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Phone: +61 7 3105 7800
Fax: +61 7 3105 7801


 
 
Request for Locum Relief

To request Locum Relief, simply complete the form below, or download a hardcopy which you can complete and return to our Locums Coordinator.

Guidelines For Requests To Health Workforce Queensland Locum Service

To download the terms and conditions of the Health Workforce Queensland Locum Programme. [Click Here]

DISCLAIMER: The contract for service arising out of the provision of Locum Services shall be as between the particular rural doctor and locum concerned and those parties shall be respectively liable for all actions, claims and demands both as between each other and with third parties arising out of such contract for service and each party shall indemnify the Health Workforce Queensland against any liability arising out of such actions, claims of Demands.


Personal Details

Given Name:
Family Name:
Address:
Telephone:
Telephone After Hours:
Fax:
Email:
Locum Details

Date of locum required:
From:
To:
Alternative:
From:
To:
Have you previously used this locum service?
If so, please provide prior dates:
Do you require locum relief for:
Continuing Medical Education
Recreational Leave
Sick Leave
Emergency
If Locum requested for CME Relief, please specify:
Proposed CME Activity:
Location:
Supervision:
Describe the objectives of the CME, and how this activity relates to the requirements of your practice and your professional development:
Practice Details

Name of Practice:
Address of Practice:
GP Division:
Type of practice:
Solo Practitioner (solo in district):
Sole Practitioner (more than one in district):
Practitioner in Group:
Number of Doctors in practice:
Practice Contact Person:
Number of GP's in town
(other than locum):
Distance to nearest GP if single doctor in town:
Does the locum have VMO rights:
Level and type of services provided in your practice. Please tick box:
Obstetrics:  
Antenatal
Simple Delivery
Forceps/LCS
   
   
Orthopaedics:  
Undisplaced#
Closed Reduction
Open Reduction
   
   
Surgery:  
Excision
Plastic
Several
   
   
Emergency:  
No Casualty
Casualty Set-up
   
   
   
Anaesthetics:  
Local Block
Epidural
G.A.
Bier's Block
   
Procedures:  
Audiogram
ECG
Respiratory
Ultrasound
Cryotherapy
X-Ray
Take
Read
General Comments:
Is your practice computerised:
Appointments:
Scripts:
Records:
Workload & Duties

Hospitals attended:
Nursing Homes attended:
Average weekly workload
(number of patients):
Hours worked per week:
Hours Monday/Friday:
Hours Saturday Morning:
Afternoon off:
On-Call Requirements:
DISCLAIMER: The contract for service arising out of the provision of Locum Services shall be as between the particular rural doctor and locum concerned and those parties shall be respectively liable for all actions, claims and demands both as between each other and with third parties arising out of such contract for service and each party shall indemnify Health Workforce Queensland against any liability arising out of such actions, claims of Demands.
This application constitutes an offer to Health Workforce Queensland to enter into an agreement to use the Health Workforce Queensland locum service. Once the offer is accepted by Health Workforce Queensland there is an agreement between you and Health Workforce Queensland for the use of the locum service.