Applicant's Personal Details

Part 1/2

Applicant's Aphra Registration # (if applicable):

Include prefix

Applicant's Title(Required)

Applicants First Name(Required)

Applicants Surname(Required)

Mobile Phone Number(Required)

Email Address(Required)

Are you or have you ever been a Member of CPCA?(Required)

CPCA Membership #

Membership Level

Section A Medical Practitioner Relevance

1. Are you a medical student?(Required)

2. Are you an intern in an accredited intern training program?(Required)

3. Are you in postgraduate year 2 position and participating in a structured program that leads to a certificate of completion?(Required)

4. Are you a medical practitioner who has limited registration in the public interest or limited registration for teaching or research (to demonstrate a procedure or participate in workshop) and who have been granted registration for no more than four weeks?(Required)

5. Are you a medical practitioner who has been granted an exemption or variation from this standard by a CPD Home in relation to continuous absence from practice of at least six (6) months and up to and including 12 months for parental or carer leave, serious illness or other approved circumstances?(Required)

6. Are you a medical practitioner with non-practising registration?(Required)

How to proceed

If you answered "No" to any of the above questions, please proceed to section B below.

If you answered "Yes" to question 6 and you are intending to return to practice, please continue with this application form. Otherwise...

If you answered "Yes" to any of the above questions, please be advised it is not mandatory for you to meet Aphra/MBA Registration standard: Continuing professional development (CPD) and therefore it is not mandatory for you to join a CPD Home. However, if you wish to proceed under an 'optional' basis, please tick the declaration below before you proceed to provide further information in this application form.

Non-mandatory Home Applicant's Declaration

I fulfil the criteria under one or more of the above questions within Section A of this form.
I acknowledge the fact that it is not mandatory requirement for me to belong to a CPD Home while this criteria/ion is applicable to me.
I accept it is not a requirement for the CPCA CPD Home to review my CPD plan/s and activities for compliance purposes and as a result, I may not receive any forewarning of CPD compliance shortfalls.
I understand that it is my responsibility to inform the administrator of the CPCA CPD Home if and when my current circumstances change and it becomes a mandatory requirement for me to belong to a CPD Home where my CPD plan/s and CPD activities are subject to compliance checks.

In addition to this check box below, by submission of this fully completed application, the applicant is deemed to have formally made this declaration.

I acknowledge and accept the dot points made above, within Section A.

Additional Personal Details

Part 2/2

Gender

Ethnicity

Secondary Phone Number(Required)

Residential Address(Required)

Postal Address(Required)

Section B Scope of Practice (SoP)

Primary Scope of Practice

Primary Scope of Practice (Other: please enter below)

Secondary Scope of Practice (if applicable)

Secondary Scope of Practice (if applicable) (Other: please enter below)

Other Scope's of Practice (if applicable)

Other Scope's of Practice (if applicable) (Other: please enter below)

Member of an Aphra accredited medical specialist college?(Required)

If you have a mandatory requirement to meet the CPD Program of an accredited medical specialist college please indicate this above.

Section C CPD Home Membership History

New/First Year of CPD & Record Keeping: If you have not used another CPD Management System provided by the CPCA or another entity, please indicate below.(Required)

True

False

Returning from Short/long Term Absence(Required)

True

False

Further information will be collected via Section D

CPCA member transferring from CPCA CPD Wizard?(Required)

True

False

Transferring from an external CPD Home: If you are transferring from another provider of a CPD Management System or CPD Home, please indicate below.(Required)

True

False

Requirement to Import CPD Records(Required)

Yes

Please indicate above if you have current year CPD records you wish to import. Instructions will be issued to you on how you can import your records.

Section D Recency of Practice

Recency of Practice

You are re-entering practice after a recent absence?
And/or
You have recently or a planning on a change to your 'scope of practice'?

If you answer "FALSE" please proceed to section E.

Recency of Practice(Required)

True

False

Please tick the relevant boxes below:

Non-practising registration or not registered and returning to practice

(includes international medical graduates)

International Med. Grad.

True

False

Less than 2 years clinical experience as a reg. med. practitioner

A registered medical practitioner who has not been registered for more than 12 months, or has not practised for more than 12 months.

<2 yr clinical/<12 mths non reg/practice

True

False

2+ years clinical experience as a reg. med. practitioner

2+ yrs clinical/<12 mths non reg/practice

True

False

2+ yr Clinical/12-36 mths non reg/practice

True

False

2+ yr clinical/36+ mths non reg/practice

True

False

Recent Change to Scope of Practice (SoP)

If you have undergone a change in your field or scope of practice, you may be required to undergo additional training to ensure you are competent in the new field or scope of practice.

Have you undergone a change to your scope of practice?

True

False

Which of the above listed field or scope of practice are new to you?

Using the below options, how would you best explain the outcome to the change of field or scope of practice? If you have undergone more than one change and cannot account for all the changes within the questions below, please email additional information to cpca@cpca.net.au or use the below "file upload" facility to provide additional documentation. Thank you.

Narrowing scope of practice?

True

False

Reasonable extension of scope of practice?

True

False

Unrelated field or scope of practice?

True

False

File Upload Facility

Please feel free to upload any additional supporting documentation

File Upload

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB.

Tick the box below

Medical specialist CPD Program Outline Uploaded?

CPD Home Application Form

DRAFT WEBPAGE ONLY – CLOSED FOR BUSINESS

CPD Home Application Form

Applicant's Personal Details

Part 1/2

Section A Medical Practitioner Relevance

How to proceed

Additional Personal Details

Part 2/2

Section B Scope of Practice (SoP)

Section C CPD Home Membership History

Section D Recency of Practice

Recency of Practice

Non-practising registration or not registered and returning to practice

Less than 2 years clinical experience as a reg. med. practitioner

2+ years clinical experience as a reg. med. practitioner

Recent Change to Scope of Practice (SoP)

File Upload Facility

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