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BACKGROUND INFORMATION: Plastics All Type 4 Positions
Hospital Role Delineation within that discipline & Level of Service.

Site                                                                          Hospital Role Delineation *

St George Hospital                                                            Level 6 Adult & Level 4/5 Paediatrics
Prince of Wales Hospital                                                      Level 6 Adult
Sydney / Sydney Eye Hospital                                                  TBA
The Sutherland Hospital                                                       Level 4 Adult and Paediatric
Sydney Children's Hospital                                                    Level 6 Paediatric
War Memorial Hospital
Garrawarra
Royal Hospital for Women                                                      Consultative Neonatal & Women’s Health

Types of Positions +                         No of          Brief Position Overview.
                                            VMP’s to
                                              be
                                           appointed


                                                            POW / RHW / Sydney Hospitals with an acute general Plastics on-call
                                                            roster for POW / RHW and phone advice to Sydney Hospital. There is
    Type 4A:                                                subspecialty streaming at POW for elective care for head and neck surgery,
    Sydney Eastern                             7            craniofacial, maxillofacial, breast reconstructive and hand and microsurgical
    Suburbs Sector                                          management. Note: there are no paediatric privileges offered at POW.
                                                            Clinical privileges may be offered and required at S / Sydney Eye Hospital
                                                            for elective waiting list cases and limited clinical privileges in plastic and
                                                            breast reconstructive surgery at RHW may be available for suitable
                                                            candidates. There are admitting, consultation, outpatient and theatre
                                                            privileges at POW and possibly elective waiting list surgical privileges at S /
                                                            Sydney Eye Hospital.


                                                            St George / The Sutherland Hospitals with an acute general Plastics on-call
     Type 4B:                                               roster for St George Hospital and phone advice to Sutherland Hospital.
     Sydney Southern
                                               3            There is subspecialty streaming at St George for elective care for head and
     Suburbs Sector                                         neck surgery, trauma, craniofacial, maxillofacial, breast reconstructive and
                                                            hand and microsurgical management If appointed with privileges in
                                                            maxillofacial or hand services it is a requirement to participate in the
                                                            relevant on call rosters. Note: There are Level 4 district level paediatric
                                                            privileges required at both sites in this position. There are admitting,
                                                            theatre, outpatient, consultation and on-call at St George with elective
                                                            waiting list theatre and consultation privileges at The Sutherland Hospital.


                                                            SCH (with cross-appointment to RHW) with acute general paediatric
     Type 4C:                                  6            Plastics on-call based at SCH with phone advice to Sydney, St George and
     Area Tertiary                                          Sutherland Hospitals. There are admitting, theatre, outpatient, on-call and
     Paediatrics                                            consultation privileges at SCH with consultation privileges at RHW.
                                                            Subspecialty streaming occurs with elective surgery at SCH.




*           Detailed Hospital Role delineation documents are available on request: In general, Level 6 facilities have a
            multi-disciplinary highly specialised team and appropriate equipment to deal with the most complex surgical
            conditions in that specialty 24 hours a day, seven days a week. Level 4 services are focussed on local and
            generally less complex cases that have an unlikely need for high dependency care and sub-speciality services.
            Level 4 facilities will in general have limited after hours services and in that discipline will be networked with
            Level 6 services for complex patient care.

+           Individuals appointed to each type of appointment must be willing and able to meet
            the needs of the relevant facilities as outlined in that background information.




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                                 VMP: PLASTICS SURGEON APPLICATION FORM
                                                                   Must be completed by all applicants

NAME:                   …………………………………………………………………………………………

Position Types Available                                      Position(s)         Preferred Category
                                                              Applied             of appointment you
(number available)                                            for*                wish to apply for +
                                                              (please tick box)   (Delete appointment not suitable)

Type 4A Sydney Eastern Suburbs
                                                                                  VMO / HMO / Other
POW/Sydney Hospital / RHW

( 7 VMP’s to be appointed)


Type 4B Sydney Southern Suburbs                                                   VMO / HMO / Other

St George / Sutherland Hospitals
( 3 VMP’s to be appointed)
Type 4C Area Tertiary Paediatrics:                                                VMO / HMO / Other

Sydney Children’s and RHW

( 6 VMP’s to be appointed)

