INZ 1096 - Chest X-Ray Certificate (INZ 1096) - March 2015
INZ 1096 - Chest X-Ray Certificate (INZ 1096) - March 2015
INZ 1096 - Chest X-Ray Certificate (INZ 1096) - March 2015
Client no.:
Date received:
Application no.:
INZ 1096
March 2015
Chest X-ray
Certificate
Who 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.
Applicants notes
The 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.
immigration.govt.nz
When filling in this form, please write clearly using CAPITAL LETTERS.
Your responsibilities
You 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
NewZealand, you may be required to leave the country.
Radiologist
If a radiographer is not involved in this process, the
radiologist must complete the steps outlined above, and:
complete sections C, D and E
complete one form only for each person having the
examination
ensure the radiologists report is attached to this certificate
where abnormalities are present or indicated, ensure
the X-ray film accompanies this certificate
ensure the complete certificate and radiologists report,
(and X-ray film if abnormalities have been noted) are
returned to the applicant
provide a copy of the radiologists report to the
referring examining physician, and
if the person has been identified with active TB in
NewZealand, please ensure the Medical Officer of
Health at the local Public Health Unit has been advised in
accordance with the Tuberculosis Act 1948.
2 Chest X-ray Certificate - March 2015
This form has been approved under section 381 of the Immigration Act 2009
Passport/identification number
Section A
Radiologist/radiographer initials
Personal details
Attach one passport-size colour photograph here. The photograph must be no more than
sixmonths old. Write your full name on the back of the photograph.
Question A1 must be completed by the radiographer or radiologist. All other questions in this
section must be completed by the applicant before the examination.
A1 Radiographer or radiologist: certify identity by placing signature and date across
photograph without obscuring the likeness of the person.
4.5cm
Issuing country
Date of issue
3.5cm
Date of expiry
Family name
Given name
Title
Mr
A3 Gender
Male
Mrs
Ms
Miss
Dr
Other (specify)
Female
A4 Date of birth
A5 Country of birth
A6 Contact address
Work/Skills
Temporary employment supported
Resident
Work to residence
Working holiday scheme
Job search
Business/Investor
When filling in this form, please write clearly using CAPITAL LETTERS.
Passport/identification number
Radiologist/radiographer initials
Family
Partner (visitor/work/resident visa)
Humanitarian
Refugee
UNHCR
Other (specify)
Pacific Residence
Samoa
Tonga
Kiribati
Tuvalu
Other (specify)
A8 What is your intended occupation in New Zealand (if you are applying under the work/skills category?
A9 How long do you intend to stay in New Zealand?
Less than 1 year 1 - 2 years 2 - 3 years
Section B
3+ years
Permanently
This 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 18 years of age.
Please read carefully before signing.
I declare that the information that I have provided in terms of my medical history and during my immigration health
examinations is true, complete and correct.
I understand that:
my personal details and health information are being collected to enable Immigration New Zealand (INZ), Ministry
of Business, Innovation and Employment (MBIE) to determine whether or not they are satisfied that I meet the
health criteria for a New Zealand visa(s);
INZ is authorised to collect and use my personal information under the Immigration Act 2009, regulations made
under that Act and in accordance with the Privacy Act 1993; further information about the purposes for which INZ
requires my information is included in my visa application form which can be found on the INZ website at www.
immigration.govt.nz;
if I have provided any false or misleading information as part of my immigration health examination, my visa
application(s) may be declined, and I may become liable for deportation. I may also be committing an offence and I
may be imprisoned;
I must inform INZ of any relevant fact or any change of circumstance that may affect the decision on my application
for a visa due to my health circumstances;
INZ will retain my personal information for use in assessing my health in the future as necessary, or for audit
reasons.
4 Chest X-ray Certificate - March 2015
Passport/identification number
Radiologist/radiographer initials
I also understand that my personal information (including medical results, bio details and photographs) may be
disclosed to:
New Zealand Government health agencies, health and settlement service providers and examining physician(s);
New Zealand Government agencies entitled to receive this information by law, to the extent necessary to make
decisions about my immigration status; and
New Zealand law enforcement, health agencies and international agencies, including overseas recipients in the
United Kingdom, the United States of America, Canada and Australia. [Note: if I am applying for a visa as a refugee
or protected person, INZ will only disclose this information to another country, if it is satisfied that this information
will not be disclosed to the country from which I have sought refugee or protection status and the disclosure is
otherwise permitted under the Immigration Act 2009].
I consent to:
INZ retaining my medical information, including any x-ray images, beyond the determination of my visa application,
for the purposes of considering future applications I may make for a visa to New Zealand;
INZ disclosing my personal information, including information about my health, to the radiologists or panel
physicians who have examined me. The reason(s) for this disclosure will be to investigate inconsistencies between
the radiologist and/or panel physicians examination and a previous/subsequent health assessment, to investigate
a complaint against the radiologist or panel physician, or to follow up adverse results with the radiologist or panel
physician to ensure the quality of the work undertaken by New Zealands panel physician network;
INZ making any enquiries it deems necessary in respect of health information I have provided and to share this
information with other Government agencies (including overseas agencies), and for these agencies to provide
information about my health to INZ, to the extent necessary to make decisions about my immigration status;
any New Zealand health service agency providing information about my state of health to INZ; and
INZ disclosing my medical information in accordance with the provisions above.
I undertake to pay the fees for this medical examination including laboratory tests and I also agree that I or my
child will undergo, at my expense, any further medical examination(s) that may be required by INZ in respect of the
immigration application.
Signature of person having chest X-ray
Date
Signature of parent or guardian if person having chest x-ray is under 18 years of age
Date
Date
When filling in this form, please write clearly using CAPITAL LETTERS.
Passport/identification number
Section C
Radiologist/radiographer initials
Normal
Abnormal
Give details
C3 Cardiac shadow
Normal
Abnormal
Give details
Normal
Abnormal
Give details
C5 Hemidiaphragms
and costophrenic
angles
Normal
Abnormal
Give details
C6 Lung fields
Normal
Abnormal
Give details
C7 Evidence of TB
Absent
Present
C8 Evidence suspicious
of active TB
No
Yes
Give details
Give details
If abnormalities/evidence are noted in C1 to C8 , 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.
C9 Radiologists comments (if any).
Passport/identification number
Section D
Radiologist/radiographer initials
Examination Grading
Please consider the information you have recorded regarding this applicant, and provide a grading on their radiology
examination below. Supporting comments are mandatory if you provide a B grading. If you provide an A grading,
comments are optional.
A No evidence of active TB, or changes consistent with old or inactive TB, or changes suggestive of other
significant diseases identified
Evidence of active TB, or changes consistent with old or inactive TB, or changes suggestive of other
B
significant diseases identified
Note this is not an assessment of whether or not the applicant has an acceptable standard of health in relation to the
Immigration New Zealand standard.
Section E
Radiologists declaration
This 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
When filling in this form, please write clearly using CAPITAL LETTERS.