2016 Application & Registration Form ARF

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1 ABN Training Assessment 2016 Application & Registration Form ARF This form applies to medical practitioners who will be training in Australia and New Zealand. You can apply or register at any time of the year once you have met the relevant criteria. 1. PERSONAL INFORMATION ANZCA ID (if applicable): Family Name: First Name: Preferred Name: Middle Name: (If different from First Name) Gender: M / F Previous or Maiden Name: (If different from Family Name) Date of Birth: Part A - Application 2. If you have previously applied to ANZCA, please indicate any changes to your contact details and proceed to part B. CONTACT ADDRESSES Home Address: Tick if preferred Suburb/City: Postcode: State: Work Address: Tick if preferred Suburb/City: Postcode: State: 3. PHONE NUMBERS Home: Country Area Local Mobile: Country Local Work: Country Area Local Fax: Country Area Local 4. ADDRESSES NOTE: For privacy reasons, we require that all ANZCA Fellows and trainees have a unique address. Primary: Secondary: PAGE 1 OF 7

2 5. INDIGENOUS STATUS ANZCA, in association with the Council of the Presidents of the Medical Colleges, is collecting workforce data to ascertain the numbers of Indigenous Fellows and trainees working in Australia and New Zealand. The following question is voluntary. Do you identify as any of the following? If so, please select one or more categories as appropriate, and indicate your current country of residence. Aboriginal Torres Strait Islander Māori Pacific Islander 6. QUALIFYING MEDICAL DEGREE Name on Degree: Degree Title: University: Date of Graduation: Attach a Passport-Size Photo here Width: mms Height: mms 7. MEDICAL REGISTRATION Please provide a copy of your medical registration. Trainees are required to notify the College should registration conditions change. Registration Number: Signature Please sign within the limits of the box Part B - Prevocational medical education and training (PMET) If you have previously supplied this information, please proceed to part C. You must demonstrate that you have met the Prevocational Medical Education and Training required to undertake specialist training. As an applicant, you must have at least 52 weeks of PMET. (You are encouraged to submit 104 weeks of PMET if already completed.) To register as an ANZCA trainee, you must have a total of at least 104 weeks (FTE) PMET experience, of which, no more than 52 weeks experience can be in any combination of anaesthesia, intensive care medicine or pain medicine. Up to 6 weeks leave may be included for each 52 weeks of PMET. From To Hospital and country Type of Experience Time (In weeks) Leave taken (In weeks) Full/part time* Total: *If part time, please indicate FTE between 0.1 and 1 PAGE 2 OF 7

3 Part C - Registration Only complete section C if you are registering as a trainee. Applicants should proceed to part D. 8. ROTATION AND HOSPITAL PLACEMENT(S) Please indicate your rotation status, i.e., the name of your rotation or if you are an independent trainee (see notes). Please also list your placement(s) and the dates for the entire hospital employment year. Trainees must commence training in an anaesthesia training position. Country OR State (if Australia) Rotation Name OR Independent Rotation Status: Training Site State/Country Full/Part- Time Type of Experience From To 9. VERIFICATION FROM ROTATIONAL SUPERVISOR OR SUPERVISOR OF TRAINING In order to achieve registration, an ANZCA supervisor of training or rotational supervisor must formally verify that a trainee is in a post which complies with all the requirements for training ANZCA trainees. These requirements include, but are not necessarily limited to, appropriate levels of supervision, a suitable mix of cases including acute emergency cases, all the required ANZCA assessment processes, and comprehensive access to all the relevant educational, teaching and quality assurance programs within the department. I can confirm Dr will be working in a post which complies with all the requirements for training ANZCA trainees. Name of Supervisor: Signature: Part D - Declaration and Payment 10. DECLARATION OF APPLICANT I solemnly declare that the statements made in this application are true and accurate. Signature of applicant: Date: PAGE 3 OF 7

