Health Act 1937
Section 18(1) Health (Drugs and Poisons) Regulation 1996
Application to Chief Executive - Approval for an organisation providing commercial
paramedic services in Queensland
When completing an application please refer to the Fact Sheet at the end of this form, and the Queensland Health guideline Approvals for
organisations providing commercial paramedic services in Queensland.
1. Corporate applicant
Company name
Australian company
number
Website
The approval will be issued in the name recorded above.
Director 1
Given names
Surname
(do not abbreviate)
(include maiden name if married)
Date of birth
Birthplace
Town
Country
Residential address
Telephone
Director 2
Given names
Mobile
Surname
(do not abbreviate)
(include maiden name if married)
Date of birth
Birthplace
Town
Country
Residential address
Telephone
Mobile
2. Business details
Business name
Australian business
number
Street address
Postal address
(for all correspondence)
Contact person
(if relevant)
Telephone
(not mobile)
Fax
E-mail address
3. Medical oversight
3(a) Employed doctor
Does the applicant (organisation) employ a doctor for medical oversight as described in the Queensland Health guideline,
Approvals for organisations providing commercial paramedic services in Queensland?
Yes – go to Section 4
No – go to Section 3(b)
3(b) Arrangement with doctor
Does the applicant (organisation) have an arrangement with a doctor to provide medical oversight as described in the
Queensland Health guideline, Approvals for organisations providing commercial paramedic services in Queensland?
Yes – attach copy of written arrangement (see
No – processing of application will be delayed until evidence of
Section 7)
appropriate medical oversight is provided
Commercial Paramedic Form HDPR96.02– July 2012
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4. Site environments (attach further list if necessary)
If approval is granted, at what sites or events in Queensland are commercial paramedic services to be provided? Please
state the site/event name(s) and location(s). Provide the expected commencement date that commercial paramedic
services will be provided at each site and, if known, the expected end date.
If the applicant does not know what sites or events commercial paramedic services are to be provided at (if granted approval), draw a line through this
section and write “currently unknown”.
Note: If granted an approval, all approval holders must notify Queensland Health of every site or event where commercial paramedic services will be
provided throughout the duration of the approval. A separate notification form, Site environment notification form – organisations providing
commercial paramedic services in Queensland is available for this purpose and accessible from Queensland Health’s poisons and pest management
webpage at www.health.qld.gov.au/industry/poisons_pest. The form is also to be used once an approval has been granted and site environments are
known.
Site environment 1
Commencement and end dates
Name
Location
Site environment 2
Commencement and end dates
Name
Location
Site environment 3
Commencement and end dates
Name
Location
Site environment 4
Commencement and end dates
Name
Location
Site environment 5
Commencement and end dates
Name
Location
5. Storage of medicines (scheduled drugs and poisons)
Describe the type of storage and security measures intended to be used for any site or event for each class of drug or
poison (Include details of cupboard/room, if lockable, key possession etc.)
Controlled (Schedule 8) drugs
Type of storage
Security measures
Restricted (Schedule 4) drugs
Type of storage
Security measures
Schedule 2 and Schedule 3 poisons
Type of storage
Security measures
Commercial Paramedic Form HDPR96.02– July 2012
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6. Drugs and poisons for which approval is requested
Is the applicant (organisation) seeking to gain approval to utilise all scheduled drugs and poisons listed in Appendix 3List of Allowed Medicines of the Queensland Health guideline, Approvals for organisations providing commercial
paramedic services in Queensland? (clinical practice protocols or equivalent must include the medicines for which approval is sought)
Yes – go to Section 7
No – Attach details of the medicine(s) from the list which are being sought.
7. Period for which approval is requested
Period approval is requested
(2 years is the maximum approval period)
8. Required documentation
Copies of the following documentation are submitted with this application (For specific requirements refer to the guideline, Approvals
for organisations providing commercial paramedic services in Queensland and the Fact Sheet at the end of this form).
Applications will not be processed until all documentation is received.

