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It also collects emergency contact information and details of the proposed field work, including nature, location, and supervisor details. The form includes a health concerns section covering conditions like epilepsy, asthma, migraines, vision or hearing issues, heart and circulatory problems, blood pressure, musculoskeletal issues, and allergies, with instructions to specify details if any answers are yes.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":20,"@type":76,"position":81},"https://docshare.wps.com/document/exam/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/field-placement-medical-declaration-gen114-last-updated-september-2022/269844/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/field-placement-medical-declaration-gen114-last-updated-september-2022/269844.png","ImageObject",300,407,{"name":92,"@type":93},"Aurora","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-30","2026-09-15",true,{"@type":102,"interactionType":103,"userInteractionCount":52},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What information must students provide in the postal address section?","Question",{"text":112,"@type":113},"Students must complete their postal address fields, including number and street or PO Box, suburb/town, state, and country if outside Australia.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What emergency contact details are required?",{"text":117,"@type":113},"Students must provide the emergency contact title, surname, given names, relationship to the student, contact email, contact number, and mobile phone, plus activity description and supervisor information.",{"name":119,"@type":110,"acceptedAnswer":120},"Which health concerns does the form ask about for the proposed field work?",{"text":121,"@type":113},"The form asks whether the student has concerns such as epilepsy/fitting, dizziness/balance problems, asthma/respiratory problems, migraines/persistent headaches, visual/eye problems, hearing difficulties, chest/heart problems, circulatory problems, blood pressure issues, muscular/skeletal problems, and allergies; if yes, students must specify details.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},269844,1789454038,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":19,"category_name":20,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":52,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":129,"read_time":24},4810365810221,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Field Placement Medical Declaration  \nPostal Address (must be completed by all students) Number & Street or  \nPO Box  \nSuburb / Town  \nState  \nCountry  \n(if outside Australia)  \nHome Phone  \nWork Phone  \nMobile Phone  \nGEN114 Last updated September 2022  \nEmail  \nHave you activated your student account?  \nAll correspondence sent to students by CDU will be sent to the student’s official CDU email address.  \nCourse Code  \nCampus/Centre  \nCourse Mode  \n􀁆  \nInternal  \n􀁆  \nExternal  \n􀁆 Mixed  \nEmergency Contact (This must be completed by all students)  \nTitle  \n Mr  \n Mrs  Ms  \n Miss   \nMx  \nDr  \nSurname  \nGiven Names  \nRelationship to student?  \nContact email  \nDescription of activity  \nUnit code  \nWhat is the nature and location of the field work?  \nStreet address  \nSuburb / Town  \nState  \nCountry  \n(if outside Australia) Contact number  \nMobile Phone  \nSupervisor name  \n|  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  | Postcode |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n\n\n|  |\n| --- |\n|  |\n|  |\n\nDo you have any health concerns regarding the proposed field work, such as;  \nEpilepsy/Fitting Yes 􀁆 No 􀁆 Dizziness/Problems with balance Yes 􀁆 No 􀁆  \nAsthma/Lung/Respiratory problems Yes 􀁆 No 􀁆 Migraines/Persistent Headaches Yes 􀁆 No 􀁆  \nVisual/Eye problems Yes 􀁆 No 􀁆 Hearing difficulties Yes 􀁆 No 􀁆  \nChest/Heart problems Yes 􀁆 No 􀁆 Circulatory problems Yes 􀁆 No 􀁆  \nHigh/Low Blood Pressure Yes 􀁆 No 􀁆 Muscular/skeletal problems Yes 􀁆 No 􀁆  \nAllergies Yes 􀁆 No 􀁆 Other Yes 􀁆 No 􀁆  \nIf yes to any of the above, please specify;  \n\n|  |\n| --- |\n|  |\n\nI hereby declare that the above information is true and correct. I state I have no impediment that would restrict me in undertaking the full range of duties of the proposed field work.  \nStudent Signature: Date: / /  \nPlease return this form to Student Central, Charles Darwin University, Darwin, NT 0909. Fax (08) 8946 6642 Email: [student.central@cdu.edu.au](student.central@cdu.edu.au)  \nGEN 114 Updated September 2022 • Controlled by Academic Liaison Unit  \n73390 UniPrint 09.22 PAGE 1 of 2  \n\n| OFFICE USE ONLY |  |  |\n| --- | --- | --- |\n| Received: | Processed by: | Supervisor |\n|  |  | Name: |\n|  | Date: | Signature: |\n|  |  | Date: |\n| Comments |  |  |\n| Trim Number | STU |  |\n\nGEN 114 Updated September 2022 • Controlled by Academic Liaison Unit PAGE 2 of 2","cbCaikvOajhOKSEW","https://ap.wps.com/l/cbCaikvOajhOKSEW","pdf",184564,"English","# Postal Address\n## Emergency Contact\n# Course and Field Work Details\n## Health Concerns\n# Declaration and Submission","[{\"question\":\"What information must students provide in the postal address section?\",\"answer\":\"Students must complete their postal address fields, including number and street or PO Box, suburb/town, state, and country if outside Australia.\"},{\"question\":\"What emergency contact details are required?\",\"answer\":\"Students must provide the emergency contact title, surname, given names, relationship to the student, contact email, contact number, and mobile phone, plus activity description and supervisor information.\"},{\"question\":\"Which health concerns does the form ask about for the proposed field work?\",\"answer\":\"The form asks whether the student has concerns such as epilepsy/fitting, dizziness/balance problems, asthma/respiratory problems, migraines/persistent headaches, visual/eye problems, hearing difficulties, chest/heart problems, circulatory problems, blood pressure issues, muscular/skeletal problems, and allergies; if yes, students must specify details.\"}]","Field Placement Medical Declaration - GEN114 - Last updated September 2022 | PDF"]