participant enrolment form - revive2survive

Z:\R2S_Courses\22282VIC Management of Asthma Risks and Emergencies\Assessments\Course Pack 22282VIC V3.7 200320.docx

Please complete all sections of this form. The information contained on this form is completely private and confidential and is collected in accordance with Australian Government statistical collection requirements.

Course Code and Name: 22282VIC Course in the Management of Asthma Risks and Emergencies in the Workplace

Course Date: Course Venue:

PLEASE NOTE YOU MUST PROVIDE YOUR LEGAL NAME AS SHOWN ON YOUR DRIVER’S LICENSE OR OTHER ID DOCUMENT.

Title: Mr Mrs Ms Miss Dr Other

First Name/s:

Surname:

Date Of Birth: D D / M M / Y Y Y Y

Gender: Male Female Other

Residential address: MANDATORY FIELD

Suburb: MANDATORY FIELD

P/code: State:

Postal address: (if different from above):

Suburb/ locality / town: P/code: State:

Telephone Home: Work: Mobile:

Email Address:

Alternative Email: (optional)

Employer:

UNIQUE STUDENT IDENTIFIER (USI) RTOs are required to collect and validate a Unique Student Identifier from all participants. If participants do not provide a valid USI,

RTOs are not permitted to issue an accredited Statement of Attainment.

Please provide your Unique Student Identifier (USI)

In the event that I do not provide a valid USI, I give permission for

Revive2Survive First Aid to search the government website

www.usi.gov.au, so that my USI can be located and filed in my training

records.

LANGUAGE, EDUCATION, EMPLOYMENT AND CULTURAL DIVERSITY

In which country were you born: Australia Other, please specify...................................................

Are you of Aboriginal or Torres Strait Island origin? No Yes, Aboriginal Yes, Torres Strait Islander

Do you speak a language other than English at home: No, English only Other....................................

Proficiency in spoken English: Very Well Well Not well Not at all

Are you currently enrolled in secondary education? Yes No

Year highest school completed: Y Y Y Y

What is your highest COMPLETED level at school (TICK ONE BOX)

If you are currently enrolled in secondary education, the highest school level completed refers to the highest school level you have actually completed and not the level you are currently undertaking. For example, if you are currently in Year 10 the highest school level completed is Year 9.

Year 12 or equivalent Year 11 or equivalent Year 10 or equivalent Year 9 or equivalent Year 8 or below Never attended school

PARTICIPANT ENROLMENT FORM

REVIVE2SURVIVE FIRST AID TRAINING / WORKPLACE TRAINING SOLUTIONS- RTO 21688


Which BEST describes your current employment status? (TICK ONE BOX)

For casual, seasonal, contract and shift work, use the current number of hours worked per week to determine whether full time (35 hours or more per week) or part-time employed (less than 35 hours per week).

Full-time employee Part-time employee Self employed – not employing others Self employed – employing others Employed – unpaid worker in a family business Unemployed – seeking full-time work Unemployed – seeking part-time work Not employed – not seeking employment

Do you consider yourself to have a disability, impairment or long term condition that may affect your participation in the practice/ physical elements of this training course?

Yes No

If you indicated the presence of a disability, impairment or long-term condition, please select the area(s) in the following list. (You may include more than one area)

Hearing/deaf Physical Intellectual Learning Mental Illness Acquired brain impairment Vision Medical Condition Other

Have you completed any of the following qualifications? Yes No

If yes, tick ALL applicable boxes

Advanced diploma or associate degree level Bachelor degree or higher degree level Certificate I Certificate II Certificate III (or trade certificate) Certificate IV Diploma level Other education (including overseas qualification not listed)

From these categories, which best describes your main reason for undertaking the training? (TICK ONE BOX)

To get a job To develop my existing business To start my own business To try for a different career To get a better job or promotion It was a requirement of my job I wanted extra skills for my job To get into another course of study For personal interest/self-development To get skills for community/voluntary work Other reason/s……………………………………………………

PRIVACY NOTICE

Under the Data Provision Requirements 2012, Revive2Survive is required to collect personal information about you and to disclose that personal information to the National Centre for Vocational Education Research Ltd (NCVER). Your personal information (including the personal information contained on this enrolment form) may be used or disclosed by Revive2Survive for statistical, administrative, regulatory and research purposes. Revive2Survive may disclose your personal information for these purposes to:

Commonwealth and State or Territory government departments and authorised agencies; and

NCVER; Personal information that has been disclosed to NCVER may be used or disclosed by NCVER for the following purposes:

populating authenticated VET transcripts;

facilitating statistics and research relating to education, including surveys and data linkage;

pre-populating RTO student enrolment forms;

understanding how the VET market operates, for policy, workforce planning and consumer information; and

administering VET, including program administration, regulation, monitoring and evaluation. You may receive a student survey which may be administered by a government department or NCVER employee, agent or third party contractor or other authorised agencies. Please note you may opt out of the survey at the time of being contacted. NCVER will collect, hold, use and disclose your personal information in accordance with the Privacy Act 1988 (Cth), the National VET Data Policy and all NCVER policies and protocols (including those published on NCVER’s website at www.ncver.edu.au).

http://www.ncver.edu.au/


ASSESSMENT INSTRUCTIONS

You are required to answer all questions and complete all activities, including documentation. These assessments are to be your own work and will be marked by your trainer. Please ensure you sign and date below acknowledging all work is to be your own.

