PGY1 Extension Application Form

PGY1 Extension Application Form Steps:

1. Application Start
2. Request Type
3. Contact Details
4. Health Service Details
5. Intern Extension Details
6. Proposed Extension Details
7. Additional comments / documentation
8. Declaration

For assistance contact the Accreditation team via: accreditation@pmcv.com.au

URL

This field is for validation purposes and should be left unchanged.

This form is to be submitted when a PGY1 doctor in Victoria will require additional time beyond their initial year to complete the requirements for General Registration.

Common reasons for requiring additional time include not meeting the outcome statements or not completing the time requirements (either because of a part time role, late commencement or additional leave).

If extending the completion time will temporarily increase the number of PGY1s in that post at the Health Service, you should also complete the Change to Accredited Post Form.

Additional information relating to PGY1 Extensions can be found here

If you need assistance please contact the Accreditation team on: accreditation@pmcv.com.au

Request type(Required)

Extension with no change to number of accredited posts

Extension with change to number of accredited posts

Please indicate if this request will require an additional accredited PGY1 post for the completion of the extension.

Please ensure that you complete the Change to Accredited Post Form.

Health Service Contact Details

Contact Name(Required)

First Last

Contact Phone(Required)

Contact Email(Required)

Role(Required)

Health Service details

Health Service(Required)

CMO/DMS Details

CMO or DMS?(Required)

CMO

DMS

CMO/DMS Name(Required)

Prefix First Last

CMO/DMS Phone(Required)

CMO/DMS Email(Required)

DCT/SIT

DCT or SIT?(Required)

DCT

SIT

DCT/SIT Name(Required)

Prefix First Last

DCT/SIT Phone(Required)

DCT/SIT Email(Required)

Details of PGY1

Name(Required)

First Last

AHPRA Registration Number(Required)

Year internship commenced(Required)

Is the PGY1 aware of this submission?(Required)

Yes

Reason for extension(Required)

Has not met time requirement of 47 weeks - Late commencement

Has not met time requirement of 47 weeks - Registration issues

Has not met time requirement of 47 weeks - Medical reasons

Has not met time requirement of 47 weeks - Excess leave

Does not meet competency requirements/outcomes

select all applicable

Has an IPAP been implemented?(Required)

Yes

If Yes, has the IPAP been successful?

Yes

IPAP and IPAP outcomes(Required)

Drop files here or

Max. file size: 25 MB.

Anticipated duration of extension(Required)

Anticipated date of commencement(Required)

DD slash MM slash YYYY

Anticipated extension(Required)

Part time

Full time

Anticipated extension term(Required)

Anticipated Clinical Experiences(Required)

A: Undifferentiated illness patient care

B: Chronic illness patient care

C: Acute and critical illness patient care

D: Peri-operative/procedural patient care

Rationale for Unit/term selection(Required)

Upload Term Description(Required)

Drop files here or

Max. file size: 5 MB.

Upload anticipated roster(Required)

Drop files here or

Max. file size: 25 MB.

Please ensure roster includes the following where applicable: If the new roster changes week to week - a rotation-long roster should be provided; any protected teaching time; any unit-based learning opportunities (e.g. Morbidity and mortality, audit, case of the week etc), any theatre sessions for surgical terms; and any covering time/out-of-hours time.

Do you need to add an additional rotation?(Required)

Yes

If you require more than two rotations for this extension, please contact PMCV following the submission of this form.

Anticipated duration of extension(Required)

Anticipated date of commencement(Required)

DD slash MM slash YYYY

Anticipated extension(Required)

Part time

Full time

Anticipated extension term(Required)

Anticipated Clinical Experiences(Required)

A: Undifferentiated illness patient care

B: Chronic illness patient care

C: Acute and critical illness patient care

D: Peri-operative/procedural patient care

Rationale for Unit/term selection(Required)

Upload Term Description(Required)

Drop files here or

Max. file size: 5 MB.

Upload anticipated roster(Required)

Drop files here or

Max. file size: 25 MB.

Additional Comments or Documentation

Additional Comments

Additional Documentation

Drop files here or

Max. file size: 25 MB.

Declaration

By signing this declaration, you are confirming that your CMO/DMS is aware of, and has approved, this application. They will receive a copy of this application following submission.

Declaration(Required)

I declare the information contained in this application is correct at the time of submission and this post complies with the following guidelines:

PMCV Clinical Learning for Prevocational Doctors Guidelines

PMCV Clinical Supervision of Prevocational Doctors Guidelines

PMCV Performance Assessment and Feedback Guidelines for Prevocational Doctors

The above guidelines can be found here: Accreditation Resources

Declaration(Required)

Title First Last

CMO/DMS Email(Required)

Date(Required)

DD slash MM slash YYYY

CAPTCHA

Our Organisation

Our People

Resources & Guidelines

Accreditation Resources

Our Organisation

Our People

Resources & Guidelines

Accreditation Resources

PGY1 Extension Application Form

PGY1 Extension Application Form Steps:

Health Service Contact Details

Health Service details

CMO/DMS Details

DCT/SIT

Details of PGY1

Rotation Details - Completed and Expected

Term 1 details and outcome

Term 2 details and outcome

Term 3 details and outcome

Term 4 details and outcome

Term 5 details and outcome

Anticipated extension details

Additional Comments or Documentation

Declaration

Our Organisation

Our People

Resources & Guidelines

Accreditation Resources

PGY1 Extension Application Form

PGY1 Extension Application Form Steps:

Health Service Contact Details

Health Service details

CMO/DMS Details

DCT/SIT

Details of PGY1

Rotation Details - Completed and Expected

Term 1 details and outcome

Term 2 details and outcome

Term 3 details and outcome

Term 4 details and outcome

Term 5 details and outcome

Anticipated extension details

Additional Comments or Documentation

Declaration

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