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1 ABN Training Assessment Recognition of Prior Learning RPL Please tick only one of the following and read the applicable notes. Prior CAT experience: In a program pre-approved In a program not pre-approved Postgraduate qualification by exam in an affiliated training region (Reg ) In ANZCA-accredited departments while not registered as an ANZCA trainee In a senior house officer appointment in the UK from 1 April 1996 to 31 July 2007 Other clinical experience: In an anaesthesia-related specialty 1. PERSONAL INFORMATION ANZCA ID: Family Name: First Name: Preferred Name: (if different from first name) Date of Birth: Middle Name: Gender: M / F Day Month Year Country of Birth: 2. CONTACT INFORMATION Home address: Suburb/City: Country: State: Postcode: Home Phone: Country Area Local Country Local Mobile Phone: address: 3. CLINICAL EXPERIENCE UNDERTAKEN TO DATE Please tick if you have met the following requirements (You must supply supporting documentation): The Primary exam Curriculum modules PAGE 1 OF 5

2 ANZCA ID: 3. CLINICAL EXPERIENCE UNDERTAKEN TO DATE (CONTINUED) Note: you must supply supporting documents for the terms you want recognised. See note 3. Please tick to indicate training terms you wish to have assessed. Hospital and country Type of Experience AN, IC, Other (please specify) Grade or Year From DD/MM/YY To DD/MM/YY Time (In weeks) Leave taken (In weeks) Full/part time* *If part time, please indicate FTE between 0.5 and 1 3a. PART TIME TRAINING (IF INDICATED ABOVE) If not applying to have any part-time training recognised, please go to section 4. Supporting documentation will be required in order to ensure that while in part-time training: 1. Your duties comprised a minimum of 50% of the commitment of a full-time trainee in the same department 2. You participated in both in-hours and out-of-hours duties on an FTE-proportional basis 3. You participated in the local/regional teaching on at least an FTE-proportional basis. Additional comments: 4. DECLARATION OF TRAINEE I solemnly declare that the statements made in this application are true and accurate. Signature: Date: Day Month Year PAGE 2 OF 5

3 ANZCA ID: 5. PAYMENT DETAILS Payment Amount: AUD $ Cheque, Bank Draft or Money Order attached (Payable to ANZCA and crossed Not Negotiable.) Credit Card (please tick one) Credit Card Number: Expiry Date: Name on Card: Cardholder s signature: Recognition of Prior Learning (Notes) The table below lists the possible training and requirements that may be credited toward training for the various types of RPL depending on the documentation submitted: In a program pre-approved In a program not pre-approved for RPL In a senior house officer appointment in the UK from April 1, 1996 to July, Postgraduate qualification by examination (Reg ) In ANZCAaccredited departments while not registered as an ANZCA trainee In an anaesthesia-related specialty BT 104 weeks 104 weeks 52 weeks 104 weeks 52 weeks 52 weeks OCT AT 104 weeks 52 weeks OCT 2 PEx Yes No No Yes (with specific application) No No FEx No No No No No No Modules Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 No Note: the credits listed in the above table are the maximums that will be granted. The amount of training recognised by ANZCA will vary based on the supporting documentation submitted with your application. Additional training time may be required in basic training extended. 1 Exemption for module 1 may be granted if at least 52 weeks of training is approved retrospectively. Depending on supporting documentation provided, credit may also be given towards the completion of other curriculum modules. 2 An additional 13 weeks OCT may be approved if trainee has been awarded fellowship of CICM. Further approval may be granted for training in clinical anaesthesia provided it was undertaken in accredited training sites. PAGE 3 OF 5

4 Recognition of Prior Learning (Notes) Training in a program preapproved Training in a program not preapproved Postgraduate qualification by examination in an affiliated training region (Reg ) Training in an ANZCA department while not registered as a trainee* Training in an anaesthesiarelated specialty In a senior house officer appointment in the UK The two programs currently pre-approved for ANZCA RPL are the specialist training programs of the Royal College of Anaesthetists and the College of Anaesthetists of Ireland. All clinical anaesthesia training in programs that have not been pre-approved for ANZCA RPL, e.g., recognition of foreign training for a medical practitioner who is not an international medical graduate specialist. This currently applies to holders of Fellowship of the Hong Kong College of Anaesthesiologists, and M. Med. in Anaesthesiology from Singapore or Malaysia. Medical practitioners who, prior to registering as ANZCA trainees, have completed anaesthesia experience in a position that is equivalent to that of an ANZCA trainee in an ANZCA-accredited department. *You must have completed at least 13 weeks of anaesthesia training in order to apply for this. This applies to medical practitioners who, prior to commencement of anaesthesia vocational training have undertaken vocational training in Australia, New Zealand or overseas in a specialty recognised by ANZCA as anaesthesia related. If a trainee has been awarded Fellowship of the College of Intensive Care Medicine, up to 117 total weeks of other clinical time may be approved retrospectively. A trainee must have occupied a senior house officer appointment in anaesthesia in the United Kingdom between April 1, 1996 and July 31, 2007, to be eligible to apply. Instructions for Completing the Recognition of Prior Learning Form (RPL) 1. Personal Information First Name: If your first name is hyphenated or two words, e.g., Wu Xiao Ping, Anne-Marie Jones, enter this in the first name box. Preferred Name: Only complete if the name you prefer to be called by is not your first name. For example, you may go by your middle name, or use an English name. This helps ensure that we get your name correct on correspondence, name tags, and other communications. 2. Contact information Phone and Fax Numbers: Please give your country and area or city codes, in addition to your local number. If you do not have an area or city code, e.g., Hong Kong or Singapore applicants, leave this space blank. For privacy reasons, we require that all ANZCA Fellows and Trainees have a unique address. Fellows and Trainees cannot share an address with another Fellow or Trainee. 3. Clinical experience undertaken to date Please include all clinical experience undertaken to date. This will provide the assessor necessary information for determining the appropriate amount of prior experience to recognise. For each of the boxes ticked, you must have a supporting letter on original hospital letterhead that confirms the following: Dates of appointment Type of experience Amount of leave taken Accreditation of training by relevant training body. If you have received the diploma of Fellowship from a program pre-approved by ANZCA Council, please provide a certified true copy of the certificate. 3a. Part-time training Any retrospective approval of experience gained parttime must meet the ANZCA requirements for part-time training. If some or all of the prior training was undertaken on a part-time basis, the certified documentation provided must include confirmation that the requirements of Reg , and were met. 4. Declaration of trainee The College requires that you sign and date the declaration that the information on the application is true and accurate. PAGE 4 OF 5

5 Recognition of Prior Learning (checklist) The following documents should be attached to your completed Recognition of Prior Learning Form with all the appropriate signatures: Completed ANZCA RPL Form Relevant payment details For each term you have ticked to indicate that you wish to have assessed, a supporting letter on original hospital letterhead that confirms the following: Dates of appointment Type of experience Amount of leave taken Accreditation of training by relevant training body. Evidence of your logbook and/or assessments If you are submitting a photocopy of an original document, it must be certified by a Justice of the Peace (JP) or an equivalent official and have the following information written on it: Certified True Copy of Original Document written on the photocopy Date of certification Signature of certifier Name and position of the certifier. Send the completed form to: ANZCA c/o Training Assessment PO Box 6095 ST KILDA ROAD CENTRAL VIC 8008 AUSTRALIA PAGE 5 OF 5