Emergency Medical Kit Application Form
Manager
Medicines & Poisons Control
Department of Health Email: [email protected]
PO Box 40596 Phone: (08) 8922 7341
CASUARINA NT 0811 Fax: (08) 8922 7200
I hereby apply under Section 142 of the Medicines, Poisons and Therapeutic Goods Act to possess scheduled medicines in a Department of Health ‘Emergency Medical Kit’.
I am aware that:
I must keep the contents in locked storage which cannot be accessed by non-authorised persons;
and
I must record all use of prescription only medicines (S4 and S8) of items in the kit in the relevant register; and
I must follow workplace policies and procedures, and I must report use of prescription only medicines (S4 and S8) to the supervising medical practitioner before use or as soon as practicable after use;
and
I must report each administration of a S8 substance to Medicines and Poisons Control (via [email protected]); and
I must report loss, misappropriation or theft to Medicines and Poisons Control (via [email protected]); and
I must notify of any change of circumstances with regard to authorisation holders or kit contents such as expected staff changes, closure of site, stolen/missing kit contents; and
I must comply with the ‘Exit Strategy’ attached to this application.
In support of my application I submit the following information:
Details of Person to be in Charge of Medical Kit
Name (In Full) Date Of Birth / /
Occupation
Residential Address
Postal Address
Phone Number Fax Number
Mobile Number Email Address
Details Of Drug Related Criminal Offences (If Any)
Can This Applicant Read And Write In The
English Language? ☐ Yes ☐No
Signature of Person Named in
Part A
📎 attach a copy of Drivers Licence or other official photographic ID To possess injectables 📎 attach one of the following:
☐ Current Certificate of attendance at a Medical Kit Training Information Day run by Remote Health’, or
☐ Current Nurse Registration, Paramedic or other health qualification Certificate which covers use of medicines including injectables, or
☐ Hold other current qualifications or can demonstrate recent experience in the administration of injections e.g. Defence medic
Details of Deputy/Deputies to be in Charge of Medical Kit
Name (In Full) Date Of Birth / /
Occupation
Residential Address
Phone Number Fax Number
Mobile Number Email Address
Details of Drug Related Criminal Offences (If Any)
Can this applicant read and write in the English
language? ☐ Yes ☐No
Signature Of Person Named In Part B
📎 attach a copy of Drivers Licence or other official photographic ID To possess injectables 📎 attach one of the following:
☐ Current Certificate of attendance at a Medical Kit Training Information Day run by Remote Health’, or
☐ Current Nurse Registration, Paramedic or other health qualification Certificate which covers use of medicines including injectables, or
☐ Hold other current qualifications or can demonstrate recent experience in the administration of injections e.g. Defence medic
Title: Possess Scheduled Medicines in a DoH Emergency Medical Kit Application Form TRIM: DD2016/6385 | Version: 1.0 | Controlled Doc ID: HEALTHINTRA-1880-9989
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Department of Health is a Smoke Free Workplace
Details of Deputy/Deputies to be in Charge of Medical Kit
Name (In Full) Date Of Birth / /
Occupation
Residential Address
Phone Number Fax Number
Mobile Number Email Address
Details of Drug Related Criminal Offences (If Any)
Can this applicant read and write in the English
language? ☐ Yes ☐No
Signature Of Person Named In Part C
📎 attach a copy of Drivers Licence or other official photographic ID To possess injectables 📎 attach one of the following:
☐ Current Certificate of attendance at a Medical Kit Training Information Day run by Remote Health’, or
☐ Current Nurse Registration, Paramedic or other health qualification Certificate which covers use of medicines including injectables, or
☐ Hold other current qualifications or can demonstrate recent experience in the administration of injections e.g. Defence medic
**If you consider that more deputies should be authorised, please attach a paper showing (for each person) the details of items above. Each deputy named must add his/her signature
Details of the Medical Kit
State Full Physical Address or Site Where Medical Kit Will Be Stored:
Postal Address
Phone Number Fax Number
Mobile Number Email Address
How many people will the kit
cover? Adult
s Childr
en State name & distance of nearest Medical or Health Centre
📎 Please attach the following:
☐ Copy of Exit strategy which covers closure of site, absence of authorised persons, what happens before authorised persons leave employment.
☐ Photographs of storage for all items.
☐ Copy of documents used for recording use of kit contents.
📎 For existing Medical Kits attach
☐ Copy of ‘Record of Use of Medicines Form’ and ‘S8 Register’ for previous authorisation period.
☐ Stocktake of medicines, including item, strength, quantity and expiry date.
Maintenance and availability of documents is standard procedure and requirement for all persons authorised for medical kits.
I declare that the information provided above and in the attachments here to is true and correct Name of Applicant in
Charge
Signature of Applicant in
Charge Date / /20
Payment Details
📎 Attach cheque or copy of receipt. All queries on payment methods are to be referred to the Receiver of Territory Monies (RTM) on (08) 8943 6219 (see Fee info sheet No. 300.2)
☐Cheque (payable to Receiver of Territory Monies)
☐Payment by Credit Card (please call Casuarina RTM (08) 8943 6219 for all credit card payments) Amount
Paid Receipt
Number Date Of
Payment / /20
Office Use Only
For Department of Health Senior Rural Medical Practitioner - Operations Use ONLY
☐Basic (Nil
Injections) O
r ☐All (Including Injections) Comments (if any):
Title: Possess Scheduled Medicines in a DoH Emergency Medical Kit Application Form TRIM: DD2016/6385 | Version: 1.0 | Controlled Doc ID: HEALTHINTRA-1880-9989
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Department of Health is a Smoke Free Workplace
Name:
Signature: Date / /20
