Poisons permit application
Anaesthetic technician
Poisons Regulation 10AA or 10A
Poisons Act 1964
For enquiries or assistance with completing this form, please contact the Medicines and Poisons
Regulation Branch on 9222 6883 or email [email protected].
Applicants please note:
1.
Only qualified anaesthetic technicians employed by a public or private hospital in an
anaesthetic technician position will be issued with a permit for Schedule 8 medicines.
2.
All anaesthetic technicians employed by a private hospital must provide a recent (within 3
years) National Police Clearance as part of their application. Criminal records screening is
a mandatory condition of employment for all Government employees.
3.
Permits are issued for the purpose of an anaesthetic technician accessing the storage
location for Schedule 8 medicines (including keys) and completing the Schedule 8
register. A permit does not authorise an anaesthetic technician to administer doses to a
patient.
4.
Penalties apply for providing false or misleading information in this application under
Section 35 of the Poisons Act 1964.
5.
It is the responsibility of the permit holder to ensure compliance with the Act and Poisons
Regulations 1965, and compliance with conditions placed on the permit.
1. Applicant
Title:
Surname:
Hospital:
Premises address:
Premises suburb:
Telephone:
Email:
Postal address the same as above?
Postal address:
Postal suburb:
Forename/s:
Postcode
:
Fax:
Yes
No
Postcode:
2. Employment and training
Please attach copy of certificate showing attainment of Certificate IV in Anaesthetic
Technology or equivalent.
Please tick to confirm applicant is employed at the Hospital in an anaesthetic technician
position.
Please attach documentation to confirm applicant has satisfactorily completed a drug
calculation test.
(Private hospital ONLY) Please attach a copy of a recent (within 3 years) National Police
Clearance
Poisons permit application Anaesthetic
technician
page 2 of 3
3. Other required documentation
Please tick to confirm applicant is familiar with any hospital policies and procedures
relating to anaesthetic technicians and medications
Please attach a letter signed by the Medical Director of the Department of Anaesthetics
and the Chief Pharmacist for the Hospital recommending the applicant for a poisons permit
and confirming all relevant training and assessment has been completed.
5. Declaration
I,
provide full name
of:
provide full address
hereby declare:
i.
I am over 21 years of age.
ii.
The information contained in this application form to be true and correct.
iii.
I am aware that penalties apply under section 35 of the Poisons Act 1964 for providing
false or misleading information in this application.
iv.
I am familiar with the provisions of the Poisons Act 1964 and Poisons Regulations 1965
relevant to the poisons to which this application relates.
v.
As permit holder I am aware of my responsibility for the safe storage and use of poisons
and will ensure compliance with the Poisons Act 1964 and Poisons Regulations 1965,
and compliance with conditions placed on the permit.
vi.
I will notify the Department of Health if details on this form change including:
if the permit holder leaves employment or takes extended leave
if there is a change of premises or storage address
when additional poisons are required
Signature of applicant:
Date:
Poisons permit application Anaesthetic
technician
page 3 of 3
Payment options
Application fee (private hospital):
1 year: $265, 3 years: $398
Application fee (public hospital):
No fee
Cheque or money order – made payable to: DEPARTMENT OF HEALTH
Credit card - American Express and Diners not accepted
Card type:
Mastercard
Visa
Name on card:
Amount :
$265
Card number:
Expiry date:
Signature of cardholder:
Date:
Direct debit to bank
Bank: Commonwealth Bank
BSB: 066 040
Amount:
$265
$398
Receipt Number:
Account number: 13300018
Payment date:
Submission
Private hospital application
Please post completed form to:
Health Corporate Network
PO Box 8549
PERTH BUSINESS CENTRE WA 6849
Payment enquiries: 1300 367 132
Public hospital application ONLY
Post completed form to:
Medicines and Poisons Regulation Branch
Department of Health
PO Box 8172
PERTH BUSINESS CENTRE WA 6849
2015 Updated July 2016
$398