Form SY061, Medical statement - Assistance for Isolated Children (AIC) Scheme Instructions

Please provide the applicant's home phone number, including the area code.

Please provide the applicant's mobile phone number.

Enter the first line of the applicant's permanent address.

Enter the second line of the applicant's permanent address.

Enter the suburb or town and the state for the applicant's permanent address.

Enter the postcode for the applicant's permanent address.

Check this box if there are no exceptional circumstances that have led to the student being treated by an Allied Health Professional rather than a medical practitioner or specialist. Fill only if 'Are you a:' is 'registered Allied Health Professional'.

Check this box if there are exceptional circumstances that have led to the student being treated by an Allied Health Professional rather than a medical practitioner or specialist. Fill only if 'Are you a:' is 'registered Allied Health Professional'.

Please provide any reference or brief identifier for the exceptional circumstances. Fill only if 'Are you a:' is 'registered Allied Health Professional'.

Please provide a detailed explanation of the exceptional circumstances that led to the student being treated by an Allied Health Professional rather than a medical practitioner/specialist. Fill only if 'Yes' is 'Yes'.

Check this box to confirm that you have read, understood, and agree to the applicant declaration.

Please enter the date the applicant made this declaration. Fill only if 'I have read, understood and agree to the above.' is checked.

Please enter the first segment of the applicant's customer reference number.

Please enter the second segment of the applicant's customer reference number.

Please enter the third segment of the applicant's customer reference number.

Please enter the fourth segment of the applicant's customer reference number.

Check this box if the applicant's title is Mr.

Check this box if the applicant's title is Mrs.

Check this box if the applicant's title is Miss.

Check this box if the applicant's title is Ms.

Check this box if the applicant's title is Mx.

Please specify the applicant's title if it is not one of the provided options. Fill only if 'Mr', 'Mrs', 'Miss', 'Ms', 'Mx' is not selected.

Please enter the applicant's family name.

Please enter the applicant's first given name.

Please enter the applicant's second given name.

Check this box if the student's condition is not harmful to their health if they attended any local school full-time.

Check this box if the student's condition is harmful to their health if they attended any local school full-time.

Provide the number of the next question to go to if this condition is not harmful to the student's health and the answer to question 28 was 'No'.

Provide the total length of time the student has had this condition. Fill only if 'Are you a:' is 'medical practitioner/specialist'.

Provide a comprehensive explanation of the student's disability or health-related condition, detailing its effects on their psychological, emotional, or physical well-being, and any instances where it led to expulsion or removal from the local school. Fill only if 'What special need applies to this student who either needs to study at home or live away from home to study?' is 'Student needs to be removed from local school environment.'

Enter the estimated number of school days the student is likely to be absent in the year due to their medical condition.

Check this box if the expected duration of the condition is permanent. Fill only if 'Are you a:' is 'medical practitioner/specialist'.

Check this box if the expected duration of the condition is temporary. Fill only if 'Are you a:' is 'medical practitioner/specialist'.

Enter the initial period for which the condition is expected to be temporary. Fill only if 'Temporary' is 'Yes'.

Enter the number of months after which the temporary condition will be reviewed. Fill only if 'Temporary' is 'Yes'.

Indicate whether you are a registered Allied Health Professional. Fill only if 'What special need applies to this student who either needs to study at home or live away from home to study?' is selected

Check this box if the student is pregnant and this condition applies to their need to study from home. Fill only if 'What special need applies to this student' is 'A'.

Check this box if the student requires access to special facilities or environmental conditions within the family home to study. Fill only if 'What special need applies to this student' is 'A'.

Check this box if the student needs to avoid the sort of travel that would be necessary to attend school each day. Fill only if 'What special need applies to this student' is 'A'.

Provide detailed information regarding the conditions that necessitate the student's home study. Fill only if 'Special facilities/environmental conditions', 'Avoid daily school travel' is 'Yes' for any.

Check this box if there are no facilities that cater for the student's medical or other condition at any local government school.

Check this box if there are facilities that cater for the student's medical or other condition at any local government school.

Provide the medical diagnosis for the student's condition. Fill only if 'Are you a:' is 'medical practitioner/specialist'.

Enter the details of the prescribed treatment for the student. Fill only if 'Are you a:' is 'medical practitioner/specialist'.

Please provide the signature of the medical practitioner, specialist, or allied health professional. Fill only if 'What special need applies to this student' is ticked

Please enter the date of this declaration. Fill only if 'What special need applies to this student' is ticked

Describe how your professional qualification relates to the treatment of the student's condition. Fill only if 'What special need applies to this student who either needs to study at home or live away from home to study?' is selected

Provide your professional registration number. Fill only if 'What special need applies to this student who either needs to study at home or live away from home to study?' is selected

Check this box if your professional qualification is at a tertiary level. Fill only if 'What special need applies to this student who either needs to study at home or live away from home to study?' is selected

Check this box if your professional qualification is at a specialist level. Fill only if 'What special need applies to this student who either needs to study at home or live away from home to study?' is selected

Enter any specific code or brief detail related to your specialist qualification level. Fill only if 'What special need applies to this student who either needs to study at home or live away from home to study?' is selected

Provide details of your specialisation or any additional qualification relevant to the student's condition, such as a Masters in clinical psychology. Fill only if 'Specialist' is checked.