4 11. PAYMENT DETAILS Please tick to indicate which fee(s) you intend to pay. AUS Step 1 Application Fee Step 2 Registration fee AUD 655 Includes 10% GST AUD 2122 NZ NZD 863 Includes 15% GST NZD 3082 Includes 15% GST Annual training fee Select the relevant training fee from the table below. Training start Australia New Zealand Includes 15% GST November 2015 AUD NZD December 2015 AUD NZD January 2016 AUD NZD February 2016 AUD NZD March 2016 AUD NZD April 2016 AUD NZD May 2016 AUD NZD June 2016 AUD NZD July 2016 AUD NZD August 2016 AUD NZD September 2016 AUD NZD October 2016 AUD NZD November 2016 AUD NZD December 2016 AUD NZD Cheque, Bank Draft or Money Order attached (Payable to ANZCA and crossed Not Negotiable.) Credit Card (please tick one) Credit Card Number: Expiry Date: Name on Card: Cardholder s signature: 2016 Application & Registration Form (Notes) Registering as an ANZCA trainee is a two step process. In the first step (Application) you provide identification, and information on your medical degree and PMET experience to assess your eligibility. Applicant status is valid for two full calendar years, after which, if you have not registered, you must reapply before registering. The second step (Registration) is undertaken once you have met the qualifications required of an ANZCA trainee. The two steps can be done separately or together. Once all the correct documentation has been submitted and payment made, processing will normally be done within five working days. Application and Registration Requirements Application is part of the registration process but may be done separately. You must be a registered medical practitioner and have completed at least 52 weeks of Prevocational Medical Education and Training (PMET) in order to be an applicant. To qualify as an ANZCA trainee in an ANZCA-approved department of anaesthesia you must be working at that training site in a way which complies with all the requirements for training ANZCA trainees. These requirements include, but are not necessarily limited to, appropriate levels of supervision, a suitable mix of cases including acute emergency cases, the ANZCA PAGE 4 OF 7

5 2016 Application & Registration Form (Notes) assessment processes, and comprehensive access to all the educational, teaching and quality assurance programs. Applicant status is valid for two full calendar years, e.g., if you are assessed in September 2014, you will be a current applicant until 31 December Until you register as a trainee with the College, you must pay an application maintenance fee (AMF) at the start of each hospital employment year. Failure to pay the AMF by March 31 will result in your file being archived. If you have not yet registered by the end of two full calendar years, or if you have not paid the required AMF, your applicant status will be withdrawn. You will need to reapply before registering. Applicants whose status has become revoked will need to submit a letter to the Director of Professional Affairs (Assessor) outlining why the status should be renewed for another period. Personal and Contact Details ANZCA ID: If you have applied, you will have been provided with an ANZCA ID. Previous or Maiden Name: If your family name has changed since birth by marriage or deed poll, you must include a copy of your Marriage Certificate, Change of Name Notice or your Medical Registration indicating a change of name. Photograph and signature You must supply one passport quality photograph. This will be used to verify identity at exams. Please secure the photograph to the form. Signature: Please sign your usual signature within the boundaries of the signature box. This may be used for identification purposes. Qualifying Medical Degree You must include a certified copy of your degree in English. Name on Degree: If the name on your degree varies from the name on your application, you must show proof of Change of Name, e.g., Marriage Certificate or Change of Name Notice. Medical Registration Provide a certified copy of your current medical registration, i.e., evidence of license to practice medicine. Prevocational Medical Education and Training You must have completed a minimum number of weeks PMET prior to registering with the College: At least 52 weeks PMET required for applicants At least 104 weeks PMET in order to register ANZCA requires an original hospital document or a copy certified by a Justice of the Peace or an equivalent official that confirms required PMET experience. This must include dates of appointments and type of experience. Leave: Please indicate the amount of leave taken in weeks. You may include up to 12 weeks leave in your PMET. Type of Experience: Indicate the area of training, e.g., anaesthesia, intensive care medicine, pain medicine, clinical medicine, emergency. Rotation and hospital placements This section should only be filled out by trainees who are in approved training at an approved training site. Rotation Status: The Rotation Status has two components: State (if Australia) OR Country (if New Zealand) Name of Rotation OR Independent The name of rotations can be found on edu.au/trainees/supervisory-roles/. Training Site: Indicate the training site in which you will be training during the hospital employment year. Full/Part Time: Part-time training requires prospective approval and must be at least 0.5 FTE. The application form can be found on training/2013-training-program/special-requests Type of Experience: Clinical Anaesthesia or Intensive Care Medicine Please note: A total of at least 22 weeks full-time equivalent continuous clinical anaesthesia time (interrupted only by normal leave and/or one week other clinical training) must be completed in introductory training. No more than 1 week training in intensive care may be completed in introductory training. Verification from Supervisor To achieve registration as a trainee, an ANZCA supervisor of training or rotational supervisor must formally verify that a trainee is in a post which complies with all the requirements for training ANZCA trainees. This applies to all ANZCA training sites. In addition to this verification, formal confirmation of a trainee s appointment to an anaesthesia training position at an accredited training site must also be provided. Payment details Please review the requirements, and indicate the amount you intend to pay. If you select the incorrect amount, you will be contacted in order to authorise payment of the full amount required before your registration is processed. Application fee: You must pay this fee if you have never applied to ANZCA before or your applicant status has lapsed. Acceptance as an applicant does not guarantee registration as an ANZCA trainee. You must also meet all the eligibility requirements for trainee registration. Registration fee: You must pay this fee if: 1. You are currently an applicant 2. You have obtained an anaesthesia training position and 3. You have met all of the PMET requirements You may pay both the application and registration fees at the same time. You must also pay the annual training fee prior to the start of training. Note: All fees are non-refundable. Please ensure that all documentation is complete prior to submitting your application PAGE 5 OF 7

