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INVICTUS GAMES 2018(IG18) - EXPRESSION OF INTEREST

Privacy Statement

In performing its functions, the IG18 Management Team recognises and respects your privacy and is committed to the Australian Privacy Principles set out in the Privacy Act 1988 (Cth).

The information collected when submitting the Expression of Interest (EOI), or in the course of IG18 Management Team performing its functions will be collected, used and disclosed as described below.

How your information will be collected and to whom it may be disclosed

The EOI is an assessment of your suitability to take part in IG18 sporting activities and as such, is somewhat detailed. The IG18 Management Team collects information from and discloses your relevant personal information to:

  • IG18 Team Management (Selection Panel);
  • Appropriate medical staff; and/or
  • Defence IT systems (PMKeyS for in-service personnel)

The purpose for collecting your personal information

Your personal information will be collected by the IG18 Management Team to:

  • Ensure youmeet the medical criteria to take part in the IG18 activities;
  • Assist in the assessment of and to monitor your ongoing suitability to take part in the IG18 activities;
  • Ensure there is continuity of medical care and appropriate exchange of medical information.
  • Ensure general control and administration by IG18 Management Team staff;
  • clarify your medical status; and/or
  • Assist in the assessment of your requirements while taking part in the IG18 activities.

Disclosure of your information

The IG18 Management Team will not use or disclose your personal information to any other person or organisation, other than those listed above, unless:

  • it would reasonably be expected by you that such a disclosure would occur and the disclosure is related to the IG18 activity in which you are involved; and/or
  • a ‘permitted general situation’ exists in relation to the use or disclosure of the information.

A ‘permitted general situation’ is defined in the Privacy Act 1988 (Cth)

Accessing and updating your personal information

If you wish to request access to your personal information held by the IG18 Management Team, please contact the IG18 Team Manager at .

INVICTUS GAMES 2018 (IG18) - EXPRESSION OF INTEREST

PART A - To be completed by the applicant

What sports are you currently playing or have competed in the past three years / Years Competed
How many times a week do you train:
How many hours a day do you train:
Indicate your clothing size for each item below (XS – S – M – L – XL – XXL)
Swimsuit / Polo / T-Shirt / Tracksuit Top / Tracksuit Bottom / Shorts / Shoe Size
Waist Size - / Weight - / Height - / Chest size -
  1. I have been briefed on the dates and commitments by my supervisor. My unit chain-of-command support my application (part B/C).
  2. I understand that completion of this form with signatures does not confirm my attendance on the activity.
  3. I understand I am on duty for the duration for the activity and representing the ADF and will train and compete within my restrictions.
  4. I understand that failure to give accurate information may result in me receiving and incorrect categorisation and result in removal from this or any subsequent adaptive sports event.

Affirmation: The information on this form is correct to the best of my knowledge and I confirm my understanding of the above requirements.

______

Printed Name

______

Signature Date

PART B - To be completed by the member’s supervisor/OC (for in-service members)

(Please circle the appropriate answer)

Has the member made a positive effort towards their rehabilitation?YES / NO

Has the member had any disciplinary issuesnow or in the past two years to be noted?YES / NO

Has the member had negative personal report findings in the past two years?YES / NO

Is the member able to undertake thesportsnominated within their restrictions? YES / NO

Will the member be a sound respective of the ADF if they are selected in the activity?YES / NO

Has the member consulted a Fitness Advisor (PTI) regarding training for this activity?YES / NO

Is the member approved to participate in media engagement?YES / NO

Does the member require any specialised support for physical or mental conditions?YES / NO

Has the member attended any ADF sponsored WII activity previously? (eg Invictus Games)YES / NO

Are the member’s family circumstances conducive to allow participation in the activity? YES / NO

If YES, please specify ______

What are the members current Medical Classification:

What date did this Medical Classification commence?

The members EOI is RECOMMENDED / NOT RECOMMENDED

Signature:______Date:______

Printed Name:______Rank:______Tel:______

PART C - To be completed by the members Manager/CO (for in-service members)

The members’ Expression of InterestisAPPROVED / NOT APPROVED.

If selected, the member IS/IS NOT available to participate in theIG18 activity.

Signature:______Date:______

Printed Name:______Rank:______Tel:______

EXPRESSION OF INTEREST

MEDICAL CLEARANCE FORM AND INITIAL CATEGORISATION

Personal particulars

PMKeyS:Rank: / Full Name:

Member must be cleared by their Medical Officer in order to participate in any IG18 activity. Medical Officers are requested to complete this form.

