新西兰留学签证 X光 体检表 INZ1096[1].pdf

OFFICE USE ONLYClient no.:Date received:/Application no.:Chest X-rayCertificateINZ 1096For further information on immigration visit www.immigration.govt.nzJuly 2013Who should use this form?Applicants for entry to New Zealand are required to have an acceptable standard of health(Health Requirements(INZ 1121)has more details).This chest X-ray certificate records information about your health that Immigration New Zealand requires to assess whether you meet this standard.Deciding whether you are eligible for a visa Immigration New Zealand collects the information about you on this form to decide whether you are eligible for a visa.Collecting the information is authorised by the Immigration Act 2009 and the Immigration Regulations made under that Act.You do not have to provide the information,but if you do not we are likely to decline your application.Immigration New Zealand may also share the information you have provided with other government agencies that are entitled to it by law,or with other agencies(as you have agreed in the declaration).You are able to ask for the information we hold about you and request to have any of it corrected if you think it is necessary.The address of Immigration New Zealand is PO Box 3705,Wellington,New Zealand.This is not where your application should be sent.Applicants notesThe information in this section will help you complete this chest X-ray certificate.Please read the information in this section before you start to complete this certificate.When do I use this chest X-ray certificate?You must use this chest X-ray certificate if:you are applying for residence,oryou are applying for a temporary entry class visa and you intend to stay longer than 12 months,unless you are applying for a military visa,diplomatic,consular or official visa,or a visa related to the Antarctic Treaty,oryou are applying for a temporary entry class visa and you intend to stay between six to 12 months and you are from,or have visited,a place that is not on Immigration New Zealands list of countries,areas and territories with a low incidence of tuberculosis(TB)The guide Health Requirements(INZ 1121)has more details and includes the full list.Children under 11 years of age and women who are pregnant are not required to undergo a chest X-ray examination unless requested by INZ.What if I submitted a chest X-ray certificate with my last application?You may not need a new chest X-ray certificate if you have submitted a chest X-ray certificate completed and dated by a radiologist or a radiographer within the last 36 months with a previous application,and that information has been retained by Immigration New Zealand*.Your immigration officer will let you know if a new chest X-ray certificate is required.If a new certificate is required you are responsible for any fees.Note:You will need to provide a new chest X-ray certificate if you have spent six consecutive months in a place that is not on Immigration New Zealands list of countries,areas and territories with a low incidence of TB since any previous chest X-ray certificate was completed and dated by a radiologist or radiographer.The guide Health Requirements(INZ 1121)has more details and includes the full list.*Immigration New Zealand does not necessarily retain medical information about applicants.2 Chest X-ray Certificate-July 2013When filling in this form,please write clearly using CAPITAL LETTERS.This form has been approved under section 381 of the Immigration Act 2009Where do I get my immigration chest X-ray?This chest X-ray certificate must be completed by a radiologist.This certificate is not to be completed by a radiologist or radiographer who is related to the person having the chest X-ray examination.Please note you may require a referral from a registered medical practitioner for a chest X-ray.In most countries Immigration New Zealand has approved lists of panel physicians who must be used for the examination.If you require information on the panel physicians list,please visit the INZ website at www.immigration.govt.nz/healthinfo.If you live in a country which does not have any panel physicians,a registered radiologist can complete this certificate.Your responsibilitiesYou must pay the fees for the chest X-ray,any tests required and all postage and courier fees.You must tell the truth.False statements on a medical certificate may result in your application being declined,any visa granted being cancelled,and if you are in New Zealand,you may be required to leave the country.Completing the certificateThis certificate must be completed in English.If any accompanying specialist report cannot be provided in English,a certified translation must be provided along with the original specialist report.RadiographerThe radiographer must:certify the identity of the person being examined,by signing and dating the front of the photograph at A1(without obliterating the image).These details must extend beyond the photographs edgecheck passport details and record the passport number(or other form of identification)at A4 and on every following page in the top right-hand corner,andwitness Section A:Confirmation of identity.RadiologistIf a radiographer is not involved in this process,the radiologist must complete the steps outlined above,and:complete sections D and Ecomplete one form only for each person having the examinationensure the radiologists report is attached to this certificatewhere abnormalities are present or indicated,ensure the X-ray film accompanies this certificateensure the complete certificate and radiologists report,(and X-ray film if abnormalities have been noted)are returned to the applicantprovide a copy of the radiologists report to the referring examining physician,andif the person has been identified with active TB in New Zealand,please ensure the Medical Officer of Health at the local Public Health Unit has been advised in accordance with the Tuberculosis Act 1948.Person having chest X-ray examinationWhen you have your chest X-ray examination you must:attach one recent passport-size colour photograph of yourself in the space provided.The photograph must be no more than six months oldbring your valid passport(or other photographic identification,for example national identity card where passport unavailable).The examining physician will not proceed with the examination without photographic identificationcomplete sections A and B before attending the examinationcomplete Section C:Declaration of person having chest X-ray examination in the presence of the