Associateship Training Programs RPL Application Form (New/Former trainees)

Documentation

The following additional documentation is to be submitted by an applicant for verification purposes and must be included with this application form.
Was the training and/or experience that forms the basis of this application completed in the past 5 years?*

YesNo
Based on your answers, your RPL will not be considered. Please contact ematp@acem.org.au if you have further questions.
Placement One
Please indicate below the details of the training for which you are applying for recognition.
Start date
End date
Name of training site
Role
Full Time Equivalent (FTE) hours
Placement Two
Start date
End date
Name of training site
Role
Full Time Equivalent (FTE) hours
Placement Three
Start date
End date
Name training site
Role
Full Time Equivalent (FTE) hours
Please upload supporting documentation for ED Placements

Cancelof

Do you have a current and valid certificate of competency for the Advanced Life Support 2 (ALS 2)?*

YesNo
Do you have a current and valid certificate of competency for the Advanced Paediatric Life Support (APLS) workshop?*

YesNo
Do you have a current and valid certificate of competency for the Early Management of Severe Trauma (EMST) or Emergency Trauma Management (ETM) workshops?*

YesNo
Have you completed a suitably credentialed Ultrasound workshop? (for further information on approved courses, see the Advanced EM Training Program Ultrasound Document)*

YesNo
Please upload completion certificates for ALS 2, APLS, EMST/ETM and/or Ultrasound

Cancelof

Please provide certified copies of written in-training assessments or workplace-based assessment forms relevant to the application, clearly showing the name and signature of the Supervisor of Training, details of the term, and site.
Copies of In-training assessments/WBAs

Cancelof
You will need an Foundational, Intermediate and/or Advanced Emergency Medicine Training Program Procedural Checklist signed off by an ACEM Director of Emergency Training that confirms your ability to perform specific procedures outlined on the checklist.

EMC-Procedural-Checklist

IEMTP-Procedural-Checklist

AEMTP-Procedural-Checklist
Please upload your signed off Procedural Checklist

Cancelof
Please upload a confirmation letter from your DEMT/Primary Supervisor of the training program 

Cancelof
Please upload a copy of your current Curriculum Vitae

Cancelof
Should be Empty:

Placement One