Certificate of Incorporation issued by the Australian Securities and Investments Commission
(ASIC) – certified copy.
Yes

Business Names Extract issued under the Business Names Act 1962 – certified copy.
Yes

Qualifications/education of each paramedic undertaking emergency paramedic roles eg.
(a) degree, diploma; or
(b) Statement of Attainment.
These must be certified copies.
Evidence of the criteria used by the applicant (organisation) to assess the required competency
of its paramedics. This must indicate the person’s competency is equivalent to that required of
paramedics employed by the Queensland Ambulance Service (QAS) as Advanced Care
Paramedics (P3) and/or Intensive Care Paramedics (P4). Documentation must be either:
(a) certification from a registered specialist medical practitioner in emergency medicine; or
(b) a certificate from an independent assessing organisation.
These must be certified copies.
Clinical practice protocol or equivalent for each medicine for which approval is sought.


Yes
Yes
Yes
Yes
Note: Clinical practice protocols or equivalent are to developed and certified by a panel of clinicians (including
registered specialist medical practitioner in emergency medicine).
Yes

Clinical governance documentation.
Yes

If ‘yes’ at Section 3(b) – written arrangement with doctor responsible for medical oversight.
Yes
NA

Relevant documentation that establishes bonafides for the provision of commercial paramedic
services at the site environment(s).
Current or previous commercial paramedic approvals issued by another Australian State or
Territory – certified copies.
Yes
NA
Yes
NA
Yes
No
Yes
No
Yes
No
Yes
No

9. Disclosure by applicant
Have you or the company’s directors (indicated at Section 1) –
 been convicted of an indictable offence?
(Drink driving and minor traffic offences are not indictable offences)



