Fillable Application form Department of Health Application to the (Queensland Health)

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Application form Department of Health Application to the (Queensland Health)

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  • 20 check-boxes
  • 66 other fields

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Department of Health
Application form
Application to the Chief Executive for an approval for animal management and/or welfare
Page 1 of 4
Animal management/welfare – September 2020
Animal management and/or welfare form
This form is to be used to apply for an approval for
animal management and/or welfare purposes pursuant
to the Health (Drugs and Poisons) Regulation 1996.
Please print clearly or complete electronically, date and
sign. Answer all questions in full.
All documents requiring signature must bear the
original signature in ink and be retained by the
applicant.
Certified evidence of identity must be included with this
application such as a drivers licence, passport or Adult
Proof of Age Card.
Certified documents must bear the original signature,
name and occupation of an authorised identifier (i.e.
Justice of the Peace, Commissioner for Declarations,
police officer, solicitor or an officer from a local Public
Health Unit).
Applications must be scanned and emailed to
HARU@health.qld.gov.au and original documents
retained by the applicant to be produced if requested.
Information about the approval
Approvals will be granted to individuals
working/volunteering for or contracted to Government
agencies (local or State), prescribed entities under the
Animal Care and Protection Act 2001 or Animal Care
and Protection Regulation 2012, or entities who
possess a relevant permit from the Department of
Environment and Science or a licence for exhibited
animals from the Department of Agriculture and
Fisheries.
A separate application is required for an animal control
officer (employee) of a local government to possess
and administer Schedule 4 medicines.
Schedule 4 medicines used for euthanasia, sedation
prior to euthanasia, or transporting animals for
subsequent treatment by a registered veterinary
surgeon will be approved. See the list of medicines in
Section 7 of this form.
For applicants employed by certain government
agencies and the Royal Society for the Prevention of
Cruelty to Animals—Queensland, approval for the use
of Schedule 4 vaccines will also be considered. If you
require any additional medicines, please contact the
Department of Health.
Schedule 4 medicines are listed in the current
Standard for the Uniform Scheduling of Medicines and
Poisons (SUSMP) published by the Commonwealth
under the Therapeutic Goods Act 1989.
Approvals may be granted subject to certain conditions
as listed in the approval and the Guideline
– Animal welfare approval.
Further information is available via the Department of
Health or telephone (07) 3708 5264.
1. Purpose
Is the application for the Chief
Executive Officer of a local
government agency to obtain,
possess and issue Schedule 4
medicines to an employee of
the respective local
government (approval holder)?
Note: If yes, you do not need to
complete Sections 5 or 9.
Yes No
Does the applicant work for a
Government agency (local or
State Government)
Yes No
Does the applicant work for a
prescribed entity under the
Animal Care and Protection Act
2001 or Animal Care and
Protection Regulation 2012?
Yes No
Does the applicant work for an
organisation that possesses a
relevant permit from the
Department of Environment
and Science or a
licence from
the Department of Agriculture
and Fisheries?
Yes No
2. Reason/s for approval
3. Period of approval
Period for which approval is required (2 year maximum)
Continued Application to the Chief Executive for an approval for scheduled medicines for animal management and/or welfare
Page 2 of 4
A
nimal management/welfare - September 2020
4. Applicant details
Title Given name
Surname
Date of birth
Phone number
Mobile number
Email
Residential address
P/C State
Postal address Same as residential
P/C State
Current position (also state if you are employed,
contracted or a volunteer)
5. Qualifications and training
Refer to the Guideline – Animal welfare approval for
further information regarding qualifications and training.
Please tick all that apply:
I have Registered Training Organisation (RTO)
qualifications relevant to the safe administration
and use of scheduled medicines and have
attached a certified copy of my certificate of
successful completion.
I have received training from a Queensland
Registered Veterinary Surgeon
working/volunteering for or contracted to my
employer equivalent to RTO training competencies
and have attached a copy of a competency
checklist signed by the veterinary surgeon
indicating successful completion.
6. Employer details
Employer name
Company number (ACN)
Permit/Licence number (if
applicable)
Business name
Business address
P/C State
Postal address Same as business
P/C State
Contact person for approval at the entity
Title Given name
Surname
Contact email
Contact phone number
7. Scheduled medicines requested
What scheduled medicines are you requesting to use?
Please tick all that apply:
Alfaxalone (Alfaxan)
Zolazepam/tiletamine (Zoletil)
Acepromazine (ACP)
Xylazine (Xylazil)
Sodium Pentobarbitone (Lethabarb)
F3 Feline Herpes, Calicivirus, Panleukopenia
Continued Application to the Chief Executive for an approval for scheduled medicines for animal management and/or welfare
Page 3 of 4
C3 Distemper, Adenovirus, Parvo Living
C4 Distemper, Adenovirus, Parvo Living and
Parainfluenza Living
C5 Distemper, Adenovirus, Parvo Living,
