Application for approval to carry out scheme function | Medical register

Application for approval to carry out scheme function

Form CMSHR 4 — Application for approval to carry out scheme function

Section 49I, Coal Mining Safety and Health Regulation 2017 (Qld)

Version 3 — effective 19 April 2023 (first published 1 March 2019)

This form was approved by the Chief Inspector of Coal Mines under section 281 of the Coal Mining Safety and Health Act 1999 on 15 November 2022.

Questions marked with * must be completed.

What is your provider type? *

Please select one option.

The application form must be completed by a person with proper authority, or a person who is properly authorised, to act on behalf of, and to bind, the legal entity owning the practice/organisation.

Where the person completing this form is a person with proper authority to act on behalf of, and to bind, the legal entity owning the practice/organisation (e.g. for a company, a director), no separate authority is required.

Where the person completing this form is authorised on behalf of a person with proper authority (e.g. a practice manager), please upload a letter of authority signed in accordance with section 127 of the Corporations Act 2001 (Cth) (i.e. signed by two directors or one director and a company secretary or, where the company has a sole director who is also the sole company secretary, that director, or under company seal), or a copy of the relevant Power of Attorney.

* 10 digits incl. area code for landlines
* 10 digits incl. area code for landlines
* We will use this email to contact you. Please check it regularly.
Practice/organisation not owned by company/other entity
9-digit ACN number
As it appears on the ASIC Register and not the physical address of the practice being registered.
Individual/practice/organisation details

These details will be displayed on the public register.

Please use the Application for registration of multiple practices (XLS) to list the practices.

Approval criteria

Part A — Appropriately qualified

Are you or your practice/organisation accredited with Quality Innovation Performance? *

This information is required to confirm your accreditation and must be provided for your application to be processed.

Please specify type *
Professional registrations
Are you a fellow of the Royal Australian and New Zealand College of Radiologists (RANZCR)?
B-reader training
Are you a certified National Institute for Occupational Safety and Health (NIOSH) B-reader in the use of the ILO Classification? *
By ticking this box you confirm that you will maintain B-reader proficiency by both: *
  • - completing a minimum of 8,000 reads over 4 years
  • - successfully completing the NIOSH B-reader retest every 5 years (or as required by NIOSH to maintain B-reader status).
Standards
By ticking this box, you confirm that you will comply with relevant requirements of the latest version of the RANZCR Standards of Practice for Clinical Radiology. *
By ticking this box, you confirm that you will examine digital chest X-rays to the ILO International Classification of Radiographs of Pneumoconioses and report in accordance with the Guidelines for the use of the ILO International Classification of Radiographs of Pneumoconioses. *
By ticking this box, you confirm that you will comply with the technical requirements set out in the Technical Requirements for B-readers (PDF, 67KB). *
Arrangement with Lungscreen Australia
By ticking this box, you confirm that you have an arrangement in place with Lungscreen Australia Pty Ltd, either directly or through another entity (e.g. X-ray imaging practice), to transfer chest X-ray images and completed ILO Classification reports in accordance with the Technical requirements for B-readers (PDF, 67KB). *
Please upload evidence of your arrangement with Lungscreen Australia or another entity that has an arrangement with Lungscreen Australia. (e.g. letter of arrangement between parties). *

You may upload JPG, PNG, or PDF files up to 3MB

Registration with AHPRA
Do you have a general or specialist registration with AHPRA? *
Have you enrolled and completed all modules of the RSHQ's Statutory Medicals for Mine and Quarry Workers training program? *

This information is required to confirm your enrolment and completion of the relevant modules and must be provided for your application to be processed.

By ticking this box you confirm that you are aware of the Mine Dust Lung Disease Clinical Pathways Guideline used by supervising doctors when carrying out health assessments for Queensland coal mine workers. *
By ticking this box you confirm that spirometry will be carried out by a registered spirometry practice in accordance with the Standards for the delivery of spirometry for resource sector workers. Apply for approval as a spirometry practice. *

Part B — Fit and proper

In deciding whether you or your practice/organisation are fit and proper to hold an approval to undertake a scheme function, the delegate may consider the following and other matters:

Do you have, or have you had in the past 10 years, any conditions, undertakings, cautions or reprimands noted on your registration with AHPRA? *
Has your registration with AHPRA been cancelled or suspended in the past 10 years?
Are you currently, or have you in the past 10 years, been the subject of any (a) disciplinary or other legal proceedings (including coronial proceedings or proceedings in a civil court); or (b) investigations, complaints, or notifications to a regulatory agency (including AHPRA or the Office of the Health Ombudsman), relating to a current or former patient (including any adverse outcomes or complications) or relating to your role? *
In the past 5 years, have you, your practice/organisation or any relevant employees (being radiographers or persons providing spirometry or spirometry training) been found liable for, or guilty of, an offence against the Coal Mining Safety and Health Act 1999 (Qld) or Coal Mining Safety and Health Regulation 2017 (Qld) (including an offence to which a civil penalty applies)? *
In the past 10 years, have you, your practice/organisation or any relevant employees (being radiographers or persons providing spirometry or spirometry training) been convicted of a criminal offence that is an indictable offence (i.e. a more serious offence usually heard in the District or Supreme Court)? *
In the past 5 years, have you, your practice/organisation or any relevant employees (being radiographers or persons providing spirometry or spirometry training) been convicted of a criminal offence that is a summary offence (i.e. a less serious offence usually heard in the Magistrates Court)? *
In the past 5 years, have you, your practice/organisation or any relevant employees (being radiographers or persons providing spirometry or spirometry training) had professional indemnity membership or insurance made conditional, not renewed or limited? *
Is there any other issue relevant (within the preceding 10 years) to whether you or your practice/organisation will likely carry out, or be perceived to carry out, the relevant scheme function to the standards expected of a person or practice engaged in the relevant profession including any issues relating to your or your practice/organisation’s ability to carry out the scheme function safely, competently and ethically? *
Is there any other issue relevant to whether you or your practice/organisation is fit and proper to carry out the scheme function? *
Declaration
The applicant / I on behalf of the applicant, the undersigned, declare(s) that: *
  • The applicant is fit and proper to hold an approval to carry out a scheme function.
  • The applicant is appropriately qualified to hold an approval to carry out a scheme function and currently meets, and will continue to meet, the qualification, training and experience requirements, including the accreditation requirements (if applicable).
  • The answers, information and attachments in this application are true and correct in every detail.
  • If the applicant has stated anything that is materially false or misleading, the application or any approval given to the applicant will be absolutely void and have no legal effect whatsoever.
  • The applicant consents to the issuing authority taking, keeping, and using the applicant's personal information and documents for the purposes associated with this application.
  • The applicant consents to the issuing authority verifying the answers, information and attachments in this application with government departments, agencies or organisations.
  • The applicant acknowledges they may be asked to provide copies of relevant decisions made by external agencies (e.g. Medical Board of Australia) in order to support the information provided and decide the application.

I acknowledge Queensland State Laws will accept this communication as containing the above applicant’s authority within the meaning of the Electronic Transactions (Queensland) Act 2001

Authority to disclose information
I authorise Resources Safety and Health Queensland to discuss my application and/or my approval details, and to disclose my personal information as necessary for that purpose with the following person/s. *

Please provide the details of any person you authorise. (e.g. representatives of your medical practice).

In addition to collecting information from government departments, agencies or organisations in order to verify the information contained in my application, I authorise Resources Safety and Health Queensland to collect personal information from the following persons.

Please provide the details of any person you authorise. (e.g. representatives of your medical practice).

I acknowledge that I can change this authorisation at any time by notifying Resources Safety and Health Queensland in writing.
Privacy statement

Resources Safety and Health Queensland is collecting your personal information for the purpose of administering the Coal Mine Workers’ Health Scheme, including to assess and decide applications for approval to carry out scheme functions and to manage and regulate approved providers under that scheme.

The Coal Mining Safety and Health Act 1999 (Qld) and Coal Mining Safety and Health Regulation 2017 (Qld) permits Resources Safety and Health Queensland to collect personal information for this purpose. Resources Safety and Health Queensland will only use your personal information for this purpose and in accordance with your authorisation in the application form, unless otherwise authorised or required by law.

Your name, address, the scheme function for which the approval is given and other information that the chief executive considers appropriate will be published on Resources Safety & Health Queensland's website in accordance with section 49X of the Coal Mining Safety and Health Regulation 2017 (Qld).

Your personal information will be handled in accordance with the Information Privacy Act 2009 (Qld) and Resources Safety & Health Queensland's privacy policy, accessible at www.rshq.qld.gov.au/privacy.

Authority to disclose information

On behalf of the applicant practice/organisation, I authorise Resources Safety and Health Queensland to discuss this application and/or the practice/organisation’s approval details, and to disclose any confidential information as necessary for that purpose, with the following persons.

Confidentiality

Resources Safety and Health Queensland is collecting this information to administer the Coal Mine Workers' Health Scheme, including to assess and decide applications for approval to carry out scheme functions and to manage and regulate approved providers under that scheme.

The information you have provided in this application form will be kept confidential and used only for this purpose unless otherwise authorised by the practice, or as authorised or required by law.

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