Navigating the process of applying for entry into New Zealand involves several steps, one of which may include completing the INZ 1096 Chest X-ray Certificate, especially for applicants needing to meet the country's health entry requirements. This form plays a pivotal role in the immigration process, serving as a record of the applicant's health status, specifically regarding tuberculosis (TB), which New Zealand is keen to control within its borders. Required by Immigration New Zealand to assess whether applicants meet the necessary health standards, this chest X-ray certificate must be completed when applying for residence or certain types of visas, particularly if the stay is intended for more than six months. There are specific guidelines on who should use this form based on previous visits or stays in countries with a high incidence of TB, and certain individuals, such as children under 11 and pregnant women, may be exempt unless specifically requested by Immigration New Zealand. Furthermore, if applicants have submitted a chest X-ray certificate with a previous application that is still within its validity period (within the last 36 months and not having spent six consecutive months in a high-risk TB country since then), they may not need to submit a new one. However, the decision ultimately rests with the immigration officer handling the application. Instructions for completing the form, including submission processes either electronically through panel physicians or directly via mail, are clearly outlined, emphasizing the responsibilities of the applicant to bear the cost of the X-ray and the potential consequences of providing false statements. The form also delves into the specifics of where and how to get the X-ray done, the identification process during the examination, and the subsequent steps once the examination is complete, highlighting a significant aspect of the immigration health requirements that must be navigated carefully by applicants.
| Question | Answer |
|---|---|
| Form Name | 1096 Form For New Zealand |
| Form Length | 8 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 2 min |
| Other names | 2020, a1, inz 1096, 2009 |
OFFICE USE ONLY Client no.:
Date received: |
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Application no.:
December 2020 |
INZ 1096 |
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Chest |
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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
Most people can submit health information electronically via their panel physician. To find out if you can
submit your health information electronically, go to www.immigration.govt.nz/paneldoctors. If you are not able to submit electronically, the medical clinic completing the form should send it directly to the following address:
Health Assessment Team C/O Immigration New Zealand PO Box 76895
Manukau City
Auckland 2241
New Zealand
Courier costs may be charged for sending medical certificates. These costs must be disclosed to the client prior to the examination taking place.
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 1473, Wellington 6140, New Zealand. This is not where your application should be sent.
Applicant’s notes
The information in this section will help you complete this chest
When do I use this chest
You must use this chest
you are applying for residence, or
you 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, or
you 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 Zealand’s 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
What if I submitted a chest
You may not need a new chest
Note: You will need to provide a new chest
*Immigration New Zealand does not necessarily retain medical information about applicants.
immigration.govt.nz
When filling in this form, please write clearly using CAPITAL LETTERS.
Where do I get my immigration chest
This chest
Please note you may require a referral from a registered medical practitioner for a chest
Your responsibilities
You must pay the fees for the chest
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 certificate
This 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.
Radiographer
The 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 photograph’s edge, and
check passport details and record the passport number
(or other form of identification) at A1 and on every following page in the top
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 radiologist’s report is attached to this certificate
where abnormalities are present or indicated, ensure the
ensure the complete certificate and radiologist’s report, (and
provide a copy of the radiologist’s report to the referring examining physician, and
if the person has been identified with active TB |
in |
New Zealand, please ensure the Medical Officer |
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Health at the local Public Health Unit has been advised |
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in accordance with the Tuberculosis Act 1948. |
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Person having chest
When you have your chest
attach one recent
bring 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 identification
complete section A before attending the examination
complete Section B: Declaration of person having chest
If you have evidence of past or present TB you may be asked to provide a respiratory physician’s report. This must include:
the date of diagnosis documentation of treatment given compliance with treatment confirmed, and
results of 3x3 sputum cultures. Smears alone will not be accepted.
What happens after the examination?
The radiologist that completes your chest
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/contactus
telephone our call centre on 0508 558 855 (within New Zealand).
2 – Chest
This form has been approved under section 381 of the Immigration Act 2009
Passport/identification number
Radiologist/radiographer initials
Section A Personal details
Attach one
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.
Valid photographic identification sighted?
Type of identity document
Original Passport |
Certificate of identity |
Refugee travel document |
National ID card with photo
Identity document number
Issuing country
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Contact address
and/or personal email address
Which visa category are you applying for a visa under?
Temporary
Visitor
Student
Worker with job offer
Worker without job offer
Residence
Skilled/Business
Pacific Categories
Family
Humanitarian (UNHCR)
Humanitarian other
Chest
When filling in this form, please write clearly using CAPITAL LETTERS.
Passport/identification number
Radiologist/radiographer initials
A8
A9
Work to Residence
Worker
Family of a Worker
If you are applying under the Temporary – Worker with a job offer, Residence – Skilled/Business or Work to Residence – Worker categories detail your intended occupation:
How long do you intend to stay in New Zealand?
Less than 6 months |
6 – 12 months |
12 – 24 months |
More than 24 months |
Section B Declaration of person having chest
This declaration must be signed and dated by the person having the chest
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 may enter and store my personal details and health information into the eMedical system;
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 2020; 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.
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
my medical information being temporarily stored on the eMedical system owned and operated by the Australian Department of Home Affairs;
4 – Chest
Passport/identification number
Radiologist/radiographer initials
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 physician’s 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 Zealand’s panel physician network;
INZ storing my photograph(s) digitally and using them for client identification purposes in addition to the health examination process where INZ deems it necessary;
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 |
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Signature of parent or guardian if person having chest |
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Full name of parent or guardian |
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Relationship to person having chest |
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Signature of radiographer or radiologist |
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Name of radiographer or radiologist |
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Chest
When filling in this form, please write clearly using CAPITAL LETTERS.
Passport/identification number
Radiologist/radiographer initials
Section C Results of chest
This 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
C1 Notes to radiologist from examining physician (if applicable).
C2 Skeleton and soft tissue
C3 Cardiac shadow
Normal Abnormal Give details
Normal Abnormal Give details
C4
C5
C6
C7
Hilar and lympathic |
Normal |
Abnormal Give details |
glands |
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Hemidiaphragms |
Normal |
Abnormal Give details |
and costophrenic |
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angles |
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Lung fields |
Normal |
Abnormal Give details |
Evidence of TB |
Absent |
Present Give details |
C8 Evidence suspicious No of active TB
Yes Give details
If abnormalities/evidence are noted in C1 to C8 , then include all
C9 Radiologist’s comments (if any).
6 – Chest
Passport/identification number
Radiologist/radiographer initials
Section D 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
B Evidence of active TB, or changes consistent with old or inactive TB, or changes suggestive of other significant diseases identified
Please list abnormal findings
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.
General supporting comments (if applicable)
Section E Radiologist’s declaration
This declaration must be signed and dated by the radiologist who examined the chest
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
D D M M Y Y Y Y
Radiologist’s details (please write)
Full name
MCNZ number for New Zealand practitioners Place of examination (city/state and country) Postal address
Telephone (daytime)
Chest
When filling in this form, please write clearly using CAPITAL LETTERS.
8 – Chest