ICB PATIENT MEDICAL REGISTRATION - Form

Please ensure each question is answered.
If the question does not apply, then write 'N/A' or 'Not Applicable' or 'Nil' accordingly.

Page 1 - General Information

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Team ID#

Verified Date

Status

Authority To Practice?:
Yes No

Supervision Required?:
Yes No

Previously Approved by MOH?:
Yes No

---

First Name

Middle Name

Last Name

AHPRA Registration No.

AHPRA Designation Choose... FACEM Emergency Doctor Senior Doctor General Practitioner Sports Doctor Registered Nurse (Div 1) Registered Nurse (Div 2) Registered Paramedic Registered Physiotherapist

Scope of Practice Choose... Event Medical Specialist Emergency Specialist Critical Care Paramedic Intensive Care Paramedic Clinical Nurse Specialist ICU Nurse Emergency Nurse Paramedic Specialist None

Post Graduate Years

Event Years

---

Non Registered Designation Choose... Event Medic (lodged) EMT Medical Support Liaison Controller First Aid Desk

Certifications Choose... Working With Children Criminal History Check Event Medic ACLS PHTLS ALS Adv Airway BLS Adv First Aid First Aid CPR Certified Harm Reduction Drug & Alcohol Adv Trauma

Qualifications Choose... Faculty of Pre-Hospital Care - The Royal College of Surgeons of Edinburgh P5 Event Medic Certification - American Academy of Event Medicine Advanced Diploma of Paramedical Science Advanced Diploma of Event Medicine Advanced Diploma of Public Safety (Emergency Management) Advanced Diploma of Mass Gathering Medicine Diploma of Applied Science (Nursing) Diploma of Paramedical Science Diploma of Occupational Health & Safety Diploma of Training & Education Diploma of Business Cert IV in Pre-Hospital Emergency Cert IV Emergency Medical Technician Pre-Hospital Care Cert IV Aviation (Air-crewman) Cert IV Trainer & Assessor

Certificates Choose... Flight Medic Certified Advanced Trauma Certification Special Events Medical Certified Advanced Airway Certified CPR First Aid Advanced First Aid Advanced Resuscitation Drivers License Ambulance Drivers License Car Festival Drugs - An understanding for EMS Teams Harm Minimisation / Reduction Course EMS Advanced Drug & Alcohol Course Basic Drug Identification An Introduction to Street Drug Identification Adverse effects associated with Physical Restraint Administer and Monitor medicines & IV Drugs Hs & Ts of ACLS EMS Evacuation Training Advanced Life Support Crush Injury Course SMART Triage Course Respiratory Arrest Positional Asphyxia Quantitative Waveform Capnograpy Assessment and Management of the Acute Festival Patient Pathophysiology and Pharmacology of Common Drug presentations Focused Assessment Model for Acute Drug Presentations Best-Practice Treatment Strategies for Acute Drug Presentations Communications / Scene Management / Documentation

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Page 2 - Medical History

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Team ID#

Verified Date

Status

Authority To Practice?:
Yes No

Supervision Required?:
Yes No

Previously Approved by MOH?:
Yes No

---

First Name

Middle Name

Last Name

AHPRA Registration No.

AHPRA Designation Choose... FACEM Emergency Doctor Senior Doctor General Practitioner Sports Doctor Registered Nurse (Div 1) Registered Nurse (Div 2) Registered Paramedic Registered Physiotherapist

Scope of Practice Choose... Event Medical Specialist Emergency Specialist Critical Care Paramedic Intensive Care Paramedic Clinical Nurse Specialist ICU Nurse Emergency Nurse Paramedic Specialist None

Post Graduate Years

Event Years

---

Non Registered Designation Choose... Event Medic (lodged) EMT Medical Support Liaison Controller First Aid Desk

Certifications Choose... Working With Children Criminal History Check Event Medic ACLS PHTLS ALS Adv Airway BLS Adv First Aid First Aid CPR Certified Harm Reduction Drug & Alcohol Adv Trauma