Medical Officers are requested to check MEC status of member and take administrative action for waivers.

Member will undergo further categorisation and classification by IG18 Team Management.

Please use one page for each individual medical condition or diagnosis

CURRENT MEDICAL CONDITION/ DIAGNOSIS
Condition/ Diagnosis:
Current MEC:
Impaired muscle power / Yes No / Amputation Yes No
Specify:
Upper limb(s) / Yes No / Specify:
Lower limb(s) / Yes No / Specify:
Spinal Cord Injury / Yes No / Level of lesion: / Complete/ Incomplete
Orthopaedic Injury / Yes No / Joints affected:
Impaired Joint Movement / Yes No / Joints affected:
MEDICATIONS (Including occasional & over-the-counter meds)
Medication name / Strength / Dosage / When taken
Please indicate category(ies) of injury or illness
Single Leg Amputee (BK) / Single Leg Amputee (AK) / Double Leg Amputee (BK)
Double Leg Amputee (AK) / Below Elbow Amputee (BE) / Above Elbow Amputee (AE)
Leg Impairment (BK) / Leg Impairment (AK) / Arm Impairment (BE)
Arm Impairment (AE) / Spinal Cord Injury (SCI) / Post-Traumatic Stress Disorder
Traumatic Brain Injury (TBI) / Depression Disorder / Anxiety Disorder
Visual Impairment (Corrected visual acuity of6/6or greater)
Other: (Temporary orthopaedic, etc.)
Allergies. List any allergies the member may have:
Restrictions. List the member’s current restrictions:
Participation:I have discussed with the member and clearedhim/her to participate in this IG18 activity. The member and I understand this may require him/her to participate in five hours of physical activity per day.
YES / NO
Is the member fit to undergo instruction and undertake supervised sports activities (all adapted for disabilities)?
YES / NO

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MEDICAL REVIEW QUESTIONS

  1. Does the member have:

  1. Any metal, shrapnel, foreign material in body;
/ Yes No
  1. Bleeding, clotting, or bruising problems;
/ Yes No
  1. Persistent or residual effects from prior brain injury;
/ Yes No
  1. Any heart or lung problems;
/ Yes No
  1. Sickle Cell trait;
/ Yes No
  1. Problems with exertion or exercise in heat, heat exhaustion or heat stroke;
/ Yes No
  1. Vision problems;
/ Yes No
  1. Anger, anxiety or stress control issues; and/or
/ Yes No
  1. Pain management issues.
/ Yes No
  1. Does the member have problems with:

  1. Light-headedness, passing out, or other difficulties with exertion or exercise;
/ Yes No
  1. Chest tightness or shortness of breath;
/ Yes No
  1. Very limited stamina or endurance;
/ Yes No
  1. Balance or susceptibility falls;
/ Yes No
  1. Nervousness or anxiety problems;
/ Yes No
  1. Crowds or crowded situations;
/ Yes No
  1. Small, tight or confined spaces;
/ Yes No
  1. Tolerance or loud noise; and/or
/ Yes No
  1. Bright lights or flashes of light.
/ Yes No
  1. Does the member require a service animal?
/ Yes No
  1. Does the member require a full time carer?
/ Yes No
  1. Does the member require a wheelchair?
/ Yes No
  1. Does the member need corrective lenses for athletic events?
/ Yes No
  1. Does the member require specialised or protective equipment?
/ Yes No

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Sensitive: Personal (when complete)

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Is member physically and mentally capable of participation in the following events.

Venue/Event / Medical Clearance / Stipulations or Comments
Golf / Yes No
Sitting Volleyball / Yes No
Wheelchair Basketball / Yes No
Archery / Yes No
Cycling / Yes No
Track (Running) / Yes No
Field (Jumping, Throwing) / Yes No
Swimming / Yes No
Wheelchair Rugby / Yes No
Wheelchair Tennis / Yes No
Powerlifting / Yes No
Indoor Rowing / Yes No
Driving / Yes No

MO or Health Provider:

______

Doctors Printed Name Doctors Signature

______

Treatment Facility Date

Service Approval (RAN: Fleet Sport & Recreation, Army : A-SWIIP, RAAF : DPERS-AF MSC)

______

Printed Name Appointment

______

Signature Date

Sensitive: Personal (when complete)

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