Contact details……………………………………………………………………………………………………………
Postal address……………………………………………………………………………………………………………
Street……………………………………………………………………………………………………………………….
Suburb / city ……………………………………………………..State ………. Postcode………………………
Home address …………………………………………………………………………………………………………...
Phone Bus: …………………………….. Home ……………………………. Fax …………………………………..
Email ………………………………………………………………………………………………………………………

This application must be accompanied by the following documentation.
 Comprehensive curriculum vitae.
 Copy of current registration with NSW Medical Board/evidence registrable.
 Copy of specialist qualification & evidence for special privileges if sought.
 Copy of current medical indemnity insurance.
 Commentary on suitability for appointment (refer to separate Selection Criteria form).
 Signed consents for a Criminal Record Check and Working with Children Declaration.

I, Dr ……………………….. certify that the information supplied with this application is correct and hereby
authorise South Eastern Sydney Area Health Service to obtain information as to my past performance as a
medical practitioner.

Signed: ………………………………………..                          Date: …… / …… / 20……
*       more than one position can be applied for but you must submit information on all selection criteria for
        each position for which you wish to be considered.
+       VMO: Contract according to Hungerford determination for clinical activity.
        HMO: Clinical appointment is honorary ie no remuneration is available for public patient activity.
        Consultant Emeritus: This is an honorary appointment with consultation privileges only and usually
        only suitable for individuals with outstanding clinical expertise towards the end of their clinical
        careers.

All positions are appointed at an Area level. The continuance of these positions will be subject to the outcome of South
Eastern Sydney and Illawarra Area Health Service Clinical Services Plan (CSP). The CSP will be negotiated with
representation from your specialty group. The CSP may result in a change in service delineation for the facility and/or
reconfiguration of services across the Area concerning your specialty’s service provision/delivery.
This means that your position and privileges may change to allow for the CSP to be successfully implemented. You will
be given reasonable and appropriate notice of at least three (3) months concerning any changes that may affect you.
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                                                      (Must be completed by all applicants)

               APPLICATION FOR APPOINTMENT AS VISITING MEDICAL PRACTITIONER
                                   SELECTION CRITERIA

All applicants for appointment as a Visiting Medical Practitioner are required to complete pages 4 –
10. Additional A4 pages may be attached if necessary.

ESSENTIAL:

1. Current NSW Medical Board Registration or eligible for same (copy to be attached).
2. Evidence of Recognised or equivalent Specialist qualification in Plastic Surgery (copy to be attached).
      Eg FRACS (Plastic Surgery).
3. Evidence of current medical indemnity insurance (copy to be attached).
4.    Demonstrated relevant current clinical practice at a high standard relevant to the years of experience.
      ____________________________________________________________________________________________
      ____________________________________________________________________________________________
      ____________________________________________________________________________________________
      ____________________________________________________________________________________________
5.    Demonstrated commitment to quality improvement, patient safety and risk management.
      ____________________________________________________________________________________________
      ____________________________________________________________________________________________
      ____________________________________________________________________________________________


6.    Preparedness to participate in any on call roster and other clinical roles as advertised, if requested and
      credentialled.
      __ Yes
      ____________________________________________________________________________________________
      ____________________________________________________________________________________________
7.    Demonstrated commitment to continuing self education and development (eg MOPS, CME certificates, peer review,
      QA)
      ____________________________________________________________________________________________
      ____________________________________________________________________________________________
      ____________________________________________________________________________________________


8.    Demonstrated ability, fitness and wellbeing to fulfil the full scope of clinical privileges advertised in the position.
      ____________________________________________________________________________________________
      ____________________________________________________________________________________________
      ____________________________________________________________________________________________
9.    Evidence of commitment to the goals of an organisation in which you have worked beyond direct patient care.(eg
      committee representation/participation)
      ____________________________________________________________________________________________
      ____________________________________________________________________________________________
      _____________________________________________________________
10. Demonstrated participation in teaching and training of medical officers both undergraduate and post-graduate.
      ____________________________________________________________________________________________
      ____________________________________________________________________________________________
                                                            Applicants name ………………………………………………….
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                                                      (Must be completed by all applicants)
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HIGHLY DESIRABLE:
Evidence of commitment to providing high quality health services and continuity of care to the local
population of that facility network as determined by South East Sydney and Illawarra Area Health
Service.