REFUNDS & CANCELLATIONS

Refer to the Student Handbook at www.Revive2Survive.com.au for details.

ALLERGIES AND INJURIES

Please notify your trainer PRIOR to training commencement if you have an allergy to latex, rubber or plastic, health issues, back or knee problems, or any condition or impairment which may hinder your ability to safely complete this course. I authorise any official from Revive2Survive in charge of first aid training, in the event of any injury or illness, to obtain on my behalf and at my expense, any medical assistance, treatment and transportation as deemed necessary. Please note to be assessed as competent in CPR you MUST be able to demonstrate CPR on the floor. If you have an injury that prevents you from demonstrating CPR on the floor you will be issued a non-accredited Statement of Attendance. It is your responsibility to exempt yourself from participation if you have any known injury or health concerns.

PARTICIPANT DECLARATION

I declare that the information I have provided to the best of my knowledge is true, correct and complete.

I understand the required fees and charges applicable to my course, and the implications of withdrawing in accordance with Revive2Survive

refund and cancellations policies.

I have read and understand the information provided in the Student Handbook available from the Revive2Survive website.

I accept Revive2Survive’s Privacy Policy and other policies and guidelines in the Student Handbook on the Revive2Survive website.

I am aware of the theory assessment obligations for the course in which I am enrolling and agree to the requirements.

I consent to Revive2Survive providing the Australian Government and relevant regulatory authorities with information concerning my

enrolment and academic results.

I consent to my employer being provided with a copy of my statement of attainment (if applicable).

I understand that Revive2Survive will not provide my personal information to any other outside parties without my consent, except if required

to do so by law.

I consent to the collection, use and disclosure of my personal information in accordance with the Privacy Notice above.

I am aware that I will be required to provide a Unique Student Identifier (USI) before I can be issued with my Statement of Attainment. In the

event that I do not provide a valid USI, I give permission for Revive2Survive First Aid to search the government website www.usi.gov.au, so that

my USI can be located and filed in my training records.

I understand that I may receive a National Centre for Vocational Educational Research (NCVER) student survey.

I give permission for Revive2Survive to use my feedback comments in testimonials on their website and social media.

I agree that Revive2Survive and its respective trainers and course participants, are absolved from all liability, however arising from injury or

damage to me, however caused whilst participating in the first aid course.

I agree to the terms above. (Please tick.)

Applicant’s Name……………………………………………................ Applicant’s Signature……………….……………..……………..………………… Parent/Guardian Name: Parent/Guardian Signature……………………………………………………………………………………………………………. (if under the age of 18) Date……......./…..……../……………..….


Scenario - Asthma Case Study

You are working in a childcare centre. It’s a cold day and there was a thunderstorm in the morning. The children have just finished their lunch at 12.00pm and are outside. You notice that the air has become very smoky from a nearby fire, JANE a 3 year old looks unwell and is coughing persistently, wheezing and having trouble speaking. JANE has no history of asthma or anaphylaxis.

Answer the questions below according to your work environment and relevant regulations.

Questions Answers

Q1 What would be your first action in this situation?

Q2 What is the potential risk to children and staff in this situation?

Q3 What are the potential triggers in this situation?

Q4 How would you treat JANE?

Q5 What colour puffer would you use?

Q6 Where is it located in your centre/workplace?

Q7 Why do you check the date on the puffer?

Q8 What information will you relay to emergency services/ambulance personnel?

Q9 In your Centre/School who takes responsibility for the Asthma Emergency Management Plan?

Q10 Where can you access your workplace policies and procedures?

Demonstrate the correct procedure for administering the asthma reliever medication with and without a spacer.

Incident Report Scenario 2 – Anaphylaxis Scenario 3 – Asthma

NAME OF PERSON GIVING FIRST AID

Name OF PERSON REQUIRING FIRST AID

Age

Sex:

Address 7 Train Lane, Melbourne P/Code: 3000

DETAILS OF INCIDENT

Exact Location

Date Time

Cause of Incident

Signs/Symptoms

Treatment Given/ Action Taken

OBSERVATION & TREATMENT OF INJURED PERSON

Did the injured person refuse treatment? Y / N Was CPR administered? What time? Y / N am/pm

Was the injured person conscious? Y / N Was an ambulance called? What time? Y / N

am/pm

Was the injured person having difficulty breathing? Y / N What time were the parents/carers notified? am/pm

What medication was administered?

Auto- injector (Epipen) / Asthma reliever puffer

Y / N Was a second dose of medication required?

If yes, what time?

