Disability Support Services Student Emergency Response Plan
The Student Emergency Response Plan is to assist students registered with Disability Support Services
with the safe management of their condition. The plan is designed to address the impacts of a student’s
medical or mental health condition in an emergency situation where an immediate response is required,
and to ensure that appropriate contact is made with people listed on the plan.
This plan is to be completed by a qualified health professional in consultation with the student. It will
be kept securely on file at Disability Support Services, and copies provided to people listed on the plan. If
a student’s registration with Disability Support Services expires, or the nature or management of their
condition changes, the student is required to provide an updated plan. A student can limit the
information they provide on this plan, or choose not to provide consent to share information, but this
may restrict Disability Support Services’ capacity to respond in an emergency situation.
Information on the condition and its impacts on the student, including any warning signs or
triggers for a health crisis occurring:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Presenting symptoms in an emergency or flare-up of student’s condition:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Emergency first aid response:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
People or other professionals who should be contacted if an emergency occurs:
Professional’s name: ____________________________________ Phone: ______________________
Local area health service crisis team: _______________________ Phone: ______________________
Emergency contact: _____________________________________ Phone: ______________________
Relationship of emergency contact person to student: ______________________________________
Other contact: _________________________________________ Phone: ______________________
Relationship of other contact person to student: ___________________________________________
Review date of Emergency Response Plan: ____ / ____ / 20____ or  Ongoing/permanent
Name of health professional completing this form: ________________________________________
Signature: _________________________________________ Date of Report: ____ / ____ / 20______
Relevant Monash contacts - to be discussed with Disability Adviser:
Course Coordinator: _____________________________________ Phone: ______________________
Monash staff contact 2: __________________________________ Phone: ______________________
Monash staff contact 3: __________________________________ Phone: ______________________
It is strongly recommended that you:
 Keep printed copies of your Emergency Response Plan on hand, in case the documentation is
required at any given time.
 Provide this document to relevant University staff (eg. lecturers/tutors/lab supervisors) during the
following situations (if relevant):
o At the beginning of each semester.
o To faculty staff who had not commenced teaching the unit at the beginning of the semester.
o To relevant Faculty staff prior to commencing field trips.
o To Field Placement Supervisors prior to commencement of the Field Placement.
o Examinations staff prior to the commencement of exams.
Student’s written permission to proceed with Emergency Response Plan:
 I hereby give permission for a copy of this plan to be shared with the people listed above. I
understand that I am responsible for keeping this information up to date and that I can revoke this
consent at any time.
Student name: ____________________________________________ Phone: ______________________
Student ID: ________________ Signature: ______________________________ Date ____/____/ 20____
To register this Emergency Response Plan with Disability Support Services, the original completed copy
of this form must be given in person by the student or posted to:
Disability Support Services
Campus Community Division
Level 1 Western Annexe, 21 Chancellors Walk
Monash University Clayton Campus
Victoria 3800, Australia
Website: monash.edu/disability
IMPORTANT: The information contained in this Emergency Response Plan includes personal and health
information to be used to facilitate the provision of reasonable assistance for the student. This
information must be stored in a safe and secure place to comply with the Information Privacy Act 2000
and the Health Records Act 2001. If you have received this form in error, please notify the sender
immediately and destroy the original. Thank you.