Qualifications Choose... Faculty of Pre-Hospital Care - The Royal College of Surgeons of Edinburgh P5 Event Medic Certification - American Academy of Event Medicine Advanced Diploma of Paramedical Science Advanced Diploma of Event Medicine Advanced Diploma of Public Safety (Emergency Management) Advanced Diploma of Mass Gathering Medicine Diploma of Applied Science (Nursing) Diploma of Paramedical Science Diploma of Occupational Health & Safety Diploma of Training & Education Diploma of Business Cert IV in Pre-Hospital Emergency Cert IV Emergency Medical Technician Pre-Hospital Care Cert IV Aviation (Air-crewman) Cert IV Trainer & Assessor

Certificates Choose... Flight Medic Certified Advanced Trauma Certification Special Events Medical Certified Advanced Airway Certified CPR First Aid Advanced First Aid Advanced Resuscitation Drivers License Ambulance Drivers License Car Festival Drugs - An understanding for EMS Teams Harm Minimisation / Reduction Course EMS Advanced Drug & Alcohol Course Basic Drug Identification An Introduction to Street Drug Identification Adverse effects associated with Physical Restraint Administer and Monitor medicines & IV Drugs Hs & Ts of ACLS EMS Evacuation Training Advanced Life Support Crush Injury Course SMART Triage Course Respiratory Arrest Positional Asphyxia Quantitative Waveform Capnograpy Assessment and Management of the Acute Festival Patient Pathophysiology and Pharmacology of Common Drug presentations Focused Assessment Model for Acute Drug Presentations Best-Practice Treatment Strategies for Acute Drug Presentations Communications / Scene Management / Documentation

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Page 3 - Allergies

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Team ID#

Verified Date

Status

Authority To Practice?:
Yes No

Supervision Required?:
Yes No

Previously Approved by MOH?:
Yes No

---

First Name

Middle Name

Last Name

AHPRA Registration No.

AHPRA Designation Choose... FACEM Emergency Doctor Senior Doctor General Practitioner Sports Doctor Registered Nurse (Div 1) Registered Nurse (Div 2) Registered Paramedic Registered Physiotherapist

Scope of Practice Choose... Event Medical Specialist Emergency Specialist Critical Care Paramedic Intensive Care Paramedic Clinical Nurse Specialist ICU Nurse Emergency Nurse Paramedic Specialist None

Post Graduate Years

Event Years

---

Non Registered Designation Choose... Event Medic (lodged) EMT Medical Support Liaison Controller First Aid Desk

Certifications Choose... Working With Children Criminal History Check Event Medic ACLS PHTLS ALS Adv Airway BLS Adv First Aid First Aid CPR Certified Harm Reduction Drug & Alcohol Adv Trauma

Qualifications Choose... Faculty of Pre-Hospital Care - The Royal College of Surgeons of Edinburgh P5 Event Medic Certification - American Academy of Event Medicine Advanced Diploma of Paramedical Science Advanced Diploma of Event Medicine Advanced Diploma of Public Safety (Emergency Management) Advanced Diploma of Mass Gathering Medicine Diploma of Applied Science (Nursing) Diploma of Paramedical Science Diploma of Occupational Health & Safety Diploma of Training & Education Diploma of Business Cert IV in Pre-Hospital Emergency Cert IV Emergency Medical Technician Pre-Hospital Care Cert IV Aviation (Air-crewman) Cert IV Trainer & Assessor

