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 2 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? 3 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. 4