PROPOSED AUSTRALIAN NATIONAL MCS VICTIM DATABASE  FORM

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

                           or

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

Date

 

Alphanumeric ID Code 

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

 

  
  • 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

 

Home

 

 

 

 

Agriculture or horticulture

 

 

 

 

Mining, oil search, or other extraction industry

 

 

 

 

Petro-Chemical type industries and other Chemical Industries.

 

 

 

 

Commerce, Retail.

 

 

 

 

Hospitality and Service industry

 

 

 

 
Education; Colleges,
TAFE, University,
Education and Training Providers. 

 

 

 


 

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

 

First Name

Second Name

Surname

Telephone, Fax or E-mail Address

 

 

 

 

 

Address

 

Town/city

 

Post code

 

Telephone Number

Fax

E-mail address

 

 


 

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

Status: Married, Divorced or Single

 

 

 

Children

 

 

 

Do you require a Carer or Home Help Services

 

 

 

Names of Treating Doctor/s or Specialists attending you.

 

Hospital/s or Clinics attended

  

 

 

 

What treatment was provided (if any)

 

Diagnosis

 

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.

 

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.

 

 

Medical History.     if available along with any other relevant commentary