken within past year or as per employers’ stipulations).Yes NoNot applicable to role Any comments2b. Aware of how to respond to an immediate serious adverse event following vaccination and knows the whereabouts of anaphylaxis and emergency care equipment and how and when to use it.YesNoNot applicable to role Any comments2c. Can explain incident response and reporting process in case of a procedural error, needlestick injury, breach of infection control measure and so on, as per local protocol.YesNoNot applicable to roleAny comments 2d. Knows how to put on and take off personal protective equipment (PPE) as required and demonstrates good practice in infection prevention and control. Uses appropriate aseptic technique when preparing vaccines and handling injection equipment (for example, syringes, needles) to prevent contamination and infection.YesNoNot applicable Any comments 2e. Disposes of sharps, vaccine syringes and vials and other vaccine equipment safely in line with local protocol.YesNoNot applicable to role Any comments 2f. Demonstrates knowledge and understanding of the rationale for and importance of maintaining the vaccine cold chain. Familiar with local protocols for cold chain management and the action to be taken in case of cold chain failure and who to contact.YesNoNot applicable to role Any comments______________Part 3. Clinical process and procedure3a. Checks patient’s identity and patient's records prior to vaccination to ascertain suitability for COVID-19 vaccination.YesNoNot applicable to role Any comments3b. Able to answer patient or carer questions, referring to leaflets to aid explanations or discussion as appropriate and using interpreter if necessary to ensure patient or carer is informed. Knows who to refer to or who to contact if further detail or advice is required.YesNoNot applicable to role Any comments3c. Able to clearly and confidently discuss the benefits and risks of COVID-19 vaccination and able to address any concerns patients and/or carers may have.YesNoNot applicable to role Any comments3d. Demonstrates knowledge of consent requirements and any relevant issues such as the capacity to consent and Mental Capacity Act. Ensures consent is obtained prior to vaccination and is appropriately documented.YesNoNot applicable to role Any comments3e. Name of COVID-19 vaccine Please choosePfizer BioNTech Comirnaty 30 ConcentratePfizer BioNTech Comirnaty 10 ConcentratePfizer BioNTech Comirnaty BivalentModerna Spikevax OriginalModerna Spikevax BivalentSanofi3e. Demonstrates knowledge and understanding of contraindications and precautions for the COVID-19 vaccines and is able to assess appropriately for these, or, if necessary, the need to postpone vaccination.YesNoNot applicable to role Any comments 3f. Checks that there is an appropriate legal authority to supply and administer the vaccine such as: they are an appropriate prescriber, vaccine has been prescribed to a specific patient via a Patient Specific Direction, or the vaccinator is authorised to administer the vaccine in accordance with a Patient Group Direction (PGD) or national Protocol.YesNoNot applicable to role Any comments3g. Name of COVID-19 vaccine Please choosePfizer BioNTech Comirnaty 30 ConcentratePfizer BioNTech Comirnaty 10 ConcentratePfizer BioNTech Comirnaty BivalentModerna Spikevax OriginalModerna Spikevax BivalentSanofi3g. Checks the presentation of the COVID-19 vaccine, the expiry date, how it has been stored prior to use and prepares it according to the vaccine manufacturer’s instructions.YesNoNot applicable to role Any comments3h. Name of COVID-19 vaccine Please choosePfizer BioNTech Comirnaty 30 ConcentratePfizer BioNTech Comirnaty 10 Concentrate3h. Knows which COVID-19 vaccines require dilution, which diluent should be used, volume of diluent required and demonstrates correct technique to dilute vaccineYesNoNot applicable to role Any comments3i. Name of COVID-19 vaccine Please choosePfizer BioNTech Comirnaty 30 ConcentratePfizer BioNTech Comirnaty 10 ConcentratePfizer BioNTech Comirnaty BivalentModerna Spikevax OriginalModerna Spikevax BivalentSanofi3i. Able to state correct dose, depending on vaccine type, and draw it up accurately.YesNoNot applicable to role Any comments 3j. Positions patient appropriately and chooses appropriate vaccination site that is, use of deltoid muscle in upper arm (or anterior lateral aspect of the thigh where there is insufficient muscle mass in deltoid muscle or deltoid muscle is otherwise unsuitable).YesNoNot applicable to role Any comments3k. Demonstrates correct intramuscular injection technique.YesNoNot applicable to role Any comments3l. Demonstrates an understanding of procedure for the reporting of any vaccine reactions and knows how to report using the MHRA’s Coronavirus Yellow Card Scheme.YesNoNot applicable to role Any comments3m. Completes all necessary documentation, recording type and product name of vaccine, batch number, expiry date, dose administered, site used, date given and name and signature.YesNoNot applicable to roleAny comments3n. Demonstrates good record keeping and understands the importance of making sure vaccine information is recorded on relevant data systems.Yes NoNot applicable to role Any comments3o. Advises patient or carer on what to expect after vaccination as appropriate (for example, local injection site reactions, fever) and management of these. Provides patient or carer with a copy of post-immunisation advice sheet or the product's Patient Information Leaflet if appropriate. YesNoNot applicable to role Any comments 3p. Understands individual limitations and knows where to refer patients where there may be more complex requirements or a more experienced vaccinator is required.YesNoNot applicable to role Any comments ______________Action plan(Record any actions required to meet any competencies assessed as ‘needs to improve’. Sign and date these once met)The vaccinator/immuniser has the appropriate knowledge, skill and competence to safely administer and/or assess suitability for COVID-19 vaccination with the vaccines stated. (Signature)Clear SignatureName of supervisors carrying out assessment *FirstLastRole or job titleSignature of supervisor or assessorsClear SignatureState names of COVID-19 vaccines assessed forDate AssessedSubmit
