PROPOSED AUSTRALIAN NATIONAL MCS VICTIM DATABASE 

Sample form and instructions. Refer to this form for guidance and instructions.  May be downloaded from site as a word doc.

• Please return to
• MCSCAN  AUSTRALIA
• PO Box 772 Denmark WA 6333

                           or

• MCSCAN AUSTRALIA
• 2 Alnus Court
• Newcomb, Victoria, 3219

• or e-mail it to MCSCAN AUSTRALIA: WEST COAST
                       MCSCAN AUSTRALIA:  EAST COAST
• Forms can be downloaded from the following site.  http://www.oocities.org/mcscanaustralia

Date

Alphanumeric ID Code 

This number will be inserted by the database administrator.  Please do not fill in.   

example jd1933v

• Information in Section 1 only will be added to the summary
  database for public access.

• Information will be used for research; research applications, submissions, use by other appropriate agencies

• Section 2 will comply with the privacy and confidential legal requirements and will be kept in a separate database, not be released without the written approval of the Victim or their legal Representative.

BACKGROUND INFORMATION

Environment background,
i.e. where you grew up or where you now live.

 Just tick in the boxes
below

Employment history (types of work)

Other Comments: 

If not born here, insert name of country and what age you migrated here

 N/A or Australian Born

Home

grew up in a country town

 office clerical, carpet making textile worker, home duties,

Agriculture or horticulture

horticultural area

 worked seasonally fruit picking

Mining, oil search, or other extraction industry

Petro-Chemical type industries and other Chemical Industries.

Commerce, Retail.

 retail

Hospitality and Service industry

high school

 studies some textile subjects as an adult at the local TAFE

Media and Entertainment Industry

Government Departments; Federal; State; Local Government or Government Authority or Utility

Textile

Other;

Other

SUMMARY OF INJURY:  Describe how you became affected with MCS or why you believe your injury may have been chemically induced.   Also Include, where applicable Information on the effects to your Carer and also the need for Respite care, including special aged care needs.

CHEMICALS: Provide lists of the chemicals you know or believe are responsible.   Alternatively if you are unsure what chemicals may be involved, describe the conditions that occur to bring on a reaction;

PROPOSED DATABASE

Part 2

• Section 2 to be excluded from Part 1 and kept separately in a secure place in compliance with the privacy and confidentiality legal requirements

Alpha-Numeric ID code

    This will be provided by the database administrator and will be a duplicate of Part 1

 jd1933v

First Name

Second Name

Surname

Telephone, Fax or E-mail Address

 John

Charles

Doe

 03 53 7689

Address

Waratah avenue

Town/city

Bexley

Post code

3****

Telephone Number

Fax

E-mail address

johd@user.net.au

  The following information is Required to assist with the development and delivery of appropriate Strategy, resources and support.

Status: Married, Divorced or Single

 M

Children

 2 girls/1 boy

Do you require a Carer or Home Help Services

 yes

Names of Treating Doctor/s or Specialists attending you.

 Dr. D.  Dr.A,

Hospital/s or Clinics attended

 Bexley General

What treatment was provided (if any)

 Oxygen and rest

Diagnosis

 not conclusive

Date of Diagnosis. NOTE: Experience has shown that diagnosis often changes as more information is obtained and/or shows it does not fully qualify for the earlier diagnosis.

 12/06/78

NO DIAGNOSIS CONFIRMED TO DATE.  Note: Where there has been no diagnosis confirmed but you believe you are a victim of MCS, please describe your personal feelings.

 No conclusive diagnosis but thought it might be allergy related

However I believe it is related to the chemicals used in the manufacture of carpets.  I did not become ill until I commenced working in the factory, handling the different chemicals there.

Medical History.     if available along with any other relevant commentary