Application for Emergeny Locum Services

The Pharmaceutical Locum Company Pty Limited
Free Call: 1 800 357 001
Phone: 02 9371 4928
Fax: 02 9371 6946
E: els@locumco.com.au

RURAL AND REMOTE PHARMACY WORKFORCE DEVELOPMENT PROGRAM

APPLICATION FOR EMERGENCY LOCUM SERVICES

Including Written Guarantee to pay wages and accommodation costs.

The Applicant
*Name of Pharmacy Requesting Services
*Contact Telephone Number
*Name and Street address of Pharmacy
Fax
Email
Mobile
Contact Person for arrangement of locum services if pharmacist unavailable
Telephone
Fax
Email
Mobile
Details of the Pharmacy
Approximate number of scripts per day
Type of computer system
Number of staff in dispensary
Approximate size of pharmacy
Opening hours of pharmacy
Is the pharmacy closed for lunch?	Yes No
Special duties required of pharmacist (e.g. home visits,mediction reviews etc)
Do you require the locum to be accredited for medication reviews?	Yes No
Do you require the locum to be QCPP (locum) accredited?	Yes No
The Emergency
Brief description of Emergency situation and why locum services are required
What is the expected duration of the emergency?
What hours will the locum be required to work?
Will the Pharmacy be required to close if locum services are not obtained?	Yes No
Please give details of and attach copies of any documentation in support of your claim, eg. statutory declaration, medical certificates, evidence of current registration, etc.