APPLICATION FOR TRAINING DETERMINATION
FOR FACULTY OF SCIENCE
Before completing this form, please refer to the relevant Trainee Handbook for the Faculty of Science
for the detailed curriculum and assessment. When completing this form you will be required to match
your qualifications and experience against the standards as detailed in Section II of the Trainee
Handbook. All Trainee Handbooks are available from www.rcpa.edu.au Trainees – Curriculum/Training
Handbooks – Faculty of Science.
Applications for retrospective accreditation will be reviewed on a case-by-case basis by the Principal
Examiner.
Please print all entries.
TITLE___________________ LAST NAME: ____________________________________________
GIVEN NAMES: ___________________________________________________________________
PREFERRED MAILING ADDRESS: ___________________________________________________
_________________________________________________________ POSTCODE: ___________
DAYTIME PHONE: __________________________
EMAIL: _____________________________
SEX:
DATE OF BIRTH: _____________________
Male
Female
NATIONALITY:
_________________________________________________________________________________
In which laboratory are you currently working? (Please specify your department and give the correct
work address)
_______________________
________________
________________
If you are not currently working in a laboratory, please provide details:
_______________________
________________
RELATED DISCIPLINE IN WHICH YOU TRAINED AND/OR ARE CURRENTLY WORKING (Please
tick)
Trained
Working
Trained Working
Anatomical Pathology
Chemical Pathology
Forensic Science
Haematology
Genetic Pathology
Microbiology
Immunopathology
Subspecialty: ___________________________________________________
DEGREES AND OTHER QUALIFICATIONS
Degree: _____________
Year: __________
Institute: ____________________________
Degree: _____________
Year: __________
Institute: ____________________________
Degree: _____________
Year: __________
Institute: ____________________________
Other qualifications (please specify):
_________________________________________________________________________________
_________________________________________________________________________________
(If applicable)
MEMBERSHIP OF PROFESSIONAL BODIES AND STATUS
PROFESSIONAL BODY
STATUS
YEAR JOINED
MEMBERSHIP
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Retrospective accreditation of training & prior experience
The RCPA Faculty of Science Fellowship training program requires a candidate at the end of training
to be competent in three areas of professional activity i.e. Research, Clinical laboratory and
Innovation, development and leadership. If you wish to receive exemptions in training time and/or
examinations, use the table(s) below to detail how you may have partially or completely met the
Standards in these areas for your particular discipline through professional qualifications, previous
training or experience, and research/publications.
Please detail how you fulfil the requirements of the content areas and learning outcomes in all three
standards as outlined in Section II of the Trainee handbook in your discipline (found under ‘Faculty of
Science’ at http://www.rcpa.edu.au/Trainees/Curriculum). Please reference your qualifications,
training, experience and research/publications to the content and learning outcomes of the curriculum
using the numbered referencing system as given in the handbook. Please use more space if needed.
Appropriate supporting documentation must be sent with your application.
Clinical Laboratory standards
Content/ outcomes
Evidence/ experience
Research standards
Content/ outcomes
Evidence/ experience
Innovation, Development and Leadership standards
Content/ outcomes
Evidence/ experience
REFEREES
Please supply 2 referees with their place of work, telephone and email addresses:
1
Name___________________________________________________________________________
Relationship to applicant____________________________________________________________
Place of work_____________________________________________________________________
Contact telephone number___________________________________________________________
Email address_____________________________________________________________________
2
Name___________________________________________________________________________
Relationship to applicant____________________________________________________________
Place of work_____________________________________________________________________
Contact telephone number___________________________________________________________
Email address_____________________________________________________________________
PRIVACY AND CONFIDENTIALITY
The College is collecting your personal information (including your name, contact details and
qualifications) in connection with providing you with training and further education. Any information
you provide will be treated as strictly confidential by the College. However, in the course of your
training it may be necessary for the College to provide your name, contact details and information
about your progress or examination performance to College committees and Fellows of the College
who are involved with supervision and training. The College may also disclose your personal
information to your employer, any medical or regulatory body including disclosure overseas, if this is
specifically required to be disclosed. If the personal information is not provided to the College, the
College may be unable to process your application, or to review and assess your training progress
and examination performance. The College will manage your personal information in accordance with
its Privacy Policy, which sets out how you can access and correct personal information that we hold
about you, as well as our complaints handling process. To obtain a copy of our Privacy Policy please
contact our Privacy Officer on + 61 2 8356 5858 or visit our website: www.rcpa.edu.au/ContentLibrary/Privacy-Policy.
I hereby consent to the RCPA providing relevant and necessary information as above.
Signature of Applicant: __________________________________________ Date: _____________
I DO NOT consent to the RCPA providing relevant and necessary information as above.
Signature of Applicant: __________________________________________ Date: ______________
PLEASE POST THIS FORM TO THE COLLEGE WITH THE FOLLOWING
The documents that the RCPA require are:



Completed RCPA Application for Training Determination
Payment details
Current Curriculum Vitae including any supervised training, Continuing Professional
Development (CPD) activities, research activities, current employment, employment
history and publications.
Certified copies of basic and specialist qualifications including transcripts
Documentation NOT required so therefore please do not submit to the College includes:

Published research papers/other specialist papers as they are listed on your CV
PLEASE ENSURE YOU HAVE COMPLETED ALL AREAS OF THIS FORM
FAXED APPLICATIONS WILL NOT BE ACCEPTED
Thank you
Application for Training Determination - Faculty of Science
PAYMENT AUTHORISATION
The College accepts payment by Cheque, Money Order, Amex, Mastercard or Visa only.
ALL PAYMENTS MUST BE IN AUSTRALIAN DOLLARS
Full Name of Applicant:____________________________________________________________________
(Please print)
Daytime contact phone no. or email: ________________________________________________________
I wish to authorise my non-refundable payment for a training determination for the Faculty of Science
Fee: $110 AUD within Australia or $100 AUD outside Australia
Signature:_________________________________________________________________
Payment
Mastercard
Visa
AMEX
Card Number
Expires
/
Cheques/Money Orders
Payable to RCPA
Send to
Royal College of Pathologists of Australasia
207 Albion Street
Surry Hills NSW 2010
Australia
Office Use Only: Payment correct
Cheque
Money Order
Enquiries
Phone:
Fax:
Email:
02 8356 5818
02 8356 5828
fscadmin@rcpa.edu.au
$ ________
Current Credit Card
Administrator: _______________________________
Entered
Qualifications
CV sufficient
To Chief Examiner:
Registrar:
References
N/A
Discipline ________________
Date: