Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Completing this form is mandatory. The form must be completed by the staff member prior to commencing
his/her role at the ASSET Summer Programme.
STAFF INFORMATION
Yes No
Please be advised that neither Educational Initiatives, nor Manipal University are liable to cover any costs
incurred due to medical visits to doctor(s)/hospital(s), medications, x-rays etc.
We shall only bear the upfront payment of the initial costs of any treatment(s), and the parent/guardian of
the above student shall be liable to reimburse Educational Initiatives for all expenses we bear for the student.
1
STAFF MEDICAL HISTORY FORM
ROLE/DESIGNATION ________________________________
MEDICAL CONDITIONS
1. History of Medical conditions: Please check if you are under treatment for/deal with any of the
following:
Other Ailments
(If yes, please explain in detail) __________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
3. Are you allergic to anything (medication, food, insect bites etc.? Yes No
2
STAFF MEDICAL HISTORY FORM
ROLE/DESIGNATION ________________________________
_____________________________________________________________________________________________________________
Residential Requirements (Please check the box that best describes your child’s requirements):
MEDICAL SPECIAL NEEDS
No Special Requirements
Physical Disability (short term, such as recovering from surgery, injury, etc.)
Other
3
STAFF MEDICAL HISTORY FORM
ROLE/DESIGNATION ________________________________
MEDICAL POLICIES
• ASSET Summer Programme staff will not prescribe, dispense or administer any medication. Staff members under
medication need to be able to administer medications on their own.
• Staff members must ensure that they are taking care of their own medication schedule. ASSET Summer
Programme will not be responsible to ensure staff members’ adherence to medication schedules.
• Please consult medication advisors regarding continuation of medication during the course of the programme.
(Note: We have observed in previous programmes that some staff members choose to avoid taking their medication
during the programme, which impacts the staff members social as well as academic adjustment to the programme.
We therefore advise you to consult your medical practitioner on the continuation of your medication during the
course of the programme.
NON-PRESCRIPTION MEDICATION
Please provide a complete list of all non-prescription medications you will be bringing along or might need to
purchase during the programme.
_______________________________________________________________________________________________________________
The medical room at the programme will have limited supply of medication such as Acetaminophen (e.g.
Paracetamol, Crocin) , Ibuprofen (e.g. Combiflam), Lomotil for diarrhoea etc. Staff members needing constant
medication are requested to bring enough supplies that can last them for the entire duration of the
programme.
4
STAFF MEDICAL HISTORY FORM
ROLE/DESIGNATION ________________________________
Please read carefully and sign. Your signature indicates that you fully understand and agree to the
authorisations and acknowledgements of your responsibilities and waiver of liabilities.
I grant my authorisation and consent to the ASSET Summer Programme staff to seek emergency diagnostic/medical
treatment or care as required by me.
I am aware of and understand the risks associated with such treatments, including (but not limited to) serious
physical injury and it is also understood that the ASSET Summer Programme is not responsible or liable for any
treatment provided.
It is also understood that the ASSET Summer Programme is not responsible for filling any insurance claims or
making payments for the emergency diagnosis and treatment. I accept full responsibility for payment of any and
every invoice or bill for treatment or care provided to me. I authorise the healthcare facility (if any) that tenders said
treatment or care to release the medical information required for payments of related insurance claims.
I hereby release the ASSET Summer Programme and its directors, officers, agents and employees from all expenses
or liabilities resulting from:
- Any emergency medical treatment or care provided to me, and/or,
- Failing to adhere to my medical schedule.
Date _________________________________
5
STAFF MEDICAL HISTORY FORM
ROLE/DESIGNATION ________________________________
PRESCRIPTION MEDICATIONS
MUST BE FILLED by a Medical Practitioner (If you are taking prescription medication)
• Medical Practitioner must list all medications prescribed to the staff member, including dosage and
schedule.
Staff member will take medication from dates (dd/mm/yyyy) _________________ to ___________________
Staff member will take medication from dates (dd/mm/yyyy _________________ to ___________________
Staff member will take medication from dates (dd/mm/yyyy) _________________ to ___________________
Staff member will take medication from dates (dd/mm/yyyy) _________________ to ___________________
Important information (side effects, toxic reactions, drug interactions, omission reactions, potential problems
resulting from physical injury) ____________________________________________________________________________