been convicted of an offence against the Health Act 1937 or the Health (Drugs and Poisons)
Regulation 1996 or a repealed provision or a corresponding law in another Australian State or
Territory?
held an approval granted under the Health (Drugs and Poisons) Regulation 1996 or a repealed
provision or a corresponding law in another Australian State or Territory that was suspended or
cancelled?
ever been refused an endorsement under the Health (Drugs and Poisons) Regulation 1996 or a
repealed provision or a corresponding law in another Australian State or Territory? (endorsements
include approvals, licences, permits)
If YES to any of the above, please attach documentation that provides details of the suspension, cancellation, refusal,
nature of the offence and the circumstances of its commission.
Commercial Paramedic Form HDPR96.02– July 2012
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10. Declaration by applicant
I/We declare that each person undertaking emergency paramedic roles under an approval (if
granted) –
 has not been convicted of an indictable offence (Drink driving and minor traffic offences are not indictable
offences).
 has not been convicted of an offence against the Health Act 1937 or the Health (Drugs and
Poisons) Regulation 1996 or a repealed provision or a corresponding law in another Australian
State or Territory.
 has not held an approval granted under the Health (Drugs and Poisons) Regulation 1996 or a
repealed provision or a corresponding law in another Australian State or Territory that was
suspended or cancelled.
 has not been refused an endorsement under the Health (Drugs and Poisons) Regulation 1996
or a repealed provision or a corresponding law in another Australian State or Territory
(endorsements include approvals, authorities, licences, permits).
 does not engage, or has not engaged, in conduct that risks or is likely to risk a controlled drug,
a restricted drug or a poison being used for an unlawful purpose, under a State or
Commonwealth law.
I/We declare that all registered health professionals undertaking roles under an approval (if granted)
and/or having responsibilities in relation to medicines and/or approval requirements do not have any
conditions on their registration that would prevent them from undertaking those roles and/or having
those responsibilities. Registration may be with the Australian Health Practitioner Regulation Agency (AHPRA) or any
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
State or Territory Medical Board prior to 1 July 2010
If NO to any of the above, please attach documentation that provides details of the suspension, cancellation, refusal,
nature of the offence and the circumstances of its commission.
I/We consent to the making of enquiries of, and the exchange of information with the authorities of
Yes
No
any State, Territory, Commonwealth or New Zealand regarding any matters relevant to this
application.
I/We have read, understand and agree to comply with my/our obligations as required under the
relevant provisions of the Health (Drugs and Poisons) Regulation 1996 (available online at
Yes
No
www.legislation.qld.gov.au) and the guideline, Approvals for organisations providing commercial
paramedic services in Queensland (available online at www.health.qld.gov.au/industry/poisons_pest).
I/We declare that the information stated by me/us on this application form is true, correct and
complete.
Yes
No
I am/We are authorised by the corporate applicant to make this declaration on behalf of the
corporate applicant.
Yes
No
Signature 1
Date
Position
Please print full name here
Signature 2
Date
Position
Please print full name here
Commercial Paramedic Form HDPR96.02– July 2012
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Fact Sheet
Health Protection Directorate
Application guide for an Application to Chief Executive – Approval for an
organisation providing commercial paramedic services in Queensland
This fact sheet has been prepared to assist you in applying for an Approval for an organisation providing commercial
paramedic services in Queensland.
Approvals granted in Queensland will be limited to certain scheduled drugs and poisons (scheduled medicines) used in
emergency medical treatment for acute health conditions only, and for use by qualified paramedics employed by
commercial paramedic organisations.
Prior to submitting an application please read the Queensland Health guideline, Approvals for organisations
providing commercial paramedic services in Queensland, available online at Queensland Health’s Poisons and Pest
Management webpage at www.health.qld.gov.au/industry/poisons_pest.
This will assist you in determining whether you may meet the criteria for such approval and understanding certain
particulars of the approval.
For contact information and application processing timeframes regarding Drugs and poisons licensing and approvals,
please refer to fact sheet, Information Circular - Application Processes for Drugs, Poisons, Pest Management and
Pharmacy Ownership located on Queensland Health's Drugs and Poisons Policy and Regulation Unit's webpage
www.health.qld.gov.au/ph/ehu/drugs_poisons.asp under the heading, Drugs and poisons licensing and approvals.
Further information, as it applies to medicines and poisons may also be available from the same webpage.
The following advice will enable timely consideration of your application.
1.
2.
3.
4.
5.
6.
When you complete the form, please print clearly and answer all questions in full.
Applications are processed only when all the information requested is provided. You will be notified by mail if
the application is granted or refused.
Queensland Health is not able to accept a facsimile (fax) or emailed copy of the completed form or any official
documents that are submitted in support of this application. Such information is to be received by post only.
All completed forms and official documents requiring signature(s) and certification must bear the original in ink.
Each page of any photocopied official documents requiring certification must bear the name, position,
certification and original signature of an authorised Identifier ie. Justice of the Peace, Commissioner for
Declarations, registered medical practitioner, police officer, solicitor or an officer from one of Queensland Health’s
Public Health Units (PHU). PHU contact details are located at www.health.qld.gov.au/cho. At least one page of
each photocopied official document must also bear the authorised Identifier’s name and occupation.
Applications must be forwarded by POST to the following address:
Attention: Approval Section
Drugs and Poisons Policy and Regulation Unit
Environmental Health Branch
Queensland Health
PO Box 2368
Fortitude Valley BC 4006
Do not return this fact sheet with the application
Commercial Paramedic Form HDPR96.02– July 2012
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How to complete an application
Please cross
each checkbox below as you complete the application form to ensure that you have provided all
information requested.
Section 1
Corporate applicant
Incorporated companies: Advise the name that appears on the Certificate of Incorporation issued by the
Australian Securities and Investments Commission (ASIC). Attach a copy of the document to the
application only if it has not previously been provided.
