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Specialist Medical Application Nov doc Overnight Position

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					                                                                            SPECIALIST MEDICAL APPLICATION

Please note: If you need to correct any error in your application, please initial the correction.


1. Applicant and contact details




Surname


Given Name/s

Previous Name
Please indicate your previous name if that appears on certificates



Date of Birth                                              Place of Birth


Residency status (Australian citizen/permanent/temporary resident)


Professional Address


                                                                            Postcode


Phone: (BH)                                                Phone (AH)


Fax                                                        Mobile


Pager


e-mail address


Postal Address (If different to Professional Address above)




Home Address


                                                                            Postcode




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                                                                    SPECIALIST MEDICAL APPLICATION
PLEASE INDICATE YOUR SPECIALITY/SUB-SPECIALITY AND ANY PROCEDURES FOR WHICH YOU WISH TO
BE APPOINTED TO UNDERTAKE

Internal Medicine

    General Medicine                                              Cardiology

    Endocrinology                                                        Diagnostic Angiography

    Geriatric Medicine                                                   Interventional Procedures

    Neurology                                                            Angioplasty

    Renal Medicine                                                Oncology

    Respiratory Medicine                                          Rehabilitation Medicine

    Infectious Diseases Medicine                                  Intensive Care Medicine

    Bronchoscopy                                                  Palliative Care Medicine

    Renal Biopsy                                                  Dermatology

    Liver Biopsy                                                  Gastroenterology

    Rheumatology                                                         Endoscopy

                                                                         ERCP

    Non Core/ Additional Scope of Clinical Practice
     If you have ticked the above, please forward evidence of the following in relation to the additional scope of clinical
     practice applied for:
    Training                     Experience                   References                     Clinical Audit data if available

Surgery
    General                                                       Ear, Nose and Throat

          Laparoscopic Procedures                                        Adult

    Urology                                                              Paediatric

    Vascular                                                             Head and Neck

    Plastic                                                       Faciomaxillary

    Orthopaedic                                                   Ophthalmology

    Cardiothoracic                                                       Adult

    Thoracic                                                             Paediatric

                                                                  Paediatric

     Non Core/ Additional Scope of Clinical Practice
     If you have ticked above, please forward evidence of the following in relation to the additional scope of clinical
     practice applied for:
    Training                     Experience                   References                     Clinical Audit data if available



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                                                                    SPECIALIST MEDICAL APPLICATION
Emergency Medicine
    Emergency

     Non Core/ Additional Scope of Clinical Practice

     If you have ticked above, please forward evidence of the following in relation to the additional scope of clinical
     practice applied for:
    Training                      Experience                  References                    Clinical Audit data if available

Psychiatry
    Psychiatry

            Specify Speciality

     Non Core/ Additional Scope of Clinical Practice
     If you have ticked above, please forward evidence of the following in relation to the additional scope of clinical
     practice applied for:
    Training                      Experience                  References                    Clinical Audit data if available

Radiology
    Radiology

               Nuclear Medicine

               Interventional

     Non Core/ Additional Scope of Clinical Practice
     If you have ticked above, please forward evidence of the following in relation to the additional scope of clinical
     practice applied for:
    Training                      Experience                  References                    Clinical Audit data if available

Paediatrics
    Paediatrics                                                   Neonatology

     Non Core/ Additional Scope of Clinical Practice
     If you have ticked above, please forward evidence of the following in relation to the additional scope of clinical
     practice applied for:
    Training                      Experience                  References                    Clinical Audit data if available

Anaesthetics
    Adult                                                         Pain Management

    Paediatric                                                            Neonatal

               Elective                                                   Elective

               Emergency                                                  Emergency

                                                                  Obstetrics

                                                                          Epidural




3 of 14                                                                                                   Revised: March 2009
                                                                    SPECIALIST MEDICAL APPLICATION
     Non Core/ Additional Scope of Clinical Practice
     If you have ticked above, please forward evidence of the following in relation to the additional scope of clinical
     practice applied for:
    Training                     Experience                   References                    Clinical Audit data if available

Obstetrics and Gynaecology
    Uncomplicated Deliveries                                      Curettage

    Instrumental deliveries                                       Gynaecological General Surgery

    Caesarean Section                                             Shared Care

    Non Core/ Additional Scope of Clinical Practice
     If you have ticked above, please forward evidence of the following in relation to the additional scope of clinical
     practice applied for:
    Training                     Experience                   References                    Clinical Audit data if available

Pathology
    Anatomical                                                    Haematology

    Histopathology                                                Microbiology

          Bone Marrow Biopsies

     Non Core/ Additional Scope of Clinical Practice
     If you have ticked above, please forward evidence of the following in relation to the additional scope of clinical
     practice applied for:
    Training                     Experience                   References                    Clinical Audit data if available

General Practice
    General Practice

     Non Core/ Additional Scope of Clinical Practice
     If you have ticked above, please forward evidence of the following in relation to the additional scope of clinical
     practice applied for:
    Training                     Experience                   References                    Clinical Audit data if available

Please list any New Technologies or Procedures in which you wish to be appointed.