radiographer.If you have evidence of past or present TB you may be asked to provide a respiratory physicians report.This must include:the date of diagnosisdocumentation of treatment givencompliance with treatment confirmed,andresults of 3x3 sputum cultures.Smears alone will not be accepted.What happens after the examination?The radiologist who completes your medical certificate will return the form and all associated reports(and X-ray film if abnormalities have been noted)to you,or to the medical practitioner who referred you.You must submit your completed chest X-ray certificate,along with any other medical certificates required,within three months from the date the radiologist signed the completed chest X-ray certificate.Your application will be assessed by Immigration New Zealand and may be referred to an Immigration New Zealand medical assessor or New Zealand health authorities.You may be required to get further specialist reports or tests.You are responsible for paying for these.Your medical information may be retained by Immigration New Zealand.For more information If you have questions about completing the form:see our website www.immigration.govt.nz/contactustelephone our call centre on 0508 558 855(within New Zealand).Chest X-ray Certificate-July 2013 3 When filling in this form,please write clearly using CAPITAL LETTERS.Section A Confirmation of identityAttach one passport-size colour photograph here.The photograph must be no more than six months old.Write your full name on the back of the photograph.Questions A1,A2 and A3 must be completed by the person having the chest X-ray examination.Question A4 must be completed by the radiographer or radiologist.A1 Full name as shown in passport Family/last name Given/first name(s)A2 Gender Male Female A3 Date of birth To be completed by radiographer or radiologistA4 Valid passport sighted?Yes Passport number Or valid photographic identification(ID)sighted?Yes Type of ID ID number Section B Details of person having chest X-ray examinationThis section must be completed by the person having the chest X-ray examination before attending the examination.B1 Name as shown in passport Family/last name Given/first name(s)B2 Full home address B3 Telephone(daytime)B4 Email B5 Gender Male Female B6 Date of birth B7 Country of birth B8 Country of citizenship 4.5cm3.5cmPassport/identification numberRadiologist/radiographer initials4 Chest X-ray Certificate-July 2013When filling in this form,please write clearly using CAPITAL LETTERS.Section C Declaration of person having chest X-ray examinationThis declaration must be signed and dated by the person having the chest X-ray examination,in the presence of the radiographer or radiologist.A parent or guardian must sign on behalf of a child under 16 years of age.Please read carefully before signing.I declare that the details given by me to the radiologist or radiographer on this X-ray certificate and set out in section A of this certificate are true and correct in every respect.I declare that I will inform INZ of any relevant fact or any change of circumstances that may affect the decision on my application for a visa due to my health circumstances.I authorise INZ to make any enquiries it deems necessary in respect of the information provided on this form and to share this information with other Government agencies(including health service agencies and overseas agencies)to the extent necessary to make a decision about my immigration status.I authorise any New Zealand health service agency to provide information about my state of health to INZ.I undertake to pay the fees for this X-ray examination and I also agree that I or my child will undergo,at my expense,any further examinations that may be required by INZ in respect of my immigration application.I agree that the radiologist or radiographer who completes this certificate may release to INZ,any information acquired with regard to the health of myself or my child.I understand that if I make any false statements,or provide any false or misleading information or have changed or altered this certificate in any way,my application may be declined,or I may become liable for deportation,and that I may be committing an offence and be liable to prosecution and imprisonment.Signature of person having chest X-ray Date (or parent or guardian)Full name of parent or guardian Relationship to person having chest X-ray Signature of radiographer or radiologist Date Name of radiographer or radiologist Passport/identification numberRadiologist/radiographer initialsChest X-ray Certificate-July 2013 5 When filling in this form,please write clearly using CAPITAL LETTERS.Section D Results of chest X-ray examinationThis section must be completed in full by the radiologist.Where abnormalities are present,the radiologist must provide details and comments in the space provided and the X-ray film must accompany this certificate.The radiologists report must be attached to this certificate and both returned to the examining physician or applicant.D1 Notes to radiologist from examining physician(if applicable).D2Skeleton and soft tissue Normal Abnormal Give details D3Cardiac shadow Normal Abnormal Give details D4Hilar and lympathic glands Normal Abnormal Give details D5Hemidiaphragms and costophrenic angles Normal Abnormal Give details D6Lung fields Normal Abnormal Give details D7Evidence of TB No Yes Give details D8Evidence of old,healed TB No Yes Give details D9Evidence suspicious of active TB No Yes Give details If abnormalities/evidence are noted in D1 to D9,then include all X-ray films/plates/scans to show recent and past history of diagnosis and treatment.X-ray films/plates/scans must have a corresponding report attached.D10 Details of other abnormalities.Passport/identification numberRadiologist/radiographer initials6 Chest X-ray Certificate-July 2013When filling in this form,please write clearly using CAPITAL LETTERS.Passport/identification numberRadiologist/radiographer initialsSection E Radiologists declarationThis declaration must be signed and dated by the radiologist who examined the chest X-ray.I certify that the statements made by me in answer to all the questions are true to the best of my knowledge and belief.Signature of radiologist Date Radiologists details(please write)Full name MCNZ number for New Zealand practitioners Place of examination(city/state and country)Postal address Telephone(daytime)Email Chest X-ray Certificate-July 2013 7 8 Chest X-ray Certificate-July 2013When filling in this form,please write clearly using CAPITAL LETTERS.