Y / N

am/pm

Have you reported this incident to your Regulatory Authority? Yes / N/A Date:___/____/____

Organise a time to debrief with children, parents, management/supervisor and/or counsellor

on the incident?

Date: Time:


INDIVIDUAL RISK ASSESSMENT & EMERGENCY MANAGEMENT PLAN An individual Anaphylaxis/Asthma Management Plan is prepared in consultation with the individual / parent / carer to minimise the individual risk, and to try and prevent an incident occurring.

Student: Date of Birth/Age:

Health conditions: Asthma Allergy Triggers: smoke, thunderstorms

Medication at School/Centre Asthma reliever

Storage of Adrenaline Auto-Injector (Epipen) /Asthma Relievers

Strategies to avoid allergens/triggers ENVIRONMENT

To be completed by Principal, Manager or Nominee. Please consider each environment/area (on and off school site) the student will utilise for the year, e.g. classroom, canteen, food tech room, sports oval, excursions and camps.

Name of environment/area Play ground

Risk identified Actions required to minimise the risk Who is responsible Completion date

Smokey atmosphere

Thunderstorm activity

RISK MINIMISATION STRATEGY – GENERAL (Workplace Environment)

A risk minimisation strategy looks at all triggers children in your care may encounter. Please take a look at your environment for Asthma and/or Anaphylaxis and put in place strategies to prevent a reaction/attack occurring. Prevention is always better than treatment.

Risk Risk Minimisation Strategy Responsible

Food allergies

Eat food only with teacher’s supervision. Eat food prepared by the childcare centre – no foods to be brought in by families. No food sharing. Have own treat box for parties and rewards. Make canteen/kitchen staff aware of products sold and children at risk – labelling.

Classroom teacher – School Kitchen staff and childcare provider

Excursion/ School Camp

COMMUNICATION PLAN – GENERAL (Workplace Environment) A communication plan informs all stakeholders (any individual who comes into contact with an “at risk” child) of key information relating to a child

and their medical condition/s. Each stakeholder is accountable for understanding and implementing the relevant information.

Possible Stakeholders

Key Messages relevant to all stakeholders

Person Responsible

Deadline

Date Completed

List all possible stakeholders

What do we tell them? Who is doing this?

When is this due?

Enter when completed

Carers/parents Triggers of allergic reactions including anaphylaxis/asthma Jo Johnson 01/02/2016 31/01/2016

Casual staff (CRT) Camp providers School Nurse Canteen/kitchen Volunteers

Develop Risk Management Strategies Group Activities: Based on Asthma Scenario.


Please tick the course you attended:

22282VIC Course in the Management of Risks and Emergencies in the Workplace (which incorporates) VU21658 Manage asthma risks and emergencies in the workplace

1. Additional comments .................................................................................................................................................................................................

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Thank you for taking the time to help us improve our training.

Name: (optional)

Training Date: Training Venue:

TRAINER EVALUATION - Please circle the number for your answer Poor Good Excellent

The trainer delivered the course in a clear and professional manner 1 2 3 4 5

The trainer provided opportunities for questions and ensured understanding 1 2 3 4 5

The presentation was well structured 1 2 3 4 5

COURSE EVALUATION

The course gave me the skills I needed 1 2 3 4 5

The venue was appropriate for the course requirements 1 2 3 4 5

The training met my expectations 1 2 3 4 5

Do you feel confident that the skills you acquired during this course would equip you to deal with an incident in the workplace?

1 2 3 4 5

COURSE FEEDBACK


Assessment Requirements Assessed as per Training and Assessment Guide

VU21658 – Manage asthma risks and emergencies on the workplace First Final Comments

Develop a risk minimisation and emergency plan for an asthma episode

Assess emergency asthma situations

Apply appropriate first aid procedures for an asthma episode

Communicate details of emergency asthma incidents

Evaluate responses to asthma emergencies

Instructions to Trainer/Assessor: To satisfy the requirements of this unit of competency, all assessments listed below are to be assessed as satisfactory in accordance with the Training and Assessment Guide for Observation of Practical Based Assessments.

Record of Outcome Key: S = Satisfied, NS = Not Satisfied

First Attempt

Final Attempt

VU21658 - Manage asthma risks and emergencies on the workplace S/NS S/NS

Practical Assessment – Individual observation of learner demonstrating correct first aid procedures for an Asthma Episode

S/NS S/NS

Participant Incident Report S/NS S/NS

Knowledge & Theory Q & A; Result ............/14 S/NS S/NS

Assessment Result

This participant has been assessed as Competent / Not Competent

This participant is to be awarded a Statement of Attendance only

Date:

Trainers Name/s:

Trainers/Assessor’s Signature:

Comments from Trainer (if applicable)

22282VIC TRAINER COMPETENCY SIGN OFF TO BE COMPLETED BY A QUALIFIED TRAINER/ASSESSOR

PRACTICAL ASSESSMENT OBSERVATION CHECKLIST TO BE COMPLETED BY A QUALIFIED TRAINER/ASSESSOR

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