Signature of Applicant:                                                                  Date:




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                                                                   SPECIALIST MEDICAL APPLICATION
2. Application for scope of clinical practice*
I wish to apply to define my scope of clinical practice to undertake the following (please indicate the position or
classification sought and list the scope of clinical practice being requested):

Position/classification sought




Scope of clinical practice requiring overnight stay




Scope of clinical practice day stay only




* Please attach a copy of your full CV to this application



3. Qualifications (undergraduate/postgraduate/formal recognised training for specialist qualifications)

Qualifications                              University/Organisation                               Year Obtained




Please provide copies of qualifications obtained




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                                                                  SPECIALIST MEDICAL APPLICATION
4. Other training and clinical experience

With respect to your response to Question 2, please provide details of relevant clinical experience and post-
qualification training

Where relevant, include the title of course/s undertaken, the organisation offering the course, and the qualification
obtained.




5. Clinical appointments
  a) Provide details on current and previous clinical appointments (including names of organisations and dates of
     appointment).

Organisation                                                                           Term of appointment

Major Appointment:
                                                                                                    to



Other Appointments:                                                                                 to

                                                                                                    to

                                                                                                    to

                                                                                                    to

                                                                                                    to

                                                                                                    to

  b) Have you ever been denied a defined scope of clinical practice?                          Yes        No

  c) Has your right to practice ever been withdrawn, suspended,
                                                                                              Yes        No
     terminated or reduced?

  If you answered YES to either of the above questions, please provide
  full details.




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                                                                SPECIALIST MEDICAL APPLICATION

6. Academic appointments/teaching experience

Provide details on current and previous teaching appointment (including names of organisations and dates of
appointment). If not applicable, please indicate.


Organisation                                              Status/level      Term of Appointment

                                                                                              to

                                                                                              to

                                                                                              to

                                                                                              to

                                                                                              to

                                                                                              to

                                                                                              to

                                                                                              to

                                                                                              to

                                                                                              to


7. Continuing medical education/Continuing professional development

(a) Provide details on current continuing medical education/continuing professional development involvement,
    including name of the College/Organisation program in which you are enrolled (including maintenance of activity
    logbook).




(b) Have you satisfied the continuing medical education/continuing professional development requirements for your
    college membership/fellowship?

          Yes      No


8. Evidence to support request for Non Core/ Additional Scope of Clinical Practice:
   Please provide evidence of
   a) Post specialist society membership eg GESA membership, Vascular Society Membership.

     b) Referee reports for supporting experience in procedures of higher complexity



7 of 14                                                                                            Revised: March 2009
                                                                          SPECIALIST MEDICAL APPLICATION
9. Clinical review/Peer review

Do you regularly participate in formal quality and peer review activities?
          Yes        No

Provide details on such health based quality/peer review activities.




10. Grand rounds

Are you prepared to conduct a Grand Round once a year?                 Yes         No


(A time for Grand Round will be set prior to finalisation of the credentialing for the next 12-month period.)


11. Regulatory and Indemnity Information


Medical Board of Victoria Registration (Attach a copy of current registration certificate)

Registration number                                Is this Registration temporary?              Yes             No

If yes, provide details.



Current professional indemnity/medical indemnity cover

Expiry date of current policy                                (Attach a copy of current policy renewal certificate)


Have there ever been or are there currently pending any claims, settlements or judgments against you?

Yes        No

Has your medical defence organisation ever excluded any specific area of practice, or terminated or denied
coverage?

Yes        No


If the answer to any of the above is yes, please provide a full explanation of the detail of each matter.




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                                                                 SPECIALIST MEDICAL APPLICATION

Do you have a Provider number?                                  Yes      No
If YES, is it subject to any restrictions?                      Yes      No
If restrictions apply, please provide full details.




Do you have a Prescriber Number?                                Yes      No
If YES please provide details.




Are you a recognised specialist under the relevant
jurisdiction for the purposes of the payment of Medicare        Yes      No
benefits to your patients?


12. Health status

Do you have a disability/health impairment that might compromise your ability to perform any of the cognitive and
physical functions related to the clinical work you may be requires to perform?

