Queensland Ambulance Service Pre Clinical Placement checklist

This form is mandatory and is required to be completed by each undergraduate paramedicine student prior to each clinical placement with the Queensland Ambulance Service.

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The following form is to be completed by all paramedicine students prior to each Clinical Placement with the Queensland Ambulance Service (QAS)
Privacy Notice:

Personal information collected by the Department of Health (Queensland Ambulance Service) (QAS) is handled in accordance with the Information Privacy Act 2009. QAS is collecting information about you regarding your training.
All personal information will be securely stored and only accessible by authorised officers of the QAS Education Centre.
Your personal information collected on this form will not be disclosed to other third parties without consent, unless required by law.
Failure to provide the information requested on this form may delay or result in it not being processed.
For information about how the QAS protects your personal information, or to learn more about your right to access your own personal information, please see our QAS Portal Privacy page and follow the Privacy links.
Name * First Last
Enter your First and Last Name

(Please DO NOT use shortened versions of your name ie. if your name is Benjamin, do not call yourself Ben as the system will only match complete names).
University student number (in full) *

Please use your student number exactly as your university has assigned you including leading letters and zeros e.g. U0123456 must be used and not just 123456
University Name *
University email address (NO personal email accounts i.e. hotmail or gmail etc) *

please ONLY use your university email address. please do not use any personal email accounts like Gmail or Hotmail etc
ACU email address (NO personal email accounts i.e. hotmail or gmail etc) *

please ONLY use your university email address. please do not use any personal email accounts like Gmail or Hotmail etc
CQU email address (NO personal email accounts i.e. hotmail or gmail etc) *

please ONLY use your university email address. please do not use any personal email accounts like Gmail or Hotmail etc
Griffith University email address (NO personal email accounts i.e. hotmail or gmail etc) *

please ONLY use your university email address. please do not use any personal email accounts like Gmail or Hotmail etc
QUT university email address (NO personal email accounts i.e. hotmail or gmail etc) *

please ONLY use your university email address. please do not use any personal email accounts like Gmail or Hotmail etc
USQ university email address (NO personal email accounts i.e. hotmail or gmail etc) *

please ONLY use your university email address. please do not use any personal email accounts like Gmail or Hotmail etc
USC university email address (NO personal email accounts i.e. hotmail or gmail etc) *

please ONLY use your university email address. please do not use any personal email accounts like Gmail or Hotmail etc
University unit code:
The Queensland Ambulance Service (QAS) requires you to review the Student Orientation Requirements section on the QAS website prior to your placement. Please ensure that you have read and understood them before completing the checklist below.

Please tick the boxes to indicate the areas you have read, understood, and where necessary completed the requirements. By submitting this document you are agreeing to comply with the necessary policies, procedures and guidelines of the QAS whilst on Clinical Placement.
*
I have completed and passed the necessary assessments including the Medical Assessment I have read and understood my obligations under the Code of Conduct of both my university and the Queensland Ambulance Service I understand and agree to comply with the QAS Infection Control procedures and have completed the necessary immunisation requirements I have read and agree to comply with the Workplace Health and Safety legislation and guidelines I understand my responsibilities in relation to privacy, confidentiality and documentation I understand I am not permitted to comment on any social media sites information pertaining to my experience whilst on clinical placement with the Queensland Ambulance Service I understand that I am required to have with me at all times, whilst on a clinical placement with the QAS, a colour printed Clinical Scope of Practice which my host university has endorsed. I understand that at the commencement of my assigned clinical placement, I am to present to my relevant Officer-In-Charge and assigned clinical supervisor a copy of the Clinical Assessment Tool (or equivalent) and discuss what activities are required to be covered during the assigned clinical placement. I understand that I am required to possess a Queensland Government issued Blue Card for the entire period that I am on placement with the QAS. I understand that I must wear, at all times, my university issued student ID that shows my full name and photo
Blue Card expiry date * / DD / MM YYYY
Has your health status changed since your formal medical assessment with the QAS approved medical provider? *

Has your health status changed since your formal medical assessment with the QAS approved medical provider? Yes No
You must contact your clinical placement coordinator at your university to arrange a supplementary medical assessment with the QAS approved medical provider.

A supplementary medical assessment must be successfully completed prior to commencing clinical placement again with the QAS.

Queensland Ambulance Service Pre Clinical Placement checklist

Queensland Ambulance Service Pre Clinical Placement checklist

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The following form is to be completed by all paramedicine students prior to each Clinical Placement with the Queensland Ambulance Service (QAS)

Privacy Notice:

You must contact your clinical placement coordinator at your university to arrange a supplementary medical assessment with the QAS approved medical provider. A supplementary medical assessment must be successfully completed prior to commencing clinical placement again with the QAS.

You must contact your clinical placement coordinator at your university to arrange a supplementary medical assessment with the QAS approved medical provider.

A supplementary medical assessment must be successfully completed prior to commencing clinical placement again with the QAS.