Extension form testing

Application Steps:

(NEED UPDATING)

1. Application Start
2. Change Type
3. Contact details
4. Post summary
5. Post details and learning outcomes
6. Education and orientation details
7. Unit structure and supervision
8. Additional comments / documentation
9. Declaration

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

Internship Extension Request form

Application Steps

Click next to begin. Your application can be saved.

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

Request type(Required)

Extension with no change to roster

Extension with change to roster

Please indicate if the request will have a change to the roster and will require an additional accredited post.

Your Details

Name(Required)

First Last

Phone(Required)

Email(Required)

Role(Required)

Health Service details

Health Service(Required)

CMO/DMS Details

Name(Required)

Prefix First Last

Phone(Required)

Email(Required)

Does your health service have a SIT or DCT?

SIT

DCT

please select both if applicable

SIT

Name

Prefix First Last

Phone

DCT

Name

Prefix First Last

Phone

PAGE BREAK

Details of Intern

Name(Required)

First Last

AHPRA Registration Number(Required)

Year internship commenced(Required)

Is the intern aware of this submission?(Required)

Yes

Reason for extension(Required)

Leave - greater than 5 weeks

Medical reasons

Additional training to meet competency

Professionalism

Registration issues

Late Commencement

Other (please specify)

select all applicable

Other reason(Required)

Has an IPAP been implemented?(Required)

Yes

If Yes, has the IPAP been successful?

Yes

Leave forms(Required)

Max. file size: 5 MB.

IPAP and IPAP outcomes(Required)

Max. file size: 5 MB.

Rotation Details - Completed and Expected

Upload Intern Rotation Planner(Required)

Drop files here or

Max. file size: 5 MB.

Rotation 1 details and outcome

First Rotation(Required)

Weeks completed(Required)

Performance Mid-term Assessment(Required)

Performance End of term Assessment(Required)

Rotation 1 - Mid & End of term assessment(Required)

Drop files here or

Max. file size: 5 MB.

Rotation 1 - Term Description(Required)

Drop files here or

Max. file size: 5 MB.

Rotation 2 details and outcome

Second Rotation

Weeks completed

Performance Mid-term Assessment

Performance End of term Assessment

Rotation 2 -Mid & End of term assessment

Drop files here or

Max. file size: 5 MB.

Rotation 2 - Term Description

Drop files here or

Max. file size: 5 MB.

Rotation 3 details and outcome

Third Rotation

Weeks completed

Performance Mid-term Assessment

Performance End of term Assessment

Mid & End of term assessment

Drop files here or

Max. file size: 5 MB.

Rotation 3 - Term Description

Drop files here or

Max. file size: 5 MB.

Rotation 4 details and outcome

Fourth Rotation

Weeks completed

Performance Mid-term Assessment

Performance End of term Assessment

Mid & End of term assessment

Drop files here or

Max. file size: 5 MB.

Rotation 4 - Term Description

Drop files here or

Max. file size: 5 MB.

Rotation 5 details and outcome

Fifth Rotation

Weeks completed

Performance Mid-term Assessment

Performance End of term Assessment

Mid & End of term assessment

Drop files here or

Max. file size: 5 MB.

Rotation 5 - Term Description

Drop files here or

Max. file size: 5 MB.

Proposed extension details

Proposed number of extension rotations(Required)

Proposed duration of extension(Required)

Proposed date of commencement(Required)

MM slash DD slash YYYY

Proposed extension(Required)

Part time

Full time

Proposed extension rotation 1(Required)

Proposed Clinical Experiences rotation 1(Required)

A: Undifferentiated illness patient care

B: Chronic illness patient care

C: Acute and critical illness patient care

D: Peri-operative/procedural patient care

Term Supervisor for extension rotation 1(Required)

First Last

Clinical Supervisor for extension rotation 1(Required)

First Last

Proposed learning outcomes of extension Rotation 1(Required)

Current roster extension rotation 1(Required)

Drop files here or

Max. file size: 5 MB.

-Required to highlight / note this post -Include full roster for unit (ie not just for this post)

New roster extension rotation 1(Required)

Drop files here or

Max. file size: 5 MB.

-Rosters required to highlight / note this post -Include full roster for unit (ie not just for this post)

Proposed extension rotation 2(Required)

Proposed Clinical Experiences of rotation 2(Required)

A: Undifferentiated illness patient care

B: Chronic illness patient care

C: Acute and critical illness patient care

D: Peri-operative/procedural patient care

Term Supervisor for extension rotation 2(Required)

First Last

Clinical Supervisor for extension rotation 2(Required)

First Last

Proposed learning outcomes of extension Rotation 2(Required)

Current roster extension rotation 2(Required)

Drop files here or

Max. file size: 5 MB.

-Required to highlight / note this post -Include full roster for unit (ie not just for this post)

New roster extension rotation 2(Required)

Drop files here or

Max. file size: 5 MB.

-Rosters required to highlight / note this post -Include full roster for unit (ie not just for this post)

Additional Comments or Documentation

Additional Comments

Additional Documentation

Drop files here or

Max. file size: 5 MB.

Declaration

NOTE:

This declaration must be completed by the CMO/DMS or your health service. If you are not the CMO/DMS please save this form using "Save and Continue later" and email the CMO/DMS the link to complete.

Declaration(Required)

Title First Last

CMO/DMS Email(Required)

Date(Required)

MM slash DD slash YYYY

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 Junior Doctors Guidelines
• PMCV Clinical Supervision of Junior Doctors Guidelines
• PMCV Performance Assessment and Feedback Guidelines for Junior Doctors

The above guidelines can be found here: Accreditation Resources

CAPTCHA

Name

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

Extension form testing

Application Steps:

Internship Extension Request form

Your Details

Health Service details

CMO/DMS Details

SIT

DCT

Details of Intern

Rotation Details - Completed and Expected

Rotation 1 details and outcome

Rotation 2 details and outcome

Rotation 3 details and outcome

Rotation 4 details and outcome

Rotation 5 details and outcome

Proposed extension details

Additional Comments or Documentation

Declaration

NOTE:

Collaboration