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
College wanting to apply for accreditation by:
ACRRM
RACGP
Both
(NTGPE’s preference is to accredit all practices to be able to train their trainees through RACGP and ACRRM
pathways)
PRACTICE ACCREDITATION
Practice Profile:
Clinic Name:
Address:
Type of Practice
Private Practice
ADF
Contact Person: Name:
Telephone:
ACCHS / AMS
Hospital
NT Dept Health Clinic
Other ………………
Position:
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
Opens
Saturday Sunday
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
% patients identified as Aboriginal or Torres Strait Islander
65 years +
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
Current Lead GP Supervisor Name:
GP Supervisors to be accredited:
Able to train
General Practice Registrars
Prevocational Doctors (PGPPP)
GP Supervisor Roster
Day of week
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Morning Session
Afternoon Session
Evening Session
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
SUPERVISOR ACCREDITATION
Please complete the Supervisor form for each GP Supervisor you wish to have accredited at this training
post:
Name
Email
Provider Number
RACGP no.:
ACRRM no.:
Qualifications: FACRRM
FRACGP
FARGP
Other:
How long have you been working in General Practice/Primary Health Care?
How many years have you been working in rural/remote areas?
Are you an Ex GP Registrar? Yes
through which RTP
Hours of Work
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
No
If you do not hold a FACRRM please fill out the following questions so NTGPE and ACRRM
can assess your suitability to become an ACRRM Supervisor:
This is done through a points system derived from the information below. Should you not meet the
points criteria we will clarify with you and you may be able to supervise ACRRM registrars with
back up of a FACRRM Mentor to them
Have you undertaken any of the following?
Activity
Further tertiary level training
relevant to rural and remote
practice?
Accredited Emergency
Courses in last 5 years?
Leadership and Academic
Activity
Cross if you have completed any
of….
FARGP
Grad Cert
Grad Diploma
Masters
PhD
REST
EMST
APLS
ALSO
PHTLS
ELS
Other Emergency Courses….
(please specify)
Evidence to be
provided
Copy of certificate of
completion / degree
Devt of or leadership in relevant
speciality field or rural and remote
medicine at national or international
level
Please outline below
what you have done:
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
Supervisors signature:
Copy of certificate of
completion
Checklist for submission
Completed Practice Form
Completed Practice Description
Copy of Practice Accreditation AGPAL / GPA
For each GP Supervisor
Completed and Signed Application Form
Up to date CV
Current CPD Activity Statement
Fellowship / Diploma Certificates
Certification of Clinical Privileges at Hospital (O&G, Anaes, ED, Surg)
2 Letters of reference (from someone who can attest to your suitability as a supervisor – template attached)
Rural and remote training – cert / dip / masters
Accredited Emergency Course Certificates
Please return this completed Form and Supporting Documentation to NTGPE Accreditation
Coordinator:
Email: emma.carroll@ntgpe.org / accreditation@ntgpe.org
Fax: 08 8946 7077
EXAMPLE LETTER OF REFERENCE
(TO BE ON PRACTICE LETTERHEAD)
..date....
EXAMPLE LETTER OF REFERENCE
To Whom It May Concern
This is to confirm that Dr. ........................................... has been practising with .......................Medical
Centre, ............address... since .....date, year.......
During that time he/she has proven himself/herself to be a dedicated and caring professional General
Practitioner. Dr ...................................... has also demonstrated his/her ability to impart her knowledge
and experience to his/her colleagues and has a genuine interest in teaching.
I have no hesitation in recommending him/her as a NTGPE Accredited GP Supervisor.
Yours faithfully,
Dr..........................
Title........................
Name of Medical Practice