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Clinical Quality Assurance & Quality Compliance Form

"*" indicates required fields

Clinician's Name*

Project*

Date QAQC Conducted*

DD slash MM slash YYYY

Clinic Name*

Type: Assessment Conducted*

Date of Assessment*

DD slash MM slash YYYY

Clinic Name

Candidate Identifier (Full Name)*

First LAST

1) Has the correct medical assessment been conducted as per the relevant standards?*

Yes

No (please provide details below)

Incorrect Medical Assessment Conducted.

Incorrect Fitness Assessment Conducted.

Incorrect Application of accredited medical standard applied.

Incorrect Client Protocols followed.

Candidate Error - Incorrect assessment request.

Assessment Abandoned - Candidate Request

Other (please enter further details below)

Enter relevant details. If non-compliant, please submit as an immediate non-compliance record.

2) Identifiers: Does the medical assessment have the required identifers available.*

Yes

No (please select missing identifier.)

Name

DOB

Address

Contact Details

Job Role

Assessing Doctor's Details including Signature

Clinic's Stamp (If applicable)

Employee Reference number (If applicable)

Legibility of the Document Unsatisfactory

ACH Consent & Declaration Form

3) Examinee History: are all relevant fields with associated documentation filled in correctly?*

Yes

No (please provide details below)

Description: Have all fields in the relevant section been completed? Has appropriate clarification been provided for all yes/abnormal responses? Are concerns about relevant reflected in Medical Examiners recommendations and assessment status/outcome?

Enter non-compliance here.*

4) Additional Information; Has the medical examiner completed the required field in the additional information section? Have comments been provided about what additional information has been requested?*

Yes

No (please provide details below)

Description: Have all fields in the relevant section been completed? Has appropriate clarification been provided for all yes/abnormal responses? Are concerns about relevant reflected in Medical Examiners recommendations and assessment status/outcome?

BMI

Vision

Urinalysis

Cardiovascular System

Respiratory System

Abdomen

Musculoskeletal System

Eyes, Ears, Nose & Throat

Skin

Neurological

Behavior

Mental Health

Physical Capacity

Vaccination Schedule

Vaccination Administration Issue

Radiological Assessment (See notes)

Drug and Alcohol

Incomplete Documents

Incomplete Referral Letter

Other (please enter further details below)

Enter non-compliance here.

5) Medical Examiners Recommendations; Do the Medical Examiner’s recommendations reflect abnormalities/issues/findings documented within the medical? If indicated, has appropriate action been taken to address any abnormalities?*

Yes

No (please provide details below)

Enter non-compliance here.*

6) Does this assessment meet the quality compliance requirements?*

Yes

No (please provide details below)

Enter non-compliance here.*

If the QAQC does not meet the compliance, please take immediate action to correct the omission or error and place an entry on the partner clinic issue log if immediate effect.

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