Certificates Choose... Flight Medic Certified Advanced Trauma Certification Special Events Medical Certified Advanced Airway Certified CPR First Aid Advanced First Aid Advanced Resuscitation Drivers License Ambulance Drivers License Car Festival Drugs - An understanding for EMS Teams Harm Minimisation / Reduction Course EMS Advanced Drug & Alcohol Course Basic Drug Identification An Introduction to Street Drug Identification Adverse effects associated with Physical Restraint Administer and Monitor medicines & IV Drugs Hs & Ts of ACLS EMS Evacuation Training Advanced Life Support Crush Injury Course SMART Triage Course Respiratory Arrest Positional Asphyxia Quantitative Waveform Capnograpy Assessment and Management of the Acute Festival Patient Pathophysiology and Pharmacology of Common Drug presentations Focused Assessment Model for Acute Drug Presentations Best-Practice Treatment Strategies for Acute Drug Presentations Communications / Scene Management / Documentation

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Page 4 - Physical Health

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Team ID#

Verified Date

Status

Authority To Practice?:
Yes No

Supervision Required?:
Yes No

Previously Approved by MOH?:
Yes No

---

First Name

Middle Name

Last Name

AHPRA Registration No.

AHPRA Designation Choose... FACEM Emergency Doctor Senior Doctor General Practitioner Sports Doctor Registered Nurse (Div 1) Registered Nurse (Div 2) Registered Paramedic Registered Physiotherapist

Scope of Practice Choose... Event Medical Specialist Emergency Specialist Critical Care Paramedic Intensive Care Paramedic Clinical Nurse Specialist ICU Nurse Emergency Nurse Paramedic Specialist None

Post Graduate Years

Event Years

---

Non Registered Designation Choose... Event Medic (lodged) EMT Medical Support Liaison Controller First Aid Desk

Certifications Choose... Working With Children Criminal History Check Event Medic ACLS PHTLS ALS Adv Airway BLS Adv First Aid First Aid CPR Certified Harm Reduction Drug & Alcohol Adv Trauma

Qualifications Choose... Faculty of Pre-Hospital Care - The Royal College of Surgeons of Edinburgh P5 Event Medic Certification - American Academy of Event Medicine Advanced Diploma of Paramedical Science Advanced Diploma of Event Medicine Advanced Diploma of Public Safety (Emergency Management) Advanced Diploma of Mass Gathering Medicine Diploma of Applied Science (Nursing) Diploma of Paramedical Science Diploma of Occupational Health & Safety Diploma of Training & Education Diploma of Business Cert IV in Pre-Hospital Emergency Cert IV Emergency Medical Technician Pre-Hospital Care Cert IV Aviation (Air-crewman) Cert IV Trainer & Assessor

Certificates Choose... Flight Medic Certified Advanced Trauma Certification Special Events Medical Certified Advanced Airway Certified CPR First Aid Advanced First Aid Advanced Resuscitation Drivers License Ambulance Drivers License Car Festival Drugs - An understanding for EMS Teams Harm Minimisation / Reduction Course EMS Advanced Drug & Alcohol Course Basic Drug Identification An Introduction to Street Drug Identification Adverse effects associated with Physical Restraint Administer and Monitor medicines & IV Drugs Hs & Ts of ACLS EMS Evacuation Training Advanced Life Support Crush Injury Course SMART Triage Course Respiratory Arrest Positional Asphyxia Quantitative Waveform Capnograpy Assessment and Management of the Acute Festival Patient Pathophysiology and Pharmacology of Common Drug presentations Focused Assessment Model for Acute Drug Presentations Best-Practice Treatment Strategies for Acute Drug Presentations Communications / Scene Management / Documentation

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Page 5 - Symptoms 1

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Team ID#

Verified Date

Status

Authority To Practice?:
Yes No

Supervision Required?:
Yes No

Previously Approved by MOH?:
Yes No

---

First Name

Middle Name

Last Name

AHPRA Registration No.

AHPRA Designation Choose... FACEM Emergency Doctor Senior Doctor General Practitioner Sports Doctor Registered Nurse (Div 1) Registered Nurse (Div 2) Registered Paramedic Registered Physiotherapist

Scope of Practice Choose... Event Medical Specialist Emergency Specialist Critical Care Paramedic Intensive Care Paramedic Clinical Nurse Specialist ICU Nurse Emergency Nurse Paramedic Specialist None

Post Graduate Years

Event Years

---

Non Registered Designation Choose... Event Medic (lodged) EMT Medical Support Liaison Controller First Aid Desk

Certifications Choose... Working With Children Criminal History Check Event Medic ACLS PHTLS ALS Adv Airway BLS Adv First Aid First Aid CPR Certified Harm Reduction Drug & Alcohol Adv Trauma

Qualifications Choose... Faculty of Pre-Hospital Care - The Royal College of Surgeons of Edinburgh P5 Event Medic Certification - American Academy of Event Medicine Advanced Diploma of Paramedical Science Advanced Diploma of Event Medicine Advanced Diploma of Public Safety (Emergency Management) Advanced Diploma of Mass Gathering Medicine Diploma of Applied Science (Nursing) Diploma of Paramedical Science Diploma of Occupational Health & Safety Diploma of Training & Education Diploma of Business Cert IV in Pre-Hospital Emergency Cert IV Emergency Medical Technician Pre-Hospital Care Cert IV Aviation (Air-crewman) Cert IV Trainer & Assessor

Certificates Choose... Flight Medic Certified Advanced Trauma Certification Special Events Medical Certified Advanced Airway Certified CPR First Aid Advanced First Aid Advanced Resuscitation Drivers License Ambulance Drivers License Car Festival Drugs - An understanding for EMS Teams Harm Minimisation / Reduction Course EMS Advanced Drug & Alcohol Course Basic Drug Identification An Introduction to Street Drug Identification Adverse effects associated with Physical Restraint Administer and Monitor medicines & IV Drugs Hs & Ts of ACLS EMS Evacuation Training Advanced Life Support Crush Injury Course SMART Triage Course Respiratory Arrest Positional Asphyxia Quantitative Waveform Capnograpy Assessment and Management of the Acute Festival Patient Pathophysiology and Pharmacology of Common Drug presentations Focused Assessment Model for Acute Drug Presentations Best-Practice Treatment Strategies for Acute Drug Presentations Communications / Scene Management / Documentation

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Page 6 - Symptoms 2

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Team ID#

Verified Date

Status

Authority To Practice?:
Yes No

Supervision Required?:
Yes No

Previously Approved by MOH?:
Yes No

---

First Name

Middle Name

Last Name

AHPRA Registration No.

AHPRA Designation Choose... FACEM Emergency Doctor Senior Doctor General Practitioner Sports Doctor Registered Nurse (Div 1) Registered Nurse (Div 2) Registered Paramedic Registered Physiotherapist

Scope of Practice Choose... Event Medical Specialist Emergency Specialist Critical Care Paramedic Intensive Care Paramedic Clinical Nurse Specialist ICU Nurse Emergency Nurse Paramedic Specialist None

Post Graduate Years

Event Years

---

Non Registered Designation Choose... Event Medic (lodged) EMT Medical Support Liaison Controller First Aid Desk

Certifications Choose... Working With Children Criminal History Check Event Medic ACLS PHTLS ALS Adv Airway BLS Adv First Aid First Aid CPR Certified Harm Reduction Drug & Alcohol Adv Trauma

Qualifications Choose... Faculty of Pre-Hospital Care - The Royal College of Surgeons of Edinburgh P5 Event Medic Certification - American Academy of Event Medicine Advanced Diploma of Paramedical Science Advanced Diploma of Event Medicine Advanced Diploma of Public Safety (Emergency Management) Advanced Diploma of Mass Gathering Medicine Diploma of Applied Science (Nursing) Diploma of Paramedical Science Diploma of Occupational Health & Safety Diploma of Training & Education Diploma of Business Cert IV in Pre-Hospital Emergency Cert IV Emergency Medical Technician Pre-Hospital Care Cert IV Aviation (Air-crewman) Cert IV Trainer & Assessor

Certificates Choose... Flight Medic Certified Advanced Trauma Certification Special Events Medical Certified Advanced Airway Certified CPR First Aid Advanced First Aid Advanced Resuscitation Drivers License Ambulance Drivers License Car Festival Drugs - An understanding for EMS Teams Harm Minimisation / Reduction Course EMS Advanced Drug & Alcohol Course Basic Drug Identification An Introduction to Street Drug Identification Adverse effects associated with Physical Restraint Administer and Monitor medicines & IV Drugs Hs & Ts of ACLS EMS Evacuation Training Advanced Life Support Crush Injury Course SMART Triage Course Respiratory Arrest Positional Asphyxia Quantitative Waveform Capnograpy Assessment and Management of the Acute Festival Patient Pathophysiology and Pharmacology of Common Drug presentations Focused Assessment Model for Acute Drug Presentations Best-Practice Treatment Strategies for Acute Drug Presentations Communications / Scene Management / Documentation

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Page 7 - Symptoms 3

Morbi tincidunt, dui sit amet facilisis feugiat, odio metus gravida ante, ut pharetra massa metus id nunc. Duis scelerisque molestie turpis. Sed fringilla, massa eget luctus malesuada, metus eros molestie lectus,

Team ID#

Verified Date

Status

Authority To Practice?:
Yes No

Supervision Required?:
Yes No

Previously Approved by MOH?:
Yes No

---

First Name

Middle Name

Last Name

AHPRA Registration No.

AHPRA Designation Choose... FACEM Emergency Doctor Senior Doctor General Practitioner Sports Doctor Registered Nurse (Div 1) Registered Nurse (Div 2) Registered Paramedic Registered Physiotherapist

Scope of Practice Choose... Event Medical Specialist Emergency Specialist Critical Care Paramedic Intensive Care Paramedic Clinical Nurse Specialist ICU Nurse Emergency Nurse Paramedic Specialist None

Post Graduate Years

Event Years

---

Non Registered Designation Choose... Event Medic (lodged) EMT Medical Support Liaison Controller First Aid Desk

Certifications Choose... Working With Children Criminal History Check Event Medic ACLS PHTLS ALS Adv Airway BLS Adv First Aid First Aid CPR Certified Harm Reduction Drug & Alcohol Adv Trauma

Qualifications Choose... Faculty of Pre-Hospital Care - The Royal College of Surgeons of Edinburgh P5 Event Medic Certification - American Academy of Event Medicine Advanced Diploma of Paramedical Science Advanced Diploma of Event Medicine Advanced Diploma of Public Safety (Emergency Management) Advanced Diploma of Mass Gathering Medicine Diploma of Applied Science (Nursing) Diploma of Paramedical Science Diploma of Occupational Health & Safety Diploma of Training & Education Diploma of Business Cert IV in Pre-Hospital Emergency Cert IV Emergency Medical Technician Pre-Hospital Care Cert IV Aviation (Air-crewman) Cert IV Trainer & Assessor

Certificates Choose... Flight Medic Certified Advanced Trauma Certification Special Events Medical Certified Advanced Airway Certified CPR First Aid Advanced First Aid Advanced Resuscitation Drivers License Ambulance Drivers License Car Festival Drugs - An understanding for EMS Teams Harm Minimisation / Reduction Course EMS Advanced Drug & Alcohol Course Basic Drug Identification An Introduction to Street Drug Identification Adverse effects associated with Physical Restraint Administer and Monitor medicines & IV Drugs Hs & Ts of ACLS EMS Evacuation Training Advanced Life Support Crush Injury Course SMART Triage Course Respiratory Arrest Positional Asphyxia Quantitative Waveform Capnograpy Assessment and Management of the Acute Festival Patient Pathophysiology and Pharmacology of Common Drug presentations Focused Assessment Model for Acute Drug Presentations Best-Practice Treatment Strategies for Acute Drug Presentations Communications / Scene Management / Documentation

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Page 8 - Symptoms 4

Morbi tincidunt, dui sit amet facilisis feugiat, odio metus gravida ante, ut pharetra massa metus id nunc. Duis scelerisque molestie turpis. Sed fringilla, massa eget luctus malesuada, metus eros molestie lectus,

Team ID#

Verified Date

Status

Authority To Practice?:
Yes No

Supervision Required?:
Yes No

Previously Approved by MOH?:
Yes No

---

First Name

Middle Name

Last Name

AHPRA Registration No.

AHPRA Designation Choose... FACEM Emergency Doctor Senior Doctor General Practitioner Sports Doctor Registered Nurse (Div 1) Registered Nurse (Div 2) Registered Paramedic Registered Physiotherapist

Scope of Practice Choose... Event Medical Specialist Emergency Specialist Critical Care Paramedic Intensive Care Paramedic Clinical Nurse Specialist ICU Nurse Emergency Nurse Paramedic Specialist None

Post Graduate Years

Event Years

---

Non Registered Designation Choose... Event Medic (lodged) EMT Medical Support Liaison Controller First Aid Desk

Certifications Choose... Working With Children Criminal History Check Event Medic ACLS PHTLS ALS Adv Airway BLS Adv First Aid First Aid CPR Certified Harm Reduction Drug & Alcohol Adv Trauma

Qualifications Choose... Faculty of Pre-Hospital Care - The Royal College of Surgeons of Edinburgh P5 Event Medic Certification - American Academy of Event Medicine Advanced Diploma of Paramedical Science Advanced Diploma of Event Medicine Advanced Diploma of Public Safety (Emergency Management) Advanced Diploma of Mass Gathering Medicine Diploma of Applied Science (Nursing) Diploma of Paramedical Science Diploma of Occupational Health & Safety Diploma of Training & Education Diploma of Business Cert IV in Pre-Hospital Emergency Cert IV Emergency Medical Technician Pre-Hospital Care Cert IV Aviation (Air-crewman) Cert IV Trainer & Assessor

Certificates Choose... Flight Medic Certified Advanced Trauma Certification Special Events Medical Certified Advanced Airway Certified CPR First Aid Advanced First Aid Advanced Resuscitation Drivers License Ambulance Drivers License Car Festival Drugs - An understanding for EMS Teams Harm Minimisation / Reduction Course EMS Advanced Drug & Alcohol Course Basic Drug Identification An Introduction to Street Drug Identification Adverse effects associated with Physical Restraint Administer and Monitor medicines & IV Drugs Hs & Ts of ACLS EMS Evacuation Training Advanced Life Support Crush Injury Course SMART Triage Course Respiratory Arrest Positional Asphyxia Quantitative Waveform Capnograpy Assessment and Management of the Acute Festival Patient Pathophysiology and Pharmacology of Common Drug presentations Focused Assessment Model for Acute Drug Presentations Best-Practice Treatment Strategies for Acute Drug Presentations Communications / Scene Management / Documentation

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Page 9 - Symptoms 5

Morbi tincidunt, dui sit amet facilisis feugiat, odio metus gravida ante, ut pharetra massa metus id nunc. Duis scelerisque molestie turpis. Sed fringilla, massa eget luctus malesuada, metus eros molestie lectus,

Team ID#

Verified Date

Status

Authority To Practice?:
Yes No

Supervision Required?:
Yes No

Previously Approved by MOH?:
Yes No

---

First Name

Middle Name

Last Name

AHPRA Registration No.

AHPRA Designation Choose... FACEM Emergency Doctor Senior Doctor General Practitioner Sports Doctor Registered Nurse (Div 1) Registered Nurse (Div 2) Registered Paramedic Registered Physiotherapist

Scope of Practice Choose... Event Medical Specialist Emergency Specialist Critical Care Paramedic Intensive Care Paramedic Clinical Nurse Specialist ICU Nurse Emergency Nurse Paramedic Specialist None

Post Graduate Years

Event Years

---

Non Registered Designation Choose... Event Medic (lodged) EMT Medical Support Liaison Controller First Aid Desk

Certifications Choose... Working With Children Criminal History Check Event Medic ACLS PHTLS ALS Adv Airway BLS Adv First Aid First Aid CPR Certified Harm Reduction Drug & Alcohol Adv Trauma

Qualifications Choose... Faculty of Pre-Hospital Care - The Royal College of Surgeons of Edinburgh P5 Event Medic Certification - American Academy of Event Medicine Advanced Diploma of Paramedical Science Advanced Diploma of Event Medicine Advanced Diploma of Public Safety (Emergency Management) Advanced Diploma of Mass Gathering Medicine Diploma of Applied Science (Nursing) Diploma of Paramedical Science Diploma of Occupational Health & Safety Diploma of Training & Education Diploma of Business Cert IV in Pre-Hospital Emergency Cert IV Emergency Medical Technician Pre-Hospital Care Cert IV Aviation (Air-crewman) Cert IV Trainer & Assessor

Certificates Choose... Flight Medic Certified Advanced Trauma Certification Special Events Medical Certified Advanced Airway Certified CPR First Aid Advanced First Aid Advanced Resuscitation Drivers License Ambulance Drivers License Car Festival Drugs - An understanding for EMS Teams Harm Minimisation / Reduction Course EMS Advanced Drug & Alcohol Course Basic Drug Identification An Introduction to Street Drug Identification Adverse effects associated with Physical Restraint Administer and Monitor medicines & IV Drugs Hs & Ts of ACLS EMS Evacuation Training Advanced Life Support Crush Injury Course SMART Triage Course Respiratory Arrest Positional Asphyxia Quantitative Waveform Capnograpy Assessment and Management of the Acute Festival Patient Pathophysiology and Pharmacology of Common Drug presentations Focused Assessment Model for Acute Drug Presentations Best-Practice Treatment Strategies for Acute Drug Presentations Communications / Scene Management / Documentation

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Page 10 - Symptoms 6

Morbi tincidunt, dui sit amet facilisis feugiat, odio metus gravida ante, ut pharetra massa metus id nunc. Duis scelerisque molestie turpis. Sed fringilla, massa eget luctus malesuada, metus eros molestie lectus,

Team ID#

Verified Date

Status

Authority To Practice?:
Yes No

Supervision Required?:
Yes No

Previously Approved by MOH?:
Yes No

---

First Name

Middle Name

Last Name

AHPRA Registration No.

AHPRA Designation Choose... FACEM Emergency Doctor Senior Doctor General Practitioner Sports Doctor Registered Nurse (Div 1) Registered Nurse (Div 2) Registered Paramedic Registered Physiotherapist

Scope of Practice Choose... Event Medical Specialist Emergency Specialist Critical Care Paramedic Intensive Care Paramedic Clinical Nurse Specialist ICU Nurse Emergency Nurse Paramedic Specialist None

Post Graduate Years

Event Years

---

Non Registered Designation Choose... Event Medic (lodged) EMT Medical Support Liaison Controller First Aid Desk

Certifications Choose... Working With Children Criminal History Check Event Medic ACLS PHTLS ALS Adv Airway BLS Adv First Aid First Aid CPR Certified Harm Reduction Drug & Alcohol Adv Trauma

Qualifications Choose... Faculty of Pre-Hospital Care - The Royal College of Surgeons of Edinburgh P5 Event Medic Certification - American Academy of Event Medicine Advanced Diploma of Paramedical Science Advanced Diploma of Event Medicine Advanced Diploma of Public Safety (Emergency Management) Advanced Diploma of Mass Gathering Medicine Diploma of Applied Science (Nursing) Diploma of Paramedical Science Diploma of Occupational Health & Safety Diploma of Training & Education Diploma of Business Cert IV in Pre-Hospital Emergency Cert IV Emergency Medical Technician Pre-Hospital Care Cert IV Aviation (Air-crewman) Cert IV Trainer & Assessor

Certificates Choose... Flight Medic Certified Advanced Trauma Certification Special Events Medical Certified Advanced Airway Certified CPR First Aid Advanced First Aid Advanced Resuscitation Drivers License Ambulance Drivers License Car Festival Drugs - An understanding for EMS Teams Harm Minimisation / Reduction Course EMS Advanced Drug & Alcohol Course Basic Drug Identification An Introduction to Street Drug Identification Adverse effects associated with Physical Restraint Administer and Monitor medicines & IV Drugs Hs & Ts of ACLS EMS Evacuation Training Advanced Life Support Crush Injury Course SMART Triage Course Respiratory Arrest Positional Asphyxia Quantitative Waveform Capnograpy Assessment and Management of the Acute Festival Patient Pathophysiology and Pharmacology of Common Drug presentations Focused Assessment Model for Acute Drug Presentations Best-Practice Treatment Strategies for Acute Drug Presentations Communications / Scene Management / Documentation

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Page 11 - Authority

Morbi tincidunt, dui sit amet facilisis feugiat, odio metus gravida ante, ut pharetra massa metus id nunc. Duis scelerisque molestie turpis. Sed fringilla, massa eget luctus malesuada, metus eros molestie lectus,

Team ID#

Verified Date

Status

Authority To Practice?:
Yes No

Supervision Required?:
Yes No

Previously Approved by MOH?:
Yes No

---

First Name

Middle Name

Last Name

AHPRA Registration No.

AHPRA Designation Choose... FACEM Emergency Doctor Senior Doctor General Practitioner Sports Doctor Registered Nurse (Div 1) Registered Nurse (Div 2) Registered Paramedic Registered Physiotherapist

Scope of Practice Choose... Event Medical Specialist Emergency Specialist Critical Care Paramedic Intensive Care Paramedic Clinical Nurse Specialist ICU Nurse Emergency Nurse Paramedic Specialist None

Post Graduate Years

Event Years

---

Non Registered Designation Choose... Event Medic (lodged) EMT Medical Support Liaison Controller First Aid Desk

Certifications Choose... Working With Children Criminal History Check Event Medic ACLS PHTLS ALS Adv Airway BLS Adv First Aid First Aid CPR Certified Harm Reduction Drug & Alcohol Adv Trauma

Qualifications Choose... Faculty of Pre-Hospital Care - The Royal College of Surgeons of Edinburgh P5 Event Medic Certification - American Academy of Event Medicine Advanced Diploma of Paramedical Science Advanced Diploma of Event Medicine Advanced Diploma of Public Safety (Emergency Management) Advanced Diploma of Mass Gathering Medicine Diploma of Applied Science (Nursing) Diploma of Paramedical Science Diploma of Occupational Health & Safety Diploma of Training & Education Diploma of Business Cert IV in Pre-Hospital Emergency Cert IV Emergency Medical Technician Pre-Hospital Care Cert IV Aviation (Air-crewman) Cert IV Trainer & Assessor

Certificates Choose... Flight Medic Certified Advanced Trauma Certification Special Events Medical Certified Advanced Airway Certified CPR First Aid Advanced First Aid Advanced Resuscitation Drivers License Ambulance Drivers License Car Festival Drugs - An understanding for EMS Teams Harm Minimisation / Reduction Course EMS Advanced Drug & Alcohol Course Basic Drug Identification An Introduction to Street Drug Identification Adverse effects associated with Physical Restraint Administer and Monitor medicines & IV Drugs Hs & Ts of ACLS EMS Evacuation Training Advanced Life Support Crush Injury Course SMART Triage Course Respiratory Arrest Positional Asphyxia Quantitative Waveform Capnograpy Assessment and Management of the Acute Festival Patient Pathophysiology and Pharmacology of Common Drug presentations Focused Assessment Model for Acute Drug Presentations Best-Practice Treatment Strategies for Acute Drug Presentations Communications / Scene Management / Documentation

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