NRMC Phased Implementation Expression of Interest

Phased implementation of the National Residential Medication Chart (NRMC)

Please read the selection criteria listed on page 1 of the
Invitation for expressions of interest before completing this form.

Instructions: You can download this form and complete it off-line. Place the cursor in the grey boxes and type in your information. Where options are provided, select the appropriate response. Either save the document in Word format and email it to the address shown on the last page of this form or print the completed form and post it to the postal address shown on the last page of this form.

Personal information

Your name:
Your position:
Work address:
Email address:
Telephone number: / Fax number:

RACF information

RAC ID:
RACF address
Approved Provider Type:
Religious based / Charitable
Government based / Not-for -Profit
Community based / Other.
Please describe:
Private
Number of beds:
Level of care provided:
High care
Low care
Both
Special needs groups if applicable: Please describe:
Does your home currently use a paper-based medication chart? / Yes No
Please describe:
Is there senior management support for the phased implementation? / Yes No
Please describe:
Senior Management signature and designation:
Is there senior clinician support for the phased implementation? / Yes No
Please describe:
Does your home have a formal policy on medication management? / Yes No
Has your RACF experienced issues with medication management? / Yes No
If Yes please describe (note: this will not exclude you from the study)
Are you able to provide incident and accident trending data to the Commission? / Yes No
Can a key contact person be nominated now? / Yes No

Key contact information

Name:
Position:
Email address:
Telephone number:

Authorisation

This section is to be signed by the Approved Provider or Key Contact Person
I confirm that:
·  There is senior management and clinician support for participation in the NRMC phased implementation;
·  A key contact person will be nominated to liaise with the Commission Project Team:
·  The RACF commits to participating in the phased implementation providing necessary data that will be stored confidentially by the Commission.
I agree to
RACF participating in the NRMC Phased Implementation.
Signature:
Name: / Date:
Email your completed expression of interest to or send to:
Dr Michele Chandler,
Executive Project Officer
NRMC Project
Australian Commission on Safety and Quality in Health Care
GPO Box 5480
SYDNEY NSW 2001
If you have any queries please contact Dr Michele Chandler on (02) 9126 3514 or email
Thank you for your expression of interest. We look forward to working with you on this important initiative for residential aged care.

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