6 2016 Application & Registration Form (Checklist) CHECKLIST FOR STEP 1 APPLICATION, AND STEP 2 REGISTRATION The following lists the submission requirements for application and registration. Documentation Step 1 Application Passport-size photograph Step 2 Registration Steps App & Reg Certified copy* (in English) of your qualifying Medical Degree showing date of graduation A copy of your birth certificate or identity page of your current passport Certified copy* of your current Medical Registration Submitted in initial application Signed Applicant agreement No Signed Library User Agreement (page 6 of this form) A copy of your Marriage Certificate, Change of Name Notice or your Medical registration indicating a change of name. If applicable If applicable If applicable Certified copy* of your Prevocational Medical Education and Training (PMET) on an original hospital document Completed payment form with payment of relevant fee Signed Training agreement Minimum of 52 weeks Residual time totalling a minimum of 104 weeks Submission of 104 weeks PMET may reduce registration processing time Minimum of 104 weeks App fee Reg fee App + Reg fee A letter on original hospital letterhead, signed by an appropriate, authorised individual, confirming your appointment to an ANZCA accredited training site, including the start date of AVT Not required Verification from Rotational Supervisor or Supervisor of Training Annual training fee * If you are submitting a photocopy of an original document, it must be certified by Justice of the Peace (or equivalent official if outside Australia) and have the following information written on it. Certified True Copy of Original Document written on the photocopy Date of certification Signature of certifier Name and position of the certifier Send the completed form to: ANZCA Training Assessment Unit PO Box 6095 Melbourne, Victoria 3004 AUSTRALIA For any enquiries, please PAGE 6 OF 7

7 If available ABN Library Library User Agreement LUA 1. PERSONAL INFORMATION User Agreement for Document Supply Requests made via Electronic Mail Family Name: First Name: 2. ADDRESSES Primary: Secondary: 3. DECLARATION Agrees with the Library that: 1. All copies requested by me under this agreement are required for the purpose of research or study, will not be used for any other purpose, and have not previously been supplied to me by the library. 2. The declaration in clause 1 applies to all requests made by me in accordance with clause The library may treat as signed by me any request and declaration made under subsection 49(1) of the Copyright Act 1968 that records that it was sent from my address. 4. I understand that it is an offence under section 203F of the Act to make a declaration under section 49 that I know, or ought reasonably to know, is false or misleading in a material particular, and I will not allow any requests to be signed in a manner provided under clause 3 (above) without my authority. 5. All requests and declarations must include at least the following declaration as well as the requestor s College ID: This request is made pursuant to my user agreement with the Library Australian and New Zealand College of Anaesthetists. I declare that any copy requested is required for the purpose of research or study, will not be used for any other purpose, and has not previously been supplied to me by the library. Signature: Date: PAGE 7 OF 7

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