DESIRABLE:
1.          Demonstrated good communication, organisational and interpersonal skills.
            ________________________________________________________________________
            ________________________________________________________________________
            ________________________________________________________________________
            ________________________________________________________________________
2.          Demonstrated ability to work in a multidisciplinary team.
            ________________________________________________________________________
            ________________________________________________________________________
            ________________________________________________________________________
            ________________________________________________________________________
3.          Demonstrated ability to adapt clinical practice in accordance with emerging trends.
            ________________________________________________________________________
            ________________________________________________________________________
            ________________________________________________________________________
            ________________________________________________________________________
4.          Preparedness to participate in provision of services at an Area level established during the
            appointment period following an appropriate consultative process.
            __ Yes                       No If No, please comment further.
            ___________________________________________________________________________
            ________________________________________________________________________


5.          Evidence of contribution to research.
            ________________________________________________________________________
            ________________________________________________________________________
            ________________________________________________________________________
            ________________________________________________________________________
            ________________________________________________________________________




                                                                           Applicants name: ______________________
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6.          Demonstrated training, interest, experience and skills required by the position type
            Type 4A Position Sydney Eastern Suburbs : (POW / Sydney Hospital & RHW) Positions Only
                     Special area of interest, training and expertise in the management of the following tertiary activity:
                         o     Head and neck surgery (at least 2 positions)
                         o     Hand and micro surgery (at least 1 position)
                         o craniofacial surgery (at least 1 position)
                         o maxillofacial surgery
                         o breast reconstruction surgery (at least one position)
                         o skin malignancies (at least one position)
                  _____________________________________________________________________________________
                  _____________________________________________________________________________________
                  _____________________________________________________________________________________
                  _____________________________________________________________________________________


                       Willingness to manage elective POW Hospital waiting list patients at either POW or Sydney Hospitals.
                                    Yes                     No (If no, please comment)
                  _____________________________________________________________________________________
                  _____________________________________________________________________________________


                  Type 4B Positions Sydney Southern Suburbs: (St George/Sutherland Hospitals) Positions Only
                     Special area of interest, training and expertise in the management of the following tertiary activity:
                         o Head and neck surgery (at least 2 positions)
                         o     Trauma (at least 1 position)
                         o     Hand and micro surgery (at least 1 position)
                         o craniofacial surgery (at least 1 position)
                         o maxillofacial surgery
                  _____________________________________________________________________________________
                  _____________________________________________________________________________________
                  _____________________________________________________________________________________


                       Willingness to manage elective St George Hospital waiting list patients at either St George or
                        Sutherland Hospitals.
                                    Yes                     No (If no, please comment)
                  _____________________________________________________________________________________
                  _____________________________________________________________________________________
                  Type 4 C Positions Area Tertiary Paediatric SCH (& RHW) Positions only
                     Demonstrated additional training and expertise in tertiary paediatrics.
                        Either 12-month paediatric Plastics fellowships within the last 5 years or
                        Regular (weekly) significant tertiary level acute paediatric Plastics expertise in the last 5 years.
                  _____________________________________________________________________________________
                  _____________________________________________________________________________________
                  _____________________________________________________________________________________
                     Special area of interest:
                        Craniofacial surgery (at least one position)
                        Vascular malformations (at least one position)
                        Microvascular reconstructive surgery (at least one position).
                        Hand surgery.




                                                                             Applicants name: _______________________



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7.          Care and Management of Children. (Type 4B & 4C positions only)
            (Applies for Sydney Children’s Hospital, St George Hospital and Sutherland Hospital))


            Note: Applicants for positions at Sydney Children’s Hospital (type 4C) will be expected to have
            substantial additional paediatric skills/experience to be suitable for roster responsibilities (e.g. 12
            months paediatric fellowship or registrar capability, significant tertiary level acute paediatric expertise
            in the last 5 years)


Please present evidence of (i) formal training and (ii) experiential learning in the management of
children less than 12 years old:

i)          Evidence of formal training …………………………………………………………………………

            ………………………………………………………………………………………………………….

            ………………………………………………………………………………………………………….

            ………………………………………………………………………………………………………….

            ………………………………………………………………………………………………………….

            ………………………………………………………………………………………………………….

