Possess Scheduled Medicines in a Medical Kit Application Form

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PPossess Scheduled Medicines in a 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 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 medicines 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 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

📎 I have attached one of the following for this applicant:

☐Current Nurse Registration, Paramedic or other health qualification Certificate which covers use of medicines including injectables if these are contained in the medical kit; or

☐Other current qualifications or can demonstrate recent experience in the administration of injections e.g.

Title: Possess Scheduled Medicines in a Medical Kit Application Form TRIM: DD2016/6385 | Version: 1.0 | Controlled Doc ID: HEALTHINTRA-1880-9990

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Department of Health is a Smoke Free Workplace

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DEPARTMENT OF HEALTH

Defence medic

📎 attach a copy of Drivers Licence or other official photographic ID Signature of Person Named in

Part A

Details of Deputy/Deputies to be In Charge of Medical Kit

Name (In Full) Date Of Birth / /

Occupation

Residential Address

Postal Address

Details Of Drug Related Criminal Offences (If Any)

Can This Applicant Read And Write In The

English Language? ☐ Yes ☐No

📎 I have attached one of the following for this applicant:

☐Current Nurse Registration, Paramedic or other health qualification Certificate which covers use of medicines including injectables if these are contained in the medical kit; or

☐Other current qualifications or can demonstrate recent experience in the administration of injections e.g.

Defence medic

📎 attach a copy of Drivers Licence or other official photographic ID Signature Of

Deputy

**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 Name of Business/Company:

State Full Physical Address or Site Where Medical Kit Will Be Stored:

Postal Address

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Department of Health is a Smoke Free Workplace

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DEPARTMENT OF HEALTH

How many people will the kit

cover? Adult

s Childr

en State name & distance of nearest Medical or Health Centre

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Department of Health is a Smoke Free Workplace

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DEPARTMENT OF HEALTH

Details of Supervising Medical Practitioner, Practice or Company providing medical support Practice, Company or Medical Practitioner Name

Full Name of Contact Person Postal Address

Standard Medical Kits are listed below, please indicate type for which authorisation is required:

☐ Australian Maritime Safety Authority (Marine Orders Part 11)

☐ Australian Yachting Federation Medical Kit

☐ Other (state type/site)

📎 Please attach the following:

☐ An imprest list of all drug items and their strengths and quantities

☐ Protocols of use for each drug in the list

☐ Letter from medical practitioner endorsing drugs to be held in the kit

☐ Copy of ‘Exit Strategy’ which covers closure of site, absence of authorised persons, what happens before authorised persons leave employment (attached)

☐ Photographs of storage for all items

☐ Copy of documents used for recording use of kit contents

📎 For existing Medical Kits attach

☐ Copy of documents used for recording use of medicines in medical kit including ‘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.

For Medical Kits wanting authorisation to position title

☐ A job description, including position title and required qualifications

☐ A Human Resources HR document outlining the credentialing process

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

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