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PRACTICE and SUPERVISOR RACGP and ACRRM
ACCREDITATION Application Form
Practice Name:
Date of Application:
Type of accreditation requested:
Initial Practice and Supervisors
Reaccreditation Practice and Supervisors
Additional Supervisor to already accredited site (please skip to Supervision Section on page 5)
Please note: NTGPE accredits all Practices and GP Supervisors to train GP Registrars through the Royal Australian College of General Practitioners (RACGP) and the Australian College of Rural and Remote Medicine (ACRRM), where eligible, unless we are otherwise notified
FOREDU014 NTGPE Accreditation Application Form Practice and Supervisor Interactive Final 2016 April 19 Page 1 of 7
PRACTICE ACCREDITATIONPractice Profile:
Clinic Name:
Address:
Type of Practice Private Practice ACCHS / AMS Hospital ADF NT Dept Health Clinic Other ………………
Contact Person: Name: Position:
Telephone: Email:
Fax:
Branch Practice/s (if applicable): (ie. a separate enterprise connected to the parent practice where the registrar is there <20% of their working week)
AGPAL / GPA Accredited?: Yes No Date of most recent AGPAL/GPA accreditation (please attach relevant certificate):
Practice Opening Hours: Day Monday Tuesday Wednesday Thursday Friday Saturday Sunday Opens
Closes
Practice Sub-Specialties:
Do the doctors at your practice have admitting rights at the local hospital? Yes No
Practice Demographics: Demographics of patients presenting at clinic:- Total No. of Patients seen per year:
% of patients presenting who are: 0-4 years 5-15 years 16-25 years 26-64 years 65 years +
% patients identified as Aboriginal or Torres Strait Islander
FOREDU014 NTGPE Accreditation Application Form Practice and Supervisor Interactive Final 2016 April 19 Page 2 of 7
Practice Staffing:
Practice Manager Name:
Other Practice Staff (non GPs):
Practice Role / Job Length of time working at practice
No. of people doing this role
GP Supervisors to be accredited:
Lead GP Supervisor Name:
GP Supervisor Roster Day of week Morning Session Afternoon Session Evening Session
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
How will GP Supervisor coverage be provided when Supervisors are on leave (eg. locums, internal coverage)?
FOREDU014 NTGPE Accreditation Application Form Practice and Supervisor Interactive Final 2016 April 19 Page 3 of 7
Training Post Teaching Plan:Please be advised that the completion of a Training Post Teaching Plan is an accreditation requirement.
Team Supervision:
Does this clinic operate under a team supervision model?
Yes No
Practice Description:
Please write a 200 word description about your clinic and what it offers for training that we can use to advertise your clinic to our GP Registrars on our Placement Guide
FOREDU014 NTGPE Accreditation Application Form Practice and Supervisor Interactive Final 2016 April 19 Page 4 of 7
SUPERVISOR ACCREDITATIONPlease complete this Supervisor Accreditation Application Form for each GP Supervisor wishing to be accredited: Name:
Email: Ph:
Provider Number:
RACGP No.: ACRRM No.:
Qualifications: FACRRM FRACGP FARGP
Other:
How long have you been working in General Practice/Primary Health Care (incl. training)?
Post General Registration, how many years have you been working in rural/remote areas, if at all (can include time in training)? Note: Darwin urban area is not considered rural and remote by ACRRM. Rural and remote would include posts located in a setting that lacks ready access to specialist medical and other services and requires the development of own knowledge and skills to match local community need.
Are you an Ex GP Registrar? Yes No If yes, through which RTO?
Have you ever supervised GP Registrars before? Yes No If yes, please give details:
Place and Hours of Work
Clinic(s) currently working at / where you will be supervising GP Registrars:-
Hours: Monday Friday
Tuesday Saturday
Wednesday Sunday
Thursday
Do you hold clinical privileges at a hospital? No Yes What speciality? If yes, please attach a copy of your notification / letter certifying this
FOREDU014 NTGPE Accreditation Application Form Practice and Supervisor Interactive Final 2016 April 19 Page 5 of 7
Have you undertaken any of the following?
Activity Cross if you have completed any of….
Evidence to be provided
Further tertiary level training relevant to rural and remote practice?
FARGP Grad Cert Grad Diploma Masters PhD
Copy of certificate of completion / degree
Accredited Emergency Courses in last 5 years?
REST EMST APLS ALSO PHTLS ELS Other Emergency Courses…. (please specify)
Copy of certificate of completion
Leadership and Academic Activity
Devt of or leadership in relevant speciality field or rural and remote medicine at national or international level
Ongoing contribution to undergraduate or postgraduate education
Five publications as a primary or secondary author in a national or international peer reviewed journal / book / scientific proceedings
Please outline below what you have done:
I declare the above information to be true and correct and have attached copies of supporting documentation where applicable
Supervisor’s signature:
FOREDU014 NTGPE Accreditation Application Form Practice and Supervisor Interactive Final 2016 April 19 Page 6 of 7
Checklist for clinic submission
Completed Practice Accreditation Application Form
Completed Practice Description
Copy of Practice Accreditation AGPAL / GPA (if applicable)
For each GP Supervisor
Completed Supervisor Accreditation Application Form, signed on page 6
Up to date CV (including current employment)
Current CPD / PDP Activity Statement
Fellowship Certificates (if applicable) If you don’t have access to this, please provide consent for us to contact the relevant College for confirmation of your Fellowship by ticking this box
A Letter of reference (for new Supervisors only – not required for reaccreditation applications)
Diploma Certificates (if applicable)
Certification of Clinical Privileges at Hospital (O&G, Anaes, ED, Surg) (if applicable)
Rural and remote training – Certificate / Diploma / Masters (if applicable)
Accredited Emergency Course Certificates attended in last 5 years If you have completed but don’t have Certificates of Attendance, a reference to the course on a CPD Activity Statement is sufficient
Each GP Supervisor, please sign on page 6 and return this completed Application Form and any relevant supporting documentation to NTGPE Practice and GP Supervisor Accreditation Coordinator:
Email: [email protected] / [email protected]
Fax: 08 8946 7077
FOREDU014 NTGPE Accreditation Application Form Practice and Supervisor Interactive Final 2016 April 19 Page 7 of 7
