CHAPERONE MEDICAL INFORMATION AND ACCEPTANCE OF LIABILITY FOR
MEDICAL COSTS FORM
This is a sample of the medical form which will be supplied to chaperones selected for The Premier’s Anzac Prize 2016.
Chaperones will be required to complete and sign this form, or a form similar to it, upon the request of The Department of
Education and Training (the Department). The Department may need to update this form before that time, or ask additional
medical questions before and on the tour. However the below form is a solid indication of what will be required.
Please carefully consider the Product Disclosure Statement, Policy Wording and Financial Services Guide provided
by GoSafe Travel Insurance: www.gosafetravelinsurance.com.au/pdses/GoSafe_pds_v1_Groups.pdf, in particular
the information about pre-existing medical conditions, what the policy covers and what is not covered. The
Department will cover the cost of the travel insurance for the tour, including the additional premium required for
covering a pre-existing condition, where applicable. Please note some pre-existing medical conditions are not
covered. If you are unsure about anything in the information provided by GoSafe Travel Insurance please contact
them directly for clarification. You will be required to inform the Department, below, about any pre-existing medical
conditions.
Privacy Notice
This information is being collected for the purpose of organising, planning and supervising The Premier’s Anzac Prize 2016 tour. Information you provide
will be used to ensure that chaperones on the tour can safely participate in the planned itinerary, can discharge their obligations for the care and supervision
of students on the tour and that any medical conditions can be appropriately accommodated. In the event of an accident, your illness or incapacity on the
tour, Departmental supervising staff, or other chaperones may be responsible for obtaining medical treatment for you. The information collected will be used
to assist the Department to discharge its duty of care to you, other chaperones and the students on the tour. The information on this form will be used by
authorised employees of the Queensland Government involved in organising the tour. The information may be disclosed to insurance organisations for the
purpose of arranging travel insurance for you. Relevant information will be disclosed to other chaperones on the tour. Information will be provided to medical
professionals in the event that you require medical attention on the tour.
The information will not be used or disclosed for any other purpose without your consent unless the use or disclosure is required or authorised by law. If you
have any questions or concerns about the collection, storage, use or disclosure of the information, please contact the Senior Project Officer on 3513 5747.
Chaperone and contact details
Chaperone name:
Emergency contact 1:
(next of kin)
Relationship:
Home phone:
Work phone:
Mobile:
24/7 contact number required
Email:
Emergency contact 2:
Relationship:
Home phone:
Work phone:
1
Mobile:
24/7 contact number required
Email:
Your doctor’s details
Name of doctor:
Tel:
Name of medical practice:
Address:
Email:
Medical specialist details (if applicable)
Name of doctor:
Tel:
Address:
Email:
Please consider the information provided by GoSafe Travel Insurance and advise:
1.
Do you have a pre-existing medical condition (as defined in the Product Disclosure Statement, Policy Wording
and Financial Services Guide provided by GoSafe Travel Insurance:
www.gosafetravelinsurance.com.au/pdses/GoSafe_pds_v1_Groups.pdf):
Yes
No
If Yes:
Please provide details of the condition, including
severity, treatment and any medication taken for
the condition. For severe medical conditions please
attach an Emergency Action Plan (the Department
may request further details, where necessary):
Please state if you have been hospitalised
[including Day Surgery or Emergency Department
attendance] for that condition in the past 24
months:
Yes
No
If yes, please provide details
Is this a condition for which there is no cover for
medical expenses, cancellation costs or additional
expenses arising from or related to these particular
conditions?
Yes
No
Is this a condition for which there is no cover
whatsoever?
Yes
No
Is this a condition for which you can pay an
additional premium in order to cover events arising
from this condition?
Yes
No
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2.
Have you been diagnosed with any medical condition, not listed above, that a medical practitioner should be
aware of if medical treatment is required (including allergies to medication)?
Yes
No
If yes, please provide details (e.g. severity, medication, special care required):
3.
Please list any conditions or health issues, not listed above, that the other chaperones should be aware of (for
example, if you suffer from travel sickness, sleep walking, phobias, food intolerance):
4.
Please provide any updated information about special requirements (refer to your response in Part A of the
expression of interest form):
Medication
Prescribed medication:
Please give details of any prescribed medication being taken by you/which will be taken with you on the tour —
include dosage, frequency and any doctor’s instructions:
Non-prescribed medication:
Please give details of any non-prescribed medication being taken by you/which will be taken with you on the tour
(for example: paracetamol, travel sickness tablets, diarrhoea tablets, hay fever/allergy tablets, throat lozenges,
vitamins):
Please note some countries have restrictions on medications able to be brought into the country. Please confirm
the medication you intend to bring is allowable for Turkey, Belgium, France and Singapore.
Administration of medication
All medications must be labelled with your name and kept with you at all times during the tour. It will be your
responsibility to keep your own medications, to store securely and appropriately and administer as required. All
medication must be supplied in original packaging. In the case of prescribed medication, the medication must be
supplied with a doctor’s note confirming the prescription and necessity for a particular condition.
Vaccinations
The Department recommends all chaperones obtain medical advice about vaccinations for travel to Turkey,
Belgium and France (noting there will be a stopover in Singapore). Please indicate whether you have received any
vaccinations for this tour by circling A or B below. If you have circled A, please provide the names and dates of
vaccinations received.
A.
I have received the following vaccinations which medical professionals have advised me are recommended
or necessary for this tour:
Name of Vaccination
Date of Vaccination
OR
B.
I have decided NOT to obtain any vaccinations for this tour.
Last anti-tetanus injection date: ___/___/___.
Have you been immunised against Hepatitis B?
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Yes
No
Acceptance of liability of medical costs
I accept liability for all costs incurred in obtaining such medical treatment, which are not covered by GoSafe Travel
Insurance (including any excess payable under the travel insurance policy) and undertake to reimburse the
Department the full amount of any costs incurred.
Declaration

I hereby declare that the foregoing medical information is true and correct and includes all relevant information

I have read and understood the privacy notice, above

I have read and understood the Product Disclosure Statement, Policy Wording and Financial Services Guide
provided by GoSafe Travel Insurance.
_____________________________________
Chaperone Signature
____________________
Date
This form must be signed and returned via email to: internationalservices@dete.qld.gov.au no later than (date).
Please photocopy this form for your records. You are required to keep the Department informed of any changes to
information you have supplied.
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