Check this box if you are a registered Allied Health Professional. Fill only if 'What special need applies to this student who either needs to study at home or live away from home to study?' is selected

Check this box if you are a medical practitioner or specialist. Fill only if 'What special need applies to this student who either needs to study at home or live away from home to study?' is selected

Please provide the specialisation of the medical practitioner, specialist, or allied health professional. Fill only if 'Medical Practitioner/Specialist' is checked.

Please state your current profession as a medical practitioner, specialist, or allied health professional. Fill only if 'Registered Allied Health Professional' is checked.

Check this box if there is no information in this report which, if released, might harm the student's physical or mental well-being, and proceed to the next question. Fill only if 'What special need applies to this student' is ticked

Check this box if there is information in this report which, if released, might harm the student's physical or mental well-being, and then identify that information and state why it should not be released. Fill only if 'What special need applies to this student' is ticked

Identify the specific medical information that, if released, might harm the student's physical or mental well-being. Fill only if 'Yes' is 'Yes'.

Provide a detailed statement explaining why the identified medical information should not be released and any special circumstances to consider. Fill only if 'Yes' is 'Yes'.

Please describe the facilities or environments that the student needs which are not available at the local government schools within the home vicinity. Fill only if 'What special need applies to this student' is 'B'.

Check this box if you do not recommend that the student is removed from the local school environment. Fill only if 'What special need applies to this student who either needs to study at home or live away from home to study?' is 'Student needs to be removed from local school environment.'

Check this box if you recommend that the student is removed from the local school environment. Fill only if 'What special need applies to this student who either needs to study at home or live away from home to study?' is 'Student needs to be removed from local school environment.'

Check this box if the medical condition is not clearly serious.

Check this box if the medical condition is clearly serious, such as a psychiatric or severe allergic condition.

Enter the full name of the specialist providing evidence for the condition. Fill only if 'Yes' is 'Yes'.

Provide a comprehensive description of the serious medical condition, including its nature, duration, and any relevant circumstances. Fill only if 'Yes' is 'Yes'.

Check this box if the special facilities or environments are not necessary to such an extent that the student is required to live away from home. Fill only if 'What special need applies to this student who either needs to study at home or live away from home to study?' is 'Student needs access to special facilities or environments'

Check this box if the special facilities or environments are necessary to such an extent that the student is required to live away from home. Fill only if 'What special need applies to this student who either needs to study at home or live away from home to study?' is 'Student needs access to special facilities or environments'

Please provide a brief summary explaining why special facilities or environments necessitate the student living away from home. Fill only if 'Yes' is 'Yes'.

Please provide comprehensive details regarding the special facilities or environments that require the student to live away from home, rather than just accessing them periodically. Fill only if 'Yes' is 'Yes'.

Please enter the code corresponding to the special need indicated in question 8, typically A, B, or C. Fill only if 'What special need applies to this student' is selected.

Check this box if the student's condition would not be better managed or overcome by access to specific facilities or environments. Fill only if 'What special need applies to this student who either needs to study at home or live away from home to study?' is 'Student needs access to special facilities or environments'

Check this box if the student's condition would be better managed or overcome by access to specific facilities or environments, and provide details in the space below. Fill only if 'What special need applies to this student who either needs to study at home or live away from home to study?' is 'Student needs access to special facilities or environments'

Provide a brief detail or summary if the student's condition would be better managed or overcome by access to facilities or environments, as indicated by the 'Yes' response to question 26. Fill only if 'Yes' is 'Yes'.

Provide a comprehensive explanation of how the student's condition would be better managed or overcome by access to specific facilities or environments, as indicated by the 'Yes' response to question 26. Fill only if 'Yes' is 'Yes'.

Enter the first segment of the student's customer reference number, if known.

Enter the second segment of the student's customer reference number, if known.

Enter the third segment of the student's customer reference number, if known.

Enter the fourth segment of the student's customer reference number, if known.

Enter the student's date of birth.

Please provide the student's family name.

Please provide the student's first given name.

Please provide the student's second given name.

Check this box if the student has a condition requiring facilities or environmental conditions only available from the family home, or needs to avoid daily travel to school.

Check this box if the student has a condition requiring access to specific facilities or an environment to manage or overcome the condition, which would prevent them from attending a local state school for more than 20 school days a year.

Check this box if the student has interpersonal problems affecting their psychological, emotional, or physical health, has been expelled, and there is no suitable local school available.

Check this box if there is no suitable medication or treatment that is both reasonably available and alleviates the effects of the condition sufficiently to allow the student to attend a local school full-time.

Check this box if suitable medication or treatment is both reasonably available and alleviates the effects of the condition sufficiently to allow the student to attend a local school full-time.