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Internship Report Form M11

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                                      Internship Report Form M11

 The purpose of this form is to provide the Board with sufficient information to consider removal of conditions from an
 intern’s general registration. This form must be completed by the intern’s Director of Clinical Training (DCT) at the
 completion of internship. It is the responsibility of the DCT to ensure that the information provided to the Medical Board of
 Queensland is true and accurate.



1. Intern details
 Family Name / Surname

 Given Names

 Registration No.

 Date of commencement (of internship)

 Date of completion (of internship)

 Name of teaching Hospital(s)


2. Record of Internship - Terms Undertaken
 An internship must include at least 10 weeks practical experience and accredited training in Medicine - other than emergency medicine,
 Surgery, and Emergency medicine.

 If a core term is not completed satisfactorily (including borderline progress) the term is not considered to be part of the required 52 weeks
 and the intern must undertake further training as required.

 The Board recognises that a mid term assessment may identify performance issues requiring the implementation of an Improving
 Performance Action Plan (IPAP). If at the end of term assessment the DCT (or term supervisor) is confident that the issues raised in the
 IPAP have been resolved it is the DCTs responsibility to determine whether the whole term is deemed as satisfactory.


   Unit/Department Rotation                                                                                                  No. of
                                      (C)º     Facility where term was                                                                   (S)³
 [as listed on PMCQ accreditation                                                 Start Date             Finish Date         weeks
               matrix]
                                      (N)¹            undertaken                                                                         (U)4
                                                                                                                             (FTE²)




                    TOTAL NUMBER OF WEEKS (FTE2) OF INTERNSHIP UNDERTAKEN

                                                                                                 3
º (Compulsory) Core term                       ² Full Time Equivalent                                End of Term Progress: Satisfactory
                                                                                                 4
¹ (Non-Compulsory) Elective term                                                                     End of Term Progress: Unsatisfactory
    Form M11 Version 26/11/2009                                                                                                Page 1 of 3
2a. Unsatisfactory Progress
Was a term assessed as “Unsatisfactory”
                                                                                              YES                   NO
If Yes, you must attach the Improving Performance Action Plan, details of its
implementation and outcome(s).


3. Record of Leave
Annual and Special Leave (the maximum permitted annual and special leave is 5 weeks)

                                              Start Date       Finish Date            Start Date            Finish Date

                                              dd / mm / yyyy   dd / mm / yyyy         dd / mm / yyyy        dd / mm / yyyy
Please indicate dates of leave taken
                                              Start Date       Finish Date            Start Date            Finish Date

                                              dd / mm / yyyy   dd / mm / yyyy         dd / mm / yyyy        dd / mm / yyyy

Total amount of leave taken
                                              Weeks:                                  Or Days:
                                                                                      Name of term/s:
Was any leave taken during a core term?             NO         YES


Has the intern made up the time?                    NO         YES          Ensure that this is detailed in the attached
                                                                            Leave Report

Did the intern take leave in excess of 5                       YES          Ensure that this is detailed in the attached
                                                    NO
weeks?                                                                      Leave Report

Has the intern made up the time?                    NO         YES          Ensure that this is detailed in the attached
                                                                            Leave Report



Sick Leave (the maximum permitted sick leave is 10 days)


                                                               YES     If yes please indicate provide dates of leave taken:
Did the intern take sick leave in excess of
10 days?                                            NO
                                                               Start Date             Finish Date

                                                               dd / mm / yyyy         dd / mm / yyyy
                                                                                      Name of term/s:
Was this during a core term?                        NO         YES


Has the intern made up additional time?             NO         YES          Ensure that this is detailed in the attached
                                                                            Leave Report


4. Recommendation
Do you in your role as Director of Clinical Training recommend removal of
                                                                                              YES                   NO
internship conditions from the intern’s general registration?


If the removal of internship conditions is not recommended outline why this recommendation has been made. The report
should include recommendations to the Medical Board regarding the amount of time and type of further experience
required.




   Form M11 Version 26/11/2009                                                                                         Page 2 of 3
5. Supporting Documentation – if applicable
Please confirm the inclusion of the required document by placing a  in the “Attached” column.
                                                                                                                      Office
             Information required                   Description of Documentation Required               Attached
                                                                                                                       Use
 Improving Performance Action Plan             To be provided if any term was deemed to be
 (IPAP)                                        unsatisfactory

                                               Full details on circumstances of recommendation,
 Report supporting recommendation
                                               including proposal on amount of time and type of
 NOT to remove intern conditions
                                               further experience required
                                               Full details on circumstances and reasons for leave
 Leave Report
                                               taken during a core term, or where excess leave
                                               was taken



6. Declaration
 I certify that –

 ………………………………………………………………………….…………………………………………………………………….…
                         (name of intern)

 has served as an intern in ………………………………………………………………………….……………………Hospital (s) for a
 period or periods amounting to a total of 52 weeks (*FTE).

 I declare that –

     the above statements are true and correct;

     all documents and supporting material lodged with this form are true and correct.

 I acknowledge that –

     the provision of this report is mandated by Section 92 of the Medical Practitioners Registration Act 2001;

     I am aware that legislative penalties apply for providing false and misleading information;

     Section 272 of the Medical Practitioners Registration Act 2001 provides protection for persons involved in supervising
      registrants.


 Print Name



 Signature




 Position

 Date                                                                        dd / mm / yyyy



Send the completed form, including all necessary supporting documents, to:


Registration Services Program                                         or deliver to:
Medical Board of Queensland                                           Level 11, Forestry House
GPO Box 1667                                                          160 Mary Street
BRISBANE QLD 4001                                                     BRISBANE QLD 4000




     Form M11 Version 26/11/2009                                                                                     Page 3 of 3

				
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Description: Internship Report Form M11