Application for Scope of Clinical Practice (SoCP) – Application Form SoCP Only (v1.00 06/2014) Instructions

Check this box if you are selecting Adult Echocardiography under the Cardiology section.

Check this box if you are requesting/indicating Level 1 training or competency in Transthoracic Echocardiography.

Check this box if you are requesting/indicating Level 2 training or competency in Transoesophageal Echocardiography.

Check this box if you are requesting/indicating Level 3 training or competency in Stress Echocardiography.

Check this box if you are requesting an Advanced Specialised Skill scope of clinical practice in Aboriginal and Torres Strait Islander Health (12 months advanced skill training with RACGP or ACRRM).

Check this box if you are applying for an Advanced Specialised Skill scope of clinical practice in Adult Internal Medicine.

Check this box if you are requesting an Advanced Specialised Skill scope of clinical practice in Anaesthetics (JCCA).

Check this box if your requested Anaesthetics (JCCA) scope includes providing anaesthesia care to adult patients.

Check this box if your requested Anaesthetics (JCCA) scope includes providing anaesthesia care to children (and you will specify the minimum age or weight).

Check this box if your requested Anaesthetics (JCCA) scope includes performing epidural anaesthesia.

Check this box if you are requesting an Advanced Specialised Skill scope of clinical practice in Child and Adolescent Health / Paediatrics.

Check this box if you are requesting an Advanced Specialised Skill scope of clinical practice for Colonoscopy and you hold GESA Certification.

Check this box if you are requesting an Advanced Specialised Skill scope of practice for Gastroscopy with GESA Certification.

Check this box if you are requesting an Advanced Specialised Skill scope of practice in Generalist Emergency Medicine.

Check this box if you are requesting an Advanced Specialised Skill scope of clinical practice in GP Emergency Medicine.

Check this box if you are requesting Scope of Clinical Practice in the Advanced Specialised Skill of Mental Health (typically requiring 12 months advanced skill training with RACGP or ACRRM).

Check this box if you are requesting an Advanced Specialised Skill scope of clinical practice in Obstetrics (DRANZCOG Advanced).

Check this box if your requested scope includes performing normal deliveries, assisted deliveries (excluding Keilland’s forceps), and caesarean sections.

Check this box if your requested scope includes basic elective and emergency gynaecological procedures, including laparotomies in emergency gynaecological situations.

Check this box if your requested scope includes Operative Laparoscopy (Level 1).

Check this box if your requested scope includes performing colposcopy.

Check this box if you are requesting an Advanced Specialised Skill scope of clinical practice in Population Health.

Check this box if you are requesting an Advanced Specialised Skill scope of clinical practice in Remote Medicine.

Check this box if you are requesting Scope of Clinical Practice in the Advanced Specialised Skill of Rural Generalist Anaesthesia (including general/regional anaesthesia, epidural anaesthesia, and paediatric anaesthesia as specified).

Check this box if you are requesting scope of clinical practice in the Advanced Specialised Skill of Rural Generalist Surgery.

Check this box if you have attached a list of the specific surgical procedures you are requesting to perform under Rural Generalist Surgery.

Enter your AHPRA registration number.

Check this box if your AHPRA registration type is Specialist registration.

Check this box if your AHPRA registration type is General registration.

Check this box if your AHPRA registration type is Limited registration (and provide the details in the space provided).

If you selected Limited Registration, specify the type or details of your limited registration. Fill only if 'Limited Registration' is 'Yes'.

Enter the applicant’s full name as it should appear in the declaration.

Enter the date on which the applicant completes and declares the application.

Enter your full legal name as the applicant making this declaration and authorisation.

Check this box if you have attached a copy of your photo identification to this application/renewal.

Check this box if you have attached your current CV, signed and dated as true and correct, with any gaps in employment explained.

Check this box if you have attached evidence of your base degree qualification.

Check this box if you have attached evidence of your specialist qualifications (if applicable).

Check this box if you have attached your training certification documentation.

Check this box if you have provided contact details for your referees.

Check this box if you have attached current evidence of CME/CPD.

Check this box if you have attached your Professional Indemnity insurance certificate of currency (if applicable).

Check this box if you are not providing CME/CPD evidence because your fellowship qualification is less than 12 months old. Fill only if 'Yes, current CME/CPD evidence attached' is 'No'.

Check this box to indicate you are selecting the Cardiac Implantable Electronic Devices (CIED) and Electrophysiology category.

Check this box if you are selecting Track 1 for Cardiac Implantable Electronic Devices (CIED).

Check this box if you are selecting Track 2 for Cardiac Implantable Electronic Devices (CIED).

Check this box if you are selecting Adult Cardiac Electrophysiology.

Check this box if you are selecting the Cardio-Thoracic Surgery (Adult) specialty.

Check this box if you are selecting the Cardio-Thoracic Surgery (Paediatric) specialty.

Check this box if the physician specialty/area selected is Cardiology.

Check this box if you are selecting Child Protection as part of your Paediatrics and Child Health scope/training on this form.

Check this box if your Child Protection training/role is Level 2 (you work predominantly with children, young people and parents). Fill only if 'Child Protection' is 'Yes'.

Check this box if your Child Protection training/role is Level 3 as a designated medical child protection practitioner. Fill only if 'Child Protection' is 'Yes'.

Enter the name of the organisation or group where the clinical audit/peer review activity was undertaken. Fill only if 'Clinical Audit/Peer Review Response: Yes (please describe)' is 'Yes'.

Describe the type of clinical audit or peer review activity performed. Fill only if 'Clinical Audit/Peer Review Response: Yes (please describe)' is 'Yes'.

State how often this clinical audit/peer review activity occurs (for example, monthly or quarterly). Fill only if 'Clinical Audit/Peer Review Response: Yes (please describe)' is 'Yes'.

Indicate whether related reports are attached and, if applicable, provide brief details of the attached reports. Fill only if 'Clinical Audit/Peer Review Response: Yes (please describe)' is 'Yes'.

Enter the name of the organisation or group where the clinical audit/peer review activity is conducted. Fill only if 'Clinical Audit/Peer Review Response: Yes (please describe)' is 'Yes'.

Describe the type of clinical audit or peer review activity undertaken (e.g., quality review, morbidity and mortality meeting). Fill only if 'Clinical Audit/Peer Review Response: Yes (please describe)' is 'Yes'.

Enter how often you participate in this clinical audit/peer review activity (e.g., monthly, quarterly). Fill only if 'Clinical Audit/Peer Review Response: Yes (please describe)' is 'Yes'.

State what reports or supporting documents are attached for this activity. Fill only if 'Clinical Audit/Peer Review Response: Yes (please describe)' is 'Yes'.

Enter the name of the organisation, committee, or group through which you complete this fourth clinical audit/peer review activity. Fill only if 'Clinical Audit/Peer Review Response: Yes (please describe)' is 'Yes'.

Describe the type of quality activity performed for this fourth entry (e.g., clinical audit, peer review, M&M meeting). Fill only if 'Clinical Audit/Peer Review Response: Yes (please describe)' is 'Yes'.

State how often you participate in this fourth clinical audit/peer review activity. Fill only if 'Clinical Audit/Peer Review Response: Yes (please describe)' is 'Yes'.

Indicate what reports or supporting documents are attached for this fourth clinical audit/peer review activity. Fill only if 'Clinical Audit/Peer Review Response: Yes (please describe)' is 'Yes'.

Enter the name of the organisation or setting where the clinical audit/peer review activity took place. Fill only if 'Clinical Audit/Peer Review Response: Yes (please describe)' is 'Yes'.

Describe the type of clinical audit or peer review activity undertaken (e.g., morbidity and mortality meeting, clinical peer review). Fill only if 'Clinical Audit/Peer Review Response: Yes (please describe)' is 'Yes'.

Enter how often you participate in this clinical audit/peer review activity (e.g., weekly, monthly, quarterly). Fill only if 'Clinical Audit/Peer Review Response: Yes (please describe)' is 'Yes'.

Indicate what supporting reports or documentation are attached for this activity. Fill only if 'Clinical Audit/Peer Review Response: Yes (please describe)' is 'Yes'.

Enter the name of the organisation, committee, or meeting group responsible for this third clinical audit/peer review activity. Fill only if 'Clinical Audit/Peer Review Response: Yes (please describe)' is 'Yes'.

Describe the type of clinical audit or peer review activity undertaken for this third entry. Fill only if 'Clinical Audit/Peer Review Response: Yes (please describe)' is 'Yes'.

State how often this third clinical audit/peer review activity occurs (e.g., monthly, quarterly). Fill only if 'Clinical Audit/Peer Review Response: Yes (please describe)' is 'Yes'.

List the report(s) or supporting documentation attached for this third activity (or note what documentation is provided). Fill only if 'Clinical Audit/Peer Review Response: Yes (please describe)' is 'Yes'.

Provide an explanation of why you do not submit your clinical work to quality activity mechanisms such as clinical audit or peer review. Fill only if 'Clinical Audit/Peer Review Response: No (please explain)' is 'Yes'.

Check this box if you do submit your clinical work to quality activity mechanisms such as clinical audit and/or peer review, and then provide details in the section below.

Check this box if you do not submit your clinical work to clinical audit/peer review mechanisms, and then explain why in the section below.

Check this box if you want to select Clinical Genetics (Paediatric) under Paediatrics and Child Health.

Check this box if you are selecting Clinical Genetics as the physician specialty/area.

Check this box if the physician’s specialty/selection is Clinical Immunology and Allergy.

Check this box if you are selecting Clinical Immunology, Allergy and Immunopathology as the relevant specialty/area for this application.

Check this box if you are selecting Clinical Pharmacology as the physician specialty/area for this form.

Check this box if you are selecting Community Child Health as your paediatrics and child health area/training option.

Enter your primary contact phone number.

Enter your fax number, if applicable.

Enter your mobile phone number.

Enter your first email address for contact and correspondence.

Enter your second email address for contact and correspondence, if applicable.

Provide an explanation for why you are not undertaking the required continuing education, re-certification, or related requirements. Fill only if 'No' is 'Yes'.

Enter the name of the college, organisation, or continuing education program for the fifth entry. Fill only if 'Yes' is 'Yes'.

State whether you are currently enrolled in the fifth listed program (e.g., Yes or No). Fill only if 'Yes' is 'Yes'.

Provide the date you completed the fifth listed program, if applicable. Fill only if 'Yes' is 'Yes'.

Enter the name of the college, organisation, or continuing education program for this first CPD/CME entry. Fill only if 'Yes' is 'Yes'.

Indicate whether you are currently enrolled in this program for the first entry. Fill only if 'Yes' is 'Yes'.

Enter the date this program was completed for the first entry, if applicable. Fill only if 'Yes' is 'Yes'.

Enter the name of the continuing education college, organisation, or program for the fourth entry. Fill only if 'Yes' is 'Yes'.

State whether you are currently enrolled in the fourth listed program. Fill only if 'Yes' is 'Yes'.

Provide the date the fourth listed program was completed (if applicable). Fill only if 'Yes' is 'Yes'.

Enter the name of the college, organisation, or continuing education program for the second entry. Fill only if 'Yes' is 'Yes'.

Indicate whether you are currently enrolled in the program listed in the second entry. Fill only if 'Yes' is 'Yes'.

Provide the date the program listed in the second entry was completed, if applicable. Fill only if 'Yes' is 'Yes'.

Enter the name of the college, organisation, or continuing education program for the sixth CPD/CME entry. Fill only if 'Yes' is 'Yes'.

State whether you are currently enrolled in the sixth listed program (e.g., Yes or No). Fill only if 'Yes' is 'Yes'.

Provide the date the sixth listed program was completed, if applicable. Fill only if 'Yes' is 'Yes'.

Enter the name of the college, organisation, or continuing education program for the third listed entry. Fill only if 'Yes' is 'Yes'.

State whether you are currently enrolled in the third listed continuing education program. Fill only if 'Yes' is 'Yes'.

Enter the date you completed the third listed continuing education program (if applicable). Fill only if 'Yes' is 'Yes'.

Check this box if you are undertaking the required continuing education/recertification requirements (supporting documentation must be attached to the application).

Check this box if you are not undertaking the required continuing education/recertification requirements and you will provide an explanation.

Check this box if you are credentialed/qualified in coronary angiography.

Check this box if you are credentialed/qualified to perform diagnostic cardiac catheterisation and coronary angiography.

Check this box if you are credentialed/qualified to perform percutaneous coronary intervention (PCI).

Check this box if you hold Level 2 competency/credentialing in stress echocardiography.

Check this box if you are certified as a CT coronary angiography (CTCA) Level A specialist.

Check this box if you are certified as a CT coronary angiography (CTCA) Level B specialist.

Check this box if you hold a lead extraction certification.

Check this box if you currently have medical indemnity insurance.

Check this box if you do not currently have medical indemnity insurance.

Check this box if your current medical indemnity insurance is provided through Queensland Health.

Provide a detailed statement explaining any 'Yes' answers above, including relevant details, dates, and any supporting documentation. Fill only if 'Question 1: Yes', 'Question 2 - Yes', 'Question 3 - Yes (Currently under investigation)', 'Question 4 - Yes (Right to practice restricted/denied)', 'Question 5 - Yes', 'Question 6 - Yes', 'Question 7 - Yes' is 'Yes' (any).

Check this box if the physician’s specialty is Diagnostic Radiology.

Check this box if the physician practices or is credentialed to provide MRI services under Diagnostic Radiology.

Check this box if the physician practices or is credentialed to provide Mammography services under Diagnostic Radiology.

Check this box if the physician practices or is credentialed to provide Peripheral Endovascular Therapy under Diagnostic Radiology.

Enter the title or position name of the eighth current clinical appointment.

Describe the scope of clinical practice for the eighth appointment, including the clinical duties performed.

Enter the Health and Hospital Service (HHS) or organisation where the eighth appointment is held.

Check this box if you are selecting the Endocrinology and Chemical Pathology specialty/area.

Check this box if you are selecting Endocrinology as the physician specialty/area.

Enter the hospital and health service and/or specific facility or facilities where the Scope of Clinical Practice (SoCP) is being requested.

Check this box if the SoCP is being requested for Regional Hospital & Health Services.

Check this box if the Scope of Clinical Practice (SoCP) is being requested for Central Qld Hospital & Health Service.

Check this box if the SoCP is being requested for one or more specific facilities (rather than a whole Hospital & Health Service).

Enter the title or role name of the fifth current clinical appointment.

Describe the scope of clinical practice associated with the fifth current clinical appointment.

Enter the HHS or organisation where the fifth current clinical appointment is held.

Enter the title or name of the first current clinical appointment you hold.

Describe the scope of clinical practice for the first current appointment.

Enter the Hospital and Health Service (HHS) or organisation where the first current appointment is held.

Enter the title or role name of the fourth current clinical appointment.

Describe the scope of clinical practice performed under the fourth current appointment.

Enter the Health and Human Services (HHS) service or organisation where the fourth current appointment is held.

Check this box if you are applying under the Gastroenterology and Hepatology specialty category.

Check this box if you perform or are credentialed for liver biopsy procedures.

Check this box if you perform or are credentialed for gastroscopy (upper GI endoscopy).

Check this box if you perform or are credentialed for colonoscopy procedures.

Check this box if you perform or are credentialed for endoscopic ultrasound (EUS) procedures.

Check this box if you perform or are credentialed for ERCP procedures.

Check this box if you perform or are credentialed for balloon enteroscopy procedures.

Check this box if you perform or are credentialed for capsule endoscopy procedures.

Check this box if you perform another endoscopy/procedure not listed here and will specify it in the space provided.

Enter the name of any other gastroenterology/hepatology endoscopy procedure you perform that is not listed above. Fill only if 'Other endoscopy (please state)' is 'Yes'.

Check this box if the referral/request is for General Medicine.

Check this box if you are requesting an echocardiography examination.

Check this box if you are requesting a colonoscopy procedure.

Check this box if you are requesting a General Medicine procedure not listed and write the details in the space provided.

Check this box if you are requesting a gastroscopy procedure.

Check this box if you are requesting a liver biopsy procedure.

Enter the specific general medicine procedure or specialty if you selected "Other" under General Medicine. Fill only if 'Other (please state)' is 'Yes'.

Check this box if your selected specialty/area of practice is General Paediatrics and Child Health.

Check this box if the practitioner’s scope of clinical practice includes General Practice (and list any exclusions separately if applicable).

Enter any exclusions or limitations that should not be included in your General Practice scope of clinical practice.

Check this box if you are requesting an advanced specialised skill in General Practice that is not listed, and specify the skill in the space provided.

Enter the name of the other General Practice advanced specialised skill you are requesting that is not listed on the form. Fill only if 'General Practice Advanced Specialised Skills - Other (please state)' is 'Yes'.

Check this box if you provide General Psychiatry services as part of the Statewide Disaster Response.

Check this box if General Surgery endoscopy services requested include a gastroscopy.

Check this box if a different type of General Surgery endoscopy is requested and specify the procedure in the space provided.

Check this box if General Surgery endoscopy services requested include a colonoscopy.

Specify the other general surgery endoscopy procedure performed if it is not gastroscopy or colonoscopy. Fill only if 'Other endoscopy (please state)' is 'Yes'.

Check this box if your General Surgery post-fellowship training is/was in Colorectal Surgery.

Check this box if your General Surgery post-fellowship training is/was in Hepato-Pancreato-Biliary (HPB) surgery.

Check this box if your General Surgery post-fellowship training is/was in Transplant Surgery, and enter the specific details in the space provided.

Check this box if your General Surgery post-fellowship training is/was in another area not listed, and specify it in the space provided.

Check this box if your General Surgery post-fellowship training is/was in Upper Gastrointestinal (GI) surgery.

Check this box if your General Surgery post-fellowship training is/was in Bariatric Surgery.

Enter the specific transplant surgery post-fellowship training area or program you completed or intend to undertake. Fill only if 'Transplant Surgery (please state)' is 'Yes'.

Enter the details of any other general surgery post-fellowship training option not listed. Fill only if 'Other (please state)' is 'Yes'.

Check this box if you are selecting General Surgery as your specialty.

Check this box if you are selecting Geriatric Medicine as the relevant physician specialty/area for this form.

Check this box if the physician’s specialty/area of practice is Haematology and Pathology.

Check this box if the physician’s specialty/area of practice is Haematology.

Check this box if you want your home address to be used as your preferred mailing/correspondence address.

Enter your full home mailing address to be used as your preferred address for correspondence.

Check this box if the physician’s specialty/selection is Infectious Diseases and Microbiology.

Check this box if the physician’s specialty/area of practice is Infectious Diseases.

Check this box if the physician provides tuberculosis services under the Regional SoCP within Infectious Diseases.

Check this box if your Intensive Care Medicine advanced specialised skill is not listed above and you will specify the other skill in the space provided.

Enter the other Intensive Care Medicine skill or area of practice that is not listed. Fill only if 'Intensive Care Medicine - Other (please state)' is 'Yes'.

Check this box if you are requesting a Scope of Clinical Practice in Intensive Care Medicine.

Check this box if you will perform echocardiography procedures as part of your Intensive Care Medicine scope.

Check this box if you will perform gastrointestinal endoscopy procedures as part of your Intensive Care Medicine scope.

Check this box if you will perform or manage ECMO as part of your Intensive Care Medicine scope.

Check this box if the interventional radiology procedures you perform include thoracic (chest) interventions.

Check this box if the interventional radiology procedures you perform include urological (urinary tract) interventions.

Check this box if the interventional radiology procedures you perform include orthopaedic (musculoskeletal) interventions.

Check this box if you perform vascular interventional procedures beyond basic diagnostic angiography.

Check this box if you perform venous or arterio-venous graft interventions beyond basic diagnostic venography or fistulography.

Check this box if the interventional radiology procedures you perform include biliary interventions, including T.I.P.S.

Check this box if the interventional radiology procedures you perform include gastro-intestinal interventions.

Check this box if the interventional radiology procedures you perform include gynaecological interventions.

Check this box if you perform neuro-interventional procedures involving intracranial and/or extracranial vessels.

Check this box if the physician performs Interventional Radiology Tier A procedures.

Check this box if the physician performs Interventional Radiology Tier B procedures.

Check this box if you are applying for a scope of clinical practice in Clinical Administration and then specify the clinical administration area/location in the space provided.

Enter the specific clinical administration area, service, or setting you are applying for under Medical Administration. Fill only if 'Clinical Administration in (please state)' is 'Yes'.

Check this box if you are applying for or requesting a scope of clinical practice in Medical Administration.

Enter the name of the medical indemnity insurance company for the first medical indemnity entry. Fill only if 'Current medical indemnity insurance selection: Yes' is 'Yes'.

Enter the category or level of medical indemnity coverage held for the first medical indemnity entry. Fill only if 'Current medical indemnity insurance selection: Yes' is 'Yes'.

Enter the expiry date of the medical indemnity insurance for the first medical indemnity entry. Fill only if 'Current medical indemnity insurance selection: Yes' is 'Yes'.

Enter the name of the insurance company providing your second listed medical indemnity coverage. Fill only if 'Current medical indemnity insurance selection: Yes