NON FACRRM SUPERVISOR SELF ASSESSMENT FORM
SUPERVISOR’S PERSONAL & PRACTICE DETAILS
First Name: …………………………………………………… Surname: ……………………………………………......
Practice Name: ……………………………………………………………………………………………………………...
Practice Address: ……………………………………………. Suburb: ……………………………………....................
State: …………………………………………………………. Postcode: ………………………………………………..
Telephone: …………………………………………………… Fax: ………………………………………………………
Regional Training Provider: ………………………………………………………………………………………………..
ELIGIBILITY CRITERIA
Self
Assessment
Yes?
()
Criteria
1
Documentation required
Current registration with AHPRA
Copy current registration
2
Not less than five years full-time equivalent
experience in Rural and Remote General Practice
or remote specialist practice
Up to date CV which
includes details relevant
to the supervisor’s rural
and remote medical
experience.
References if available.
3
Demonstrated commitment to ongoing professional
development and participates in ACRRM’s
Professional Development Program (PDP) or CME
equivalent.
Evidence of participation
in PDP/CME, e.g.,
PDP/CME statement
Page 1 of 3
Non FACRRM Supervisor Self Assessment Form/May 2008, revised November 2014
Verified by
RTP
ASSESSING PREVOUS EXPERIENCE
Appropriateness of experience/expertise will be assessed by the Vocational Training team, using the following criteria
and ‘point’ scale. An applicant must be able to demonstrate equivalent training and experience to the value of 16 points
to be considered eligible.
Self
Assessment
No. Points
Relevant Training / Experience / Assessment
Documentation
required
1
Fellowship of an AMC accredited Australian or New Zealand
Professional College (or recognised equivalent), eg FRACGP,
FACEM

Maximum of 8 points available in this category

Points may be awarded for partial completion
2
Rural Experience - Time spent in rural and/or remote clinical
practice in a peer-reviewed or accredited environment.

Maximum of 6 points available in this category

2 points can be allocated for every five years spent,
up to a maximum of 15 years
3
Active and confirmed participation in a PDP/ QA program
over the last 3 years

Maximum of 3 points available in this category
4
Current Clinical Privileges

Maximum of 4 points available in this category

1 point for each of Obstetrics and Gynaecology,
Anaesthetics, Surgery, Emergency Medicine
Letter from relevant
clinical privileging
committee (when
demonstrated
equivalence)
5
Further tertiary level training relevant to Rural and Remote
Medicine

Maximum of 4 points available in this category

Graduate Certificate = 1 point

Graduate/Post Graduate Diploma = 2 points

Masters Degree = 3 points

Professional Doctorate, MD or PhD = 4 points
Proof of
certification e.g.,
copy diploma,
certificate,
academic transcript
etc
Fellowship
Certification
Up to date CV
which includes
details relevant to
the supervisor’s
rural and remote
medical
experience.
PDP/CME
statement
Completion of accredited courses within the last 5 years

Maximum of 6 points in this category
6
7
EMST, APLS, ALSO,PHTLS, EM, REST, ELS = 1 point each
Other state-based trauma and acute care courses as
recognised by ACRRM censor and promoted via ACRRM’s
PDP. For example, Radiology and Ultrasound skills based
training = 1 point each
Leadership and Academic Activity

Maximum of 3 points in this category
Development of, or leadership in, the relevant specialty or a
relevant specialty field of rural and remote medicine at a
national or international level = 1 point
Certificate of
completion
Certificate of
completion
E.g.: Co-ordinating
mentor programs;
Co-ordinating
clinical programs;
Designing
programs/courses;
Teaching medical
educators
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Non FACRRM Supervisor Self Assessment Form/May 2008, revised November 2014
Office
use
only
Self
Assessment
No. Points
Relevant Training / Experience / Assessment
Ongoing contribution to undergraduate or postgraduate
education= 1 point
Five publications as primary or secondary author in national
or international peer-reviewed scientific
journals/books/scientific proceedings = 1 point
Documentation
required
Office
use
only
E.g., active
participation in
teaching programs
as a tutor, mentor,
supervisor, medical
educator and/or in
curriculum
development.
Includes active
contribution as a
primary or
secondary author
in peer-reviewed
national or
international
scientific journals,
books and/or
scientific
proceedings.
If the assessment leads to a score of 15 or below, two options exist at the discretion of the Vocational Training Team
within ACRRM.
1.
The Supervisor may be given provisional accreditation to act as a supervisor of FACRRM candidates, with
additional support provided by the RTP, ACRRM Medical Advisor or ACRRM, as directed by ACRRM. ACRRM
may specify actions, which should be taken by the supervisor to up skill to a point where full accreditation may be
provided.
2.
The Vocational Training Team may refer the application to the ACRRM Accreditation Review Team.
If either of these options is exercised, ACRRM may require two peer references from FACRRM’s who are familiar with
the applicant and their professional and personal competency. Potential conflicts of interest should be considered in
choosing appropriate FACRRM’s to provide references.
Page 3 of 3
Non FACRRM Supervisor Self Assessment Form/May 2008, revised November 2014