Yes        No

If yes, please describe.

13. Disclosure about disciplinary actions/criminal activity


Have you ever been the subject of disciplinary action in the course of your work as a medical practitioner?

Yes        No

If yes, please describe.




Have there been or are there any criminal charges pending against you or have you ever been convicted of any
criminal charges?

Yes        No

If yes, please describe.




9 of 14                                                                                               Revised: March 2009
                                                                   SPECIALIST MEDICAL APPLICATION


Have you ever been convicted of a drug or alcohol related offence?

Yes        No

If yes, please describe.




If you require further space to answer any questions, please attach separate pages, identified with the relevant section
number.




10 of 14                                                                                                 Revised: March 2009
                                                                  SPECIALIST MEDICAL APPLICATION

13. Referees

Please provide details of three independent refereed, preferably at least two in your speciality, who have been in a
position to judge your qualifications and experience during the past five years and who has no conflict of interest in
providing a reference.


Referee 1

Name

Position held currently

Professional address

                                                                        Postcode

Phone (BH)                                            Fax

e-mail address


Referee 2

Name

Position held currently

Professional address

                                                                        Postcode

Phone (BH)                                            Fax

e-mail address


Referee 3

Name

Position held currently

Professional address

                                                                        Postcode

Phone (BH)                                            Fax

e-mail address




11 of 14                                                                                                Revised: March 2009
                                                                           SPECIALIST MEDICAL APPLICATION

14. Agreement/undertakings

I understand that in assessing my application for appointment as a visiting medical practitioner, the health service
will make additional enquiries as to my suitability for the position.




I authorise the health service to conduct a police record check in relation to my history.     Yes          No


I authorise the health service to obtain information relevant to my application from the
Victorian Medical Practitioners Board                                                          Yes          No


I authorise the health service to obtain information relevant to my application from the
medical indemnity insurance organisation.                                                      Yes          No


I authorise access to the above information by representatives of the health service’s
credentialing committees.                                                                      Yes          No


I authorise the health service to seek information as to my past experience, performance
and current fitness. This may occur from time of submitting the application                    Yes          No


If appointed, I agree to familiarise, myself with relevant hospital bylaws, policies and
procedures and to abide by them.                                                               Yes          No


If appointed, I agree to abide by confidentiality and privacy obligations and understand
that breaches may result in the cessation of my appointment.                                   Yes          No

I agree to notify the Director of Medical Services of any event/situation which may impact
on my ability to exercise my scope of clinical practice, whether it be due to medical
registration matters, or otherwise.                                                            Yes          No

If appointed, I agree to comply with relevant ongoing educational certification programs of
my college/association/joint consultative Committee and to furnish details to the health
service on an annual basis as requested by the Director of Medical Services.                   Yes          No



If appointed, I agree to participate in annual performance appraisal.                          Yes          No


I agree to promptly notify the Director of Medical Services of any adverse clinical incident
I am involved in or become aware of.                                                           Yes          No


If appointed, I agree to work within my defined scope of clinical practice and to make a
further application should I seek to extend the scope of clinical practice granted to me.      Yes          No




12 of 14                                                                                               Revised: March 2009
                                                                   SPECIALIST MEDICAL APPLICATION

Declaration

As recommended under the Standard for Credentialling and Defining the Scope of Clinical Practice of the Australian
Council for Safety and Quality in the Health Care with respect to the information required for initial credentialing of a
medical practitioner, the health service requires that the following declaration is completed by applicants.

I hereby declare that I have not been subject to any prior change to the defined scope of clinical practice, or denial,
suspension, termination or withdrawal of the right practise) other than for organisational need and/or capability
reasons) in any other organisation and that I have not been subject to any prior disciplinary action or professional
sanctions imposed by any registration board.

I hereby declare that the information contained in this application is true and correct.




Signature of Applicant:                                                                               Date:
Please note: If for any reason you are unable to sign the Declaration above, please explain the circumstances in the
following pages.




 HAVE YOU ATTACHED?


      Substantial Curriculum Vitae (include previous posts held, names of Hospitals, dates of professional affiliations,
      research, teaching experience and referees.

      A certified copy of current Certificate of Medical Registration Certificate and Fellowship.

      Proof of Medical Indemnity.

      Any supporting documentation relating to clinical or other competencies relevant to this position.

      Letter from college regarding good standing.

      Police Records Check


      Working with Childrens Check




13 of 14                                                                                                 Revised: March 2009
           SPECIALIST MEDICAL APPLICATION




14 of 14                       Revised: March 2009

				
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Description: Specialist Medical Application Nov doc Overnight Position