Provide the Australian Company Number (ACN) as it appears on the Certificate of Incorporation.
Provide the details of at least two (2) directors of the company. Names are to be advised in full and exactly
as they appear on each person’s birth certificate. If they have ever been known by any other name, attach
any copies of documentation that provides for formal changes of name i.e. deed poll, marriage certificate
etc.
Section 2
Business details
Provide all details of the business including a contact person.
Attach a certified copy of the Business Names Extract issued under the Business Names Act 1962.
Section 3
Medical oversight
3(a) Employed doctor
Mark a checkbox to identify whether a doctor is employed by the applicant (organisation) listed at Section
1. If you have answered yes, Section 3(b) does not need to be completed.
3(b) Arrangement with doctor
Mark a checkbox to identify whether an arrangement with a doctor exists. If you have answered yes, attach
a copy of the written arrangement.
If you have answered No, your application will be delayed until evidence of appropriate medical oversight is
provided, as described in the guideline, Approvals for organisations providing commercial paramedic
services in Queensland.
Section 4
Site environments
If known, provide sufficient details to describe each site/event name and location (including street address)
in Queensland to which the approval (if granted) will be utilised at.
If known, provide the expected date of commencement at each site/event.
If known, provide the expected end date at each site/event.
If site environments are currently unknown, draw a line through this section and write “currently unknown”. If
granted an approval, the applicant (organisation) must notify Queensland Health of every site/event where
commercial paramedic services will be provided throughout the duration of the approval. A separate
notification form is available for this purpose, Site environment notification form – organisations providing
commercial
paramedic
services
in
Queensland,
available
online
at
www.health.qld.gov.au/industry/poisons_pest. That form is to be used once an approval has been granted
and site environments are known.
Attached any relevant documentation that establishes bonafides for the provision of commercial paramedic
services at the site environment(s).
Section 5
Storage of medicines (schedule drugs and poisons)
Provide sufficient details to describe the place where controlled and restricted drugs and Schedule 2 and
Schedule 3 poisons are intended to be stored and the security measures intended to be utilised. Include details of
the storage receptacle, whether the receptacle is lockable and who will have possession of the key.
Section 6
Drugs and poisons for which approval is requested
Please indicate whether the applicant (organisation) is seeking to gain approval to utilise all medicines
(scheduled drugs and poisons) detailed in Appendix 3 – List of Allowed Medicines of the Queensland Health
guideline. If you are seeking to gain approval to utilise only some of the allowed medicines, please detail and
attach which medicines from the List of Allowed Medicines are being sought.
Note: Clinical practice protocols or equivalent must include the medicines for which approval is sought.
Do not return this fact sheet with the application
Commercial Paramedic Form HDPR96.02– July 2012
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Section 7
Period for which approval is requested
Specify the period in months or years that you are requesting approval for. Ordinarily, approvals are granted for a
maximum of 2 years.
Section 8
Required documentation
All documentation requiring certification must be certified by an authorised Identifier. Refer to points 4 and 5 at the
beginning of this Fact Sheet for certification requirements. Applications will not be processed until all documentation is
received and appropriately certified.
Attach a certified copy of the Certificate of Incorporation issued by ASIC.
Attach a certified copy of the Business Names Extract issued under the Business Names Act 1962.
Attach certified evidence for each person undertaking emergency paramedic roles employed, contracted or
otherwise engaged by the company identified at Section 1, to demonstrate their competency. This should
include:
qualifications/education – in the form of a degree/diploma qualification certificate or a Statement of
Attainment detailing each unit of competency, as relevant. If a qualification includes these competency units
as part of the course, the document(s) must state the units of competency successfully completed to attain
the relevant qualification.
skills and knowledge – evidence of the criteria used by the applicant to assess the required competency of
its paramedics. This must indicate the person’s competency is equivalent to that required of paramedics
employed by the Queensland Ambulance Service (QAS) as Advanced Care Paramedics (P3) and/or
Intensive Care Paramedics (P4). Evidence may include:
certification from a registered specialist medical practitioner in emergency medicine who certifies the
current standard of competency and training is equivalent to that required by QAS P3 and/or P4
paramedics; or
a certificate from an independent assessing organisation that the current standard of competency and
training is equivalent to that required by QAS P3 and/or P4 paramedics.
Note: Evidence must include that re-certification of the competency will be undertaken on a yearly basis.
Attach a current and relevant clinical practice protocol (or equivalent) developed and certified by a panel of
clinicians.
Note: The panel of clinicians must include a registered specialist medical practitioner in emergency
medicine.
Attach relevant documents describing processes that demonstrate the company’s (identified at Section 1)
responsibility, accountability and due diligence in regard to clinical governance of paramedic practice. This may
include operational standards, education/training requirements, clinical audits, risk management arrangements
and information management.
If you have answered yes at Section 3(b), attach a copy of the written arrangement.
Attach certified copies of any similar approvals granted from another Australian State or Territory drug regulatory
agency relating to the emergency paramedic activity for the company (identified at Section 1) and for qualified
paramedics.
Section 9
Disclosure by applicant
A checkbox is marked for each question.
If you have answered yes at any checkbox, attach copies of the following documents – certificate of
conviction, court or tribunal order, police records search, ASIC Order preventing individual from managing a
corporation.
Section 10
Declaration by applicant
A checkbox is marked for each declaration.
If you have answered no at any relevant checkbox, attach copies of the following documents – certificate of
conviction, court or tribunal order, police records search.
The form is signed and dated by all persons named at Section 1 or person(s) authorised by the corporate
applicant to make this declaration on behalf of the corporate applicant.
Do not return this fact sheet with the application
Commercial Paramedic Form HDPR96.02– July 2012
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