ACO Av Med Form 1 (Paper) (1).xls

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2						ACO Av Med Form 1
3	OFFICIAL - SENSITIVE - MEDICAL (WHEN COMPLETE)
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5	CONDITIONS REQUIRING MEDICAL ASSESSMENT FOR VGS GLIDING/AEF FLYING
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7	TO COMPLETE TICK RESPONSE Y/N
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9	CONDITIONS REQUIRING SCRUTINY	YES / NO				IF YES
10	Has the Cadet had a recent immunisation (inoculation / vaccination) or given a blood donation?	No	o	Yes	o	DO NOT FLY WITHIN 24HRS OF TREATMENT. IF APPLICABLE GIVE DATE OF TREATMENT IN FURTHER INFO BOX.
11	Does the Cadet suffer any acute or chronic illness/condition or started a new course of treatment which would be aggravated by flight? This includes unstable illnesses which are likely to cause sudden incapacitation within the timescale of flight.	No	o	Yes	o	DO NOT FLY UNTIL RECOVERED
12	Is the Cadet impaired by an injury limiting the use of their limbs? For example sprains, strains or broken bones?	No	o	Yes	o	DO NOT FLY UNTIL RECOVERED
13	Is the Cadet suffering from an ear, nose, throat or sinus conditions?	No	o	Yes	o	DO NOT FLY UNTIL RECOVERED
14	Is the Cadet pregnant?	No	o	Yes	o	DO NOT FLY
15	Does the cadet have a condition that requires the use of oxygen therapy?	No	o	Yes	o	DO NOT FLY
16	Does the Cadet have a limited exercise capacity or tolerance, due to chest (heart or lung) illness or disease? If the Cadet can walk 50 yards/metres at a normal pace or climb one flight of stairs without severe breathlessness select NO.	No	o	Yes	o	DO NOT FLY
17	Does the Cadet experience fits, faints or blackouts (including epilepsy)	No	o	Yes	o	DO NOT FLY
18	Has the Cadet undergone a recent surgical procedure or had a general, spinal or epidural anaesthetic? Note: For dental (local) anaesthetics Cadets are not permitted to fly for 24Hrs after procedure.	No	o	Yes	o	DO NOT FLY UNTIL FULLY RECOVERED - MINIMUM 7 DAYS. IF APPLICABLE GIVE DATE OF TREATMENT IN FURTHER INFO BOX.
19	Does the cadet suffer from a pneumothorax (a 'collapsed lung' where air is trapped between lung and chest wall)?	No	o	Yes	o	DO NOT FLY FOR 1 MONTH FROM LAST TREATMENT. IF APPLICABLE GIVE DATE OF TREATMENT IN FURTHER INFO BOX.
20	Does the Cadet have an acute, unstable or untreated psychiatric conditions. For example: Fear of flying, claustrophobia or panic attacks.	No	o	Yes	o	DO NOT FLY UNTIL TREATED AND SYMPTOMS STABLE
21	Does the Cadet have any stable chronic disease not covered above or any disease with a sudden or unpredictable onset or deterioration.	No	o	Yes	o	ATC SQN OC / CCF (RAF) SECT CDR START F6424 PROCEDURE - REF: ACTO 31 / 32
22	Does the Cadet have stable Asthma (STEP 1 or 2)? The Cadet is considered unstable if they have night symptoms waking them more than once a week or if they require daytime reliver medication more than 3 times a week. If Cadet has used oral steroids or antibiotics to treat Asthma within the last 6 months start F6424 procedure.	No	o	Yes	o	FIT TO FLY IF CONDITIONS STABLE - MUST CARRY MEDICATION IN FLIGHT
23	Does the Cadet have Asthma which is not stable (STEP 3 or above)? This includes the use of long-acting beta agonists, oral treatments or high-dose steroids?	No	o	Yes	o	ATC SQN OC / CCF (RAF) SECT CDR START F6424 PROCEDURE. REF: ACTO 31 / 32
24	Does the Cadet have Type 1 Diabetes. Note: Type 1 Diabetes is acceptable if blood sugars are well controlled. An insulin pump (if used) must be able to be moved as to be fitted in to flying clothing. Check sugars prior to flight. Type 2 Diabetes is acceptable.	No	o	Yes	o	FIT TO FLY IF CONDITIONS STABLE - MUST CARRY GLUCOSE IN FLIGHT
25	Does the Cadet have a haematological (blood) disorder? For example: Sickle-Cell disease, Anaemias or Haemophilia. Note: All haematological disorders should be considered.	No	o	Yes	o	ATC SQN OC / CCF (RAF) SECT CDR START F6424 PROCEDURE. REF: ACTO 31 / 32
26	Does the Cadet have a history of Migraines?	No	o	Yes	o	RISK ASSESS. DO NOT FLY WITH SYMPTOMS OR ATTACK CAN OCCUR WITHIN FLIGHT TIMEFRAME
27	Does the Cadet have a cognitive, emotional, behavioural or developmental condition? For example: ADHD, conduct disorders, dyspraxia and autism spectrum disorders.	No	o	Yes	o	ATC SQN OC / CCF (RAF) SECT CDR START F6424 PROCEDURE. REF: ACTO 31 / 32
