PGY1 Extension Flagging Form

This field is for validation purposes and should be left unchanged.
This form is intended for notifying PMCV of a prospective PGY1 extension identified during the year. Such an extension may be necessitated due to a delayed commencement, excessive leave, or concerns regarding fulfillment of the outcomes required for General Registration. Completion of this form does NOT indicate that an extension is proceeding but serves to notify parties for planning purposes. If an extension is being pursued, a complete application must be submitted using this form by December of the calendar year in which the Internship begins.

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

Health Service Contact Details

Contact Name(Required)

Health Service details

CMO/DMS Details

CMO/DMS?(Required)
CMO/DMS Name(Required)

Details of PGY1

PGY1 Name(Required)
Reason for possible extension(Required)
select all applicable

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