In Notice of intention to attend an event (MPMR-35)

Notice of intention to attend an event (MPMR-35)

Section 35 of the Medicines and Poisons (Medicines) Regulation 2021 (MPMR) requires the holder of a general approval (emergency first aid) to give notice to the chief executive of Queensland Health (or delegate) if a registered nurse, first aid provider or paramedic intends to attend an event for the holder of the general approval — this form must be used to for this purpose.

Notice must be given no less than 2 business days before the event happens.

Privacy notice

Personal information collected by Queensland Health is handled in accordance with the Information Privacy Act 2009. Queensland Health is collecting your personal information on this approved form under authority of section 226 of the MPMR. All personal information will be securely stored and only accessible by Queensland Health staff. Your personal information will not be disclosed to other third parties without consent, unless the disclosure is authorised or required under law. Failure to provide information may render the form incomplete, which may constitute an offence under the Medicines and Poisons Act 2019. For information about how Queensland Health protects your personal information, or to learn about your right to access your own personal information, please see our website at www.health.qld.gov.au/global/privacy

Contact information

This notice is managed by HealthcareApprovals and Regulation Unit (HARU). Should you require assistance incompleting this form, please email: HARU@health.qld.gov.au

Required fields are marked with an asterisk (*).

1. Details of person making the notification

Title *

Given name *

Surname *

Position *

Work phone *

Work email *

2. Details of substance authority holder making the notification

Entity name *

Substance Authority Reference *

Expiry date *

Day Month Year

3. Details of intention to attend event

Please provide details of events that you intend to attend. For more than 3 events, please submit additional forms.

3.1 Details of EVENT ONE

Event name *

Street address *

Suburb *

State *

Postcode *

Type of event

If other type of event

Engagement *

Date of engagement

Day Month Year

Start time

Hour Minute

End time

Hour Minute

Start date of event

Day Month Year

End date of event

Day Month Year

Typical start time

Hour Minute

Typical end time

Hour Minute

Start date of engagement

Day Month Year

End date of engagement

Day Month Year

Times services will be provided

Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Hour Minute	Hour Minute	Hour Minute	Hour Minute	Hour Minute	Hour Minute	Hour Minute
Hour Minute	Hour Minute	Hour Minute	Hour Minute	Hour Minute	Hour Minute	Hour Minute

Other

3.2 Details of EVENT TWO

Do you want to provide details of a second event? *

SECOND EVENT

Event name *

Street address *

Suburb *

State*

Postcode *

Type of event

If other type of event

Engagement*

Date of engagement

Day Month Year

Start time

Hour Minute

End time

Hour Minute

Start date of event

Day Month Year

End date of event

Day Month Year

Typical start time

Hour Minute

Typical end time

Hour Minute

Start date of engagement

Day Month Year

End date of engagement

Day Month Year

Times services will be provided

Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Hour Minute	Hour Minute	Hour Minute	Hour Minute	Hour Minute	Hour Minute	Hour Minute
Hour Minute	Hour Minute	Hour Minute	Hour Minute	Hour Minute	Hour Minute	Hour Minute

Other

3.3 Details of EVENT THREE

Do you want to provide details of a third event? *

THIRD EVENT

Event name *

Street address *

Suburb *

State*

Postcode *

Type of event

If other type of event

Engagement*

Date of engagement

Day Month Year

Start time

Hour Minute

End time

Hour Minute

Start date of event

Day Month Year

End date of event

Day Month Year

Typical start time

Hour Minute

Typical end time

Hour Minute

Start date of engagement

Day Month Year

End date of engagement

Day Month Year

Times services will be provided

Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Hour Minute	Hour Minute	Hour Minute	Hour Minute	Hour Minute	Hour Minute	Hour Minute
Hour Minute	Hour Minute	Hour Minute	Hour Minute	Hour Minute	Hour Minute	Hour Minute

Other

4. Additional information and attachments

Additional information

Please upload

Certification *

In giving this notice I affirm that the information I have supplied is, to the best of my knowledge, complete, true, and accurate.

MPMR-35, Version 1

Last updated: 4 December 2023