PRINCIPAL INVESTIGATOR
Associate Professor Brenda Govan
PROJECT TITLE
Research Immersion Program
SCHOOL
Biomedical Sciences
CONTACT DETAILS
Biomedical Sciences Building 97 Room 008 ext. 15607
Student as asked to work with microorganism in a PC2 facility (please see research immersion student
manual for full details). Time commitments for this program is 5 days. Information collected in this
program is solely for the student to create a PowerPoint or Poster presentation and gain research
experience.
I agree that if I have a medical condition which might be affected, exacerbated or preclude me I will
inform the supervisor in charge and I shall abstain from participation. I am aware that any information
I give is confidential.
Do you have or aware of any medical conditions that might be affected, exacerbated or preclude you
from participating in the research immersion program (please indicate in the space provided);
Medical conditions (if applicable):
_________________________________________________________________________________
If you have indicated a potential medical condition and you wise to participate you must inform and
discuss with your academic supervisor in charge of your project before the undertaking of any task.
The aim of this project have been clearly explained to me.
I understand what is wanted of me.
I know that taking part is this is voluntary and I am aware that I need not participate and can stop at
any time without affect my completion of the program.
I have read the research immersion student manual and agree to participate in all activities described
in the manual.
I understand that every effort is made to keep my information confidential but this cannot be assured
in every case and no names will be used to identify me with this without my approval.
Student name (printed):
Student signature:
Date:
Guardian name (printed):
Guardian signature:
Date:
Relationship to student:
INFORMED CONSENT FROM
James Cook University
TOWNSVILLE Queensland Australia Telephone: (07) 4781 4111
Talent Release Form 2018
I (name) ________________________, hereby consent for James Cook University to use any
photograph and/or video footage taken of me or provided by me, whole or in part; recordings of my
voice and/or written extraction, whole or in part of such recordings; and to use the information
contained therein for any purpose in connection to learning and teaching including but not limited to:
study guides, websites, social media and other forms of media.
By signing this form I agree that electronic and/or hard copy of photographic images and/or recordings
of me and/or my profile are collected and stored for the purposes above.
I understand that the images and/or recordings of me and/or my profile will only be accessed by James
Cook University employees, including persons acting under its permission or authority, such as
commissioned agency.
I acknowledge that the information I have provided may be used to contact me; however, my details
will not pass on to any third party without your approval.
I waive any right to inspect or approve of the finished product, including written copy that may
appear in connection with my images and/or recordings of me and/or profile.
I understand that the use of the images and/or recordings of me and/or my profile does not give me
any right to request payment and that no payment will be made to me in return for reproduction of
any such image, recording or profile.
I have read and understood the terms of this release.
Student name (printed):
________________________________________________________________________________________
Student signature:
_____________________________________________________________
Date:
______________________
Please complete this section if the model is a minor:
I am the parent or guardian of the minor named in the release above and have legal authority to execute the
above release. I hear by approve the foregoing on behalf of the above named minor.
Guardian name (printed):
_____________________________________________________________________________________
Guardian signature:
____________________________________________________________
Date:
______________________
College of Public Health, Medical & Veterinary Sciences
James Cook University
G
eneral PC2 Laboratory Induction for Veterinary & Biomedicine Precinct
Y
ou must read and observe these instructions. Please tick beside each
instruction to indicate your understanding, sign and date the form.
A
ll persons entering the PC2 Laboratory must act in a safe and professional manner at all times.
Fully enclosed shoes, covering the dorsal surface of the foot to the ankle and heel must be worn
at all times in the laboratory.
A laboratory gown must be worn at all times in the laboratory as this is a requirement of the
PC2 laboratory regardless of the nature of the work being completed. Lab gowns must be
removed before leaving the laboratory and put on the hooks provided.
Cuts and abrasions, especially on the hands, must be covered with a waterproof dressing or
band-aid prior to entering the laboratory.
Disposable gloves must be used if hazardous chemicals, animal tissue, products of animal
tissues, and animal or human body fluids are used.
Safety glasses must be worn in the PC2 lab if you are instructed to do so.
Hair longer than shoulder length must be tied back and loose jewelry removed.
Hands must be washed every time you leave the laboratory, except in the case of a fire.
All equipment failures are to be reported immediately to the person in charge.
All incidents and hazards must be reported to the person in charge immediately. An incident
report must be generated ASAP.
All sharps must be placed in the sharps disposal bins (yellow with red lids).
All biohazard waste must be disposed of correctly.
All stools must be place under a bench or out of the way when work is completed.
If the firm alarm sounds, evacuate the laboratory immediately via the exits and assemble where
instructed. Do not return to the building or wander off until advised to by the authorities that
it is safe to do so.
Be familiar with the location of the safety showers, eye wash and spill kit locations.
T
he following is forbidden in the Laboratory:
Eating and drinking, smoking, applying cosmetics
Use of mobile phones, calculators and timer functions
Bags or handbags, hats
T
he following is permitted on the condition your recognize items bought into the PC2 Lab may
become contaminated and used at your own risk: Laptops, IPad, tablets, or other electronic devices.
Y
ou will be instructed to leave the facilities if your conduct is deemed dangerous or disruptive.
Y
ou will comply with the instructions or direction of university staff.
Name of person inducted (printed):
Signature:
Date:
Supervisor (printed):
Signature:
Date:
To be completed on first day of course by student and supervisor
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signature
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Parent / Carer Authority, Consent and Release – JCU Work Experience
I consent to my son/daughter __________________________________ attending James Cook University for the
purposes of obtaining work experience (“the Work Experience”).
Exclusion of Liability Provision
Whilst JCU will take all reasonable care to avoid injury to persons or damage to or loss of property during the Work
Experience
, JCU will not be liable for personal injury or property loss or damage of any kind whatsoever.
I confirm that I have read the exclusion of liability provision (see above paragraph) and by signing this Form
release JCU and its employees, contractors, agents and successors in title free from any and all liabilities,
claims or actions whatsoever or however caused, arising as a result of or in connection with, directly or
indirectly, my child’s participation in the Work Experience.
Accident, Illness or Damage
In the event of an accident or illness, I give permission for JCU employees to obtain or administer any medical
assistance or treatment that my child may reasonably require. Should this be necessary, I understand that I will be
notified as soon as possible and I accept liability for all reasonable costs incurred by JCU in obtaining such medical
assistance or treatment (including any transportation costs) and undertake to reimburse JCU the full amount of those
costs.
I agr
ee that if my child demonstrates any behaviour that is disruptive or negative in the opinion of JCU during the
Work Experience, I will accept the early return of my child and will collect my child from the campus at my own
expense.
I
agree that my child will be required to observe all directions given by JCU supervisors with respect to safety, the
use of JCU equipment and facilities and interaction with other persons (including other students) during the Work
Experience.
I agree to compensate JCU and any other owner of property for any damage that my child willfully or negligently
causes to their property during the Work Experience.
Us
e of Photographs and/or Video/Digital Footage
I understand that JCU and/or your school may wish to take photographs and/or video/digital footage (“the Images”)
o
f my child participating in the Work Experience, to store those Images and to use those Images in the promotion
of the Work Experience and JCU and Northern Beaches State High School.
By signing this Form, I give permission for JCU and/or your school to take Images of my child
participating in the Work Experience and to use the Images in the promotion of the Work
Experience and JCU and your school generally on TV, radio or in newspapers, in trade and other journals
and on the internet.
Si
gned: _____________________________ Date:___________________
Name:
______________________________ (Mother/Father/Carer) Telephone: __________________
Does your child have any medical requirement (please circle)? Yes No
If
Yes provide details:
______________
_________________________________________________________________________
Privacy Notice
James Cook University (JCU) is collecting the personal information requested in this form in order to:
- obtain lawful consent for your child to participate in the Work Experience;
- help coordinate the Work Experience;
- respond to any injury or medical condition that may arise during, or as a result of the Work Experience;
- for the other purposes set out in this form.
The information will only be accessed by authorised JCU employees and contractors and will be dealt with in accordance with the requirements
of the Information Privacy Act 2009 (Qld).
The information will not be disclosed to any other person or agency unless it is for a purpose stated above, the disclosure is authorised or
required by law, or you have given JCU permission for the information to be disclosed.
Your rights to access and amend your personal information are set out in the Information Privacy Act 2009 (Qld) which also places obligations
on JCU as to how we handle your personal information. For further information concerning privacy please direct your inquiries to Division of
Tropical Health and Medicine at dthmplacements@jcu.edu.au.
Confidentiality Acknowledgement JCU Work Experience
Student Name: …….………………………………
I
acknowledge that whilst I am undertaking work experience at James Cook University (JCU) I may hav
e
ac
cess to confidential and personal information about JCU or clients of JCU.
I
understand the obligation of confidentiality of information concerning JCU and the personal affairs of
clients of JCU.
I will not at any time disclose any Confidential Information or Personal Information relating to JCU or
a
c
lient of JCU that I become aware of during my work experience unless the disclosure of the information:
(a)
i
s necessary to enable an employee of JCU or I to perform our duties; or
(b)
i
s for the purpose of obtaining legal advice from a registered legal practitioner; or
(c) is required pursuant to an order of a Court, Commission or Tribunal; or
(d)
i
s in accordance with the Privacy Act 1988 (Cth) and the Information Privacy Act 2009 (Qld).
I will not disclose any private or commercial information (eg. relating to JCU or JCU staff or clients) that I
b
ecome aware of (regardless of how obtained) during the work experience.
I will not remove from the premises of JCU, any written or hardcopy documents/files or any electronic files,
which belong to JCU, including those which may contain Confidential Information or Personal Information
relating to a client of JCU or the operation of JCU.
I
will not make any record(s) (other than on documents or files which belong to JCU), during or after
completion of my work experience, which may identify any clients of JCU. I further undertake not t
o
r
emove from the premises of JCU any written or hardcopy documents/files or any electronic files which I
have prepared during my work experience and which may identify a client of JCU. I acknowledge that i
n
or
der to ensure a client is not identifiable; I must not record any of the following details where the recording
of one or more of the details would enable the client to be identified:
(a) the name of the client;
(b) initials of the client’s name;
(c) the client’s date of birth;
(d) any names of the client’s relatives;
(e) the name or details of JCU; or
(f) the names or details of any of JCU’s staff
.
I will not publish on social media (including Facebook, Twitter, or any other social media website) any
photographs, details or information of any kind, which I have gained or observed during my work
experience. I also undertake not to discuss any details or information gained or observed during my work
experience which may identify a client of JCU.
Confidential Information includes, but is not limited to:
(a)
i
nformation which by its very nature might be reasonably understood to be confidential or to have bee
n
di
sclosed in confidence;
(b)
i
nformation which JCU indicates is confidential;
(c)
i
nformation which relates to any arrangements or transactions between JCU and its clients;
(d)
i
nformation which would be of a commercial value to a competitor of JCU; or
(e)
al
l records based on or incorporating information referred to in clauses (a) to (d).
P
ersonal Information’ is information or an opinion about an identified individual, or an individual who is
reasonably identifiable:
(a) whether the information or opinion is true or not;
and
(
b) whether the information or opinion is recorded in a material form or not.
S
ignature: ___________________ Date: _____________________
Guardian Signature: ___________________
Date: _____________________
By signing below you are the guardian of the above student and you understand the
responsibility of confidentiality asked of the above student.
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signature
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