Application for approval to carry out scheme function

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

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

Version 1 – effective 1 March 2019 (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 26 February 2019.

Questions marked with * must be completed.

Provider details
What is your provider type? *

Please select one option.

Are you or your practice/organisation currently registered with DNRME under the voluntary registration scheme for this provider type? *
Applicant’s details

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.

Upload your letter of authority
* 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.
Company/other entity details (if applicable)
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.

Criteria

Part A – Appropriately qualified

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

Please note you must be accredited in order to submit this application.

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 8000 reads over 4 years
  • successfully completing the NIOSH B-reader retest every 4 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 diagnostic and interventional 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? *
Are you enrolled in the EMO training program? *
By ticking this box you confirm that you are aware of the CMWHS 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 coal mine workers (PDF, 567.3KB). 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:

Registration with AHPRA
Do you have any conditions, undertakings or reprimands noted on your registration with AHPRA? *
Are you subject to any current disciplinary or other legal proceedings relating to your role? *
Other
Have you, your practice/organisation or any relevant employees (being radiographers or persons providing spirometry or spirometry training) been convicted of an offence against the Coal Mining Safety and Health Act 1999 (Qld) or Coal Mining Safety and Health Regulation 2017 (Qld)? *
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 other departments, agencies or organisations.

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 acknowledge that I can change this authorisation at any time by notifying the Department of Natural Resources, Mines and Energy in writing.
Privacy statement

The Department of Natural Resources, Mines and Energy 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 the Department of Natural Resources, Mines and Energy to collect personal information for this purpose. The Department of Natural Resources, Mines and Energy 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 the Department'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 the Department's privacy policy, accessible at www.dnrme.qld.gov.au/home/legal/privacy.

Authority to disclose information
Confidentiality

The Department of Natural Resources, Mines and Energy 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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