28	Is the Cadet impaired by any stable injury, illness or congenital condition limiting mobility or use of limbs?	No	o	Yes	o	ATC SQN OC / CCF (RAF) SECT CDR START F6424 PROCEDURE. REF: ACTO 31 / 32
29	Does the Cadet have any psychiatric disorder?	No	o	Yes	o	ATC SQN OC / CCF (RAF) SECT CDR START F6424 PROCEDURE. REF: ACTO 31 / 32
30	Does the Cadet suffer from any severe allergy (requiring the use epipen or equivalent)? Cadets with very severe allergies which are unstable or unpredictable are unfit for flight. Those likely to be exposed to allergens in flight (Rubbers, Plastics) are also unfit to fly.	No	o	Yes	o	FIT TO FLY IF CONDITIONS ARE ACCEPTABLE TO FLIGHT ENVIRONMENT. MUST CARRY MEDICATION IN FLIGHT
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33	Further Information:
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39	Cadet Name:
40	Cadet Name:
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42	ATC Sqn / CCF (RAF) Section:			ATC Wing / CCF (RAF) Contingent:
43	ATC Sqn / CCF (RAF) Section:			ATC Wing / CCF (RAF) Contingent:
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45	Signature of Cadet:
46	Signature of Cadet:
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48	Date:
49	Date:
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51	Declaration: I hereby declare that I have carefully considered the statements made above and that to the best of my belief they are complete and correct and that I have not withheld any relevant information or made any misleading statements. I also confirm that should the cadets medical history change since the medical examination above, I will ensure that the relevant ATC Sqn OC / CCF (RAF) Section Cdr is informed and a new ACO Av Med Form 1 is produced.
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53	Parent/Guardian Signature:
54	Parent/Guardian Signature:
55						VERSION 1.02 (PAPER)
56	PERIOD OF VALIDITY: VALID FOR THREE MONTHS FROM DATE OF DECLARATION
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60	GUIDANCE NOTES FOR COMPLETION ACO Av Med Form 1
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62	1. Certain medical and physical conditions are incompatible with flying as they could place the cadet at risk and compromise Air Safety. A list of medical conditions incompatible with gliding/flying training or which may require further medical scrutiny can be found overleaf.
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64	2. This Form should be completed by ticking either Yes or No to the question asked. The form indicates the actions required by the ATC Sqn OC / CCF (RAF) Section Cdr to gain medical clearance if any responses are Yes.
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66	3. All qusetions (sections) should be completed in full . Failure to complete the form in full will result in non-acceptance of the form.
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68	4. The ACO Av Med Form 1 must be signed by you and your parent/guardian (if you are under 18 years of age) to validate the certificate.
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70	5. To satisfy gliding/flying medical requirements, cadets must be in possession of a completed ACO Av Med Form 1. Failure to be in the possession of a completed and signed Av Med Form 1 will invalidate the eligibility of a cadet to undertake gliding training. VGS/AEF staff are directed to refuse flying training to cadets not in possession of the relevant signed forms at the point of delivery.
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72	6. Period of validity: Although this declaration is valid for three months from the date of signing, it is immediately invalidated should any change in fitness or health occur.
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74	7. Reduction in Medical Fitness: If referred for a medical investigation or procedure, or after any serious illness or injury, you must reassess your medical fitness to fly. It is your responsibility to ensure that a new ACO Av Med Form 1 completed before undertaking aviation activity.
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76	8. After Signing: Cadets are to hand the ACO Av Med Form 1 to your ATC Sqn OC / CCF (RAF) Section Cdr for scrutiny.
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