            ………………………………………………………………………………………………………….

            ………………………………………………………………………………………………………….

            ………………………………………………………………………………………………………….




ii)         Evidence of experiential learning within the last five (5) years ………………………………….

            ………………………………………………………………………………………………………….

            ………………………………………………………………………………………………………….

            ………………………………………………………………………………………………………….

            ………………………………………………………………………………………………………….

            ………………………………………………………………………………………………………….

            ………………………………………………………………………………………………………….

            ………………………………………………………………………………………………………….

            ………………………………………………………………………………………………………….




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                                                          (Must be completed by all applicants)


                                                                  JOB APPLICATION
                                                         Senior Medical Positions


Name of Applicant

All applicants are to complete this section fully. Whilst it is understood you may summarise the
details of any individual matter, failure to declare a matter may result in immediate termination or
suspension of any employment offered as a result of this application. If more space is required add
an appendix

Question 1.

If appointed to the advertised position, is there any issue that may impede you fulfilling the full
scope of activities and privileges required of the position.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Question 2.

Have you had any limitations placed on your clinical privileges or appointment in any previous
medical position? If yes, please specify the nature, cause and duration of those changes.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Question 3.

Has there ever been any conditions placed on your medical registration in any state or country in
which you have practiced? If yes, please specify the nature, cause and duration of these
conditions.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

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Have you been involved in any medico-legal claim (settled/unsettled / claimed) since graduating
from medicine? If yes, please briefly specify nature of event and outcome of these actions if
known. (eg action related to inadequate consent: claim successful)

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________



Question 5.

Have you been the subject of a formal internal workplace complaint in the last 3 years? If yes,
please specify the nature of that complaint, when that complaint occurred, and if known, the
outcome. (eg written complaint about handwriting – dismissed)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Question 6.
 Have you been the subject of a complaint to the HCCC or other statutory Body in the last 3 years?
If yes, please specify the nature of the complaint and if known, the outcome (eg HCCC complaint
about an account – resolved)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________


Question 7.

Is there any relevant criminal history or pending criminal allegations that had, or may have, any
impact on your possible employment or registration as a medical officer? eg, assault, fraud,
unethical behaviour, theft, child abuse allegations.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________




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                                                      (Must be completed by all applicants)


Referees nominated by applicant:                            All applicants must nominate at least four referees meeting the
following criteria;
           Referee – criteria A;
               o At least one non-medical clinical colleague with whom you have worked in the last three
                   years.
           Referee – criteria B;
               o At least one medical clinician outside of your clinical discipline to whom you have referred or
                   been referred patients in the last three years on a regular basis.
           Referee – criteria C;
               o At least one manager (clinical or non-clinical) within your current place of work to whom you
                   have some accountability. If you hold a current public hospital clinical appointment in NSW
                   and are active in that position, it is preferable that this be the site from which you select that
                   manager.
           Referee – criteria D;
               o At least one clinical peer from your discipline who can comment on your clinical practice in
                   the last three years.
NOTE: Referees can fulfil more than one criteria but at least four referees are to be supplied. Please specify on your application
whether your referees should only be contacted consequent to you being short-listed.

The South Eastern Sydney Area Health Service reserves its right to require applicants to nominate additional referees if required. It also
reserves the right to contact their current line managers prior to any offer being made, unless there are acceptable reasons for this not
to occur. Applicants will be advised prior to this contact being made.

            Name:      __________________________ Referee criteria (A,B,C and/or D ): _____________
            Address: _________________________________ Phone no: __________________________________

                          ___________________________

            (Mob)_____________________(Email) ______________________________________

            Name:      __________________________ Referee criteria (A,B,C and/or D ): _____________

            Address: _____________________________ Phone no: _________________________________

                     _____________________________
            (Mob) ___________________________ (Email) ___________________________________
            Name: __________________________ Referee criteria (A,B,C and/or D ): _____________

            Address: _________________________________ Phone no: __________________________________

                          ___________________________

            (Mob)_____________________(Email) ______________________________________
            Name: __________________________ Referee criteria (A,B,C and/or D ): _____________

            Address: _________________________________ Phone no: __________________________________

                          ___________________________

            (Mob)______________________(Email) ______________________________________

Contact details of any referees will only be available to the appointment panel and any relevant HR officer.

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