Bordetella Bronchiseptica & Parainfluenza Living
8. Storage description
Schedule 4 medicines must be held at all times in secure,
locked storage. The keys to such storage must be kept in
the personal possession of the approval holder or an
authorised person. *Note: an inspection of
premises/storage conditions may be undertaken by an
authorised inspector of Queensland Health as part of the
approval process.
Identifying name (name of premises, building etc.)
Street address (include shed/unit number)
P/C State
Type of storage (details of vehicle, room, receptacle)
Security measures (lockable storage, key possession etc.)
9. Endorsement by veterinary surgeon
Note: This section does not apply if you are the Chief
Executive Officer of a local government.
This section is to be completed and signed by the
employer’s Queensland registered veterinary surgeon as
an endorsement that the applicant has current
competency to fulfil the requirements of the employer,
and to undertake activities with medicines as per the
employer’s protocol.
Further information for veterinary surgeons is provided in
the Guideline – Animal welfare approval.
I confirm that I have personally trained (applicant name)
in the administration and use of the Schedule 4 medicines
listed in Section 7, as per the employer’s protocol. I
believe the applicant is competent to follow the employer’s
protocol when administering and using these Schedule 4
medicines.
I confirm that I have endorsed the employer’s protocol for
the competencies required, and the procedures for the
safe and effective use of scheduled medicines.
Title Given name
Surname
Registration number
Email
Signature Date
10. Employer endorsement
This section needs to be completed by the applicant’s
employer or supervisor.
The named applicant is working/volunteering for or
contracted to
(insert employer’s name—the entity)
and is required to possess and administer the Schedule 4
medicines indicated on this form at Section 7 as part of
his/her animal welfare duties. A protocol document as
described in the Guideline – Animal welfare approval, has
been written or endorsed by a registered veterinary
surgeon working/volunteering for or contracted to the
entity.
The protocol has been submitted with this
application.
The protocol document will undergo appropriate
review, update and endorsement by a registered
veterinary surgeon every three years.
Proof of indemnity insurance cover has been
submitted with this application (where applicable).
Note: The Department of Health does not approve or
endorse protocol documents.
Employer/supervisor details
Title Given name
Surname
Animal management/welfare - September 2020
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signature
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Continued Application to the Chief Executive for an approval for scheduled medicines for animal management and/or welfare
Page 4 of 4
A
nimal management/welfare - September 2020
Contact number
Email
Signature
Date
11. Disclosure by the applicant
Have you, the applicant:
been convicted of an indictable
offence (drink driving and traffic
offences are not indictable
offences)?
Yes No
been convicted of an offence
against the Health Act 1937 or
the Health (Drugs & Poisons)
Regulation 1996 or a repealed
corresponding law?
Yes No
held an approval granted under
the Health (Drugs and Poisons)
Regulation 1996 or a repealed
provision or a corresponding
law that was suspended or
cancelled?
Yes No
ever been refused an approval
under the Health (Drugs and
Poisons) Regulation 1996 or a
repealed provision or a
corresponding law?
Yes No
*If any questions are answered ‘YES’, please attach
documentation that provides details of the offence, the nature of
the offence and the circumstances of its commission. Applicants
are advised that in order to ensure the requirements of Section
15 of the Health (Drugs and Poisons) Regulation 1996 are met,
the Department of Health may in certain circumstances, provide
the information contained in this application to relevant external
agencies.
12. Declaration
I consent to the making of enquiries of, and the
exchange of information with the authorities of
any State, Territory or Commonwealth
regarding any matters relevant to this
application.
I declare that the information stated by me on
this application form and accompanying this
application is true, correct and complete.
I understand and agree to comply with the
relevant provisions of Health (Drugs and
Poisons) Regulation 1996 and the Guideline –
Animal welfare approval.
Full name
Signature
Date
Applications must be forwarded by EMAIL to:
Chief Executive
Healthcare Approvals & Regulation Unit
HARU@health.qld.gov.au
Privacy Statement: The Department of Health provides this form
under the Health (Drugs and Poisons) Regulation 1996. The
information and documents collected for the purpose of this
application may be accessible by authorised departmental
persons. The department will not disclose your personal
information or supporting documents to third parties without your
consent unless required or authorised by law.
The Information Privacy Act 2009 sets out the rules for the
collection and handling of personal information by the
Department of Health. For information about how the
Department of Health protects your personal information, or to
learn about your right to access your own personal information,
please see our website.
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Application form Department of Health Application to the (Queensland Health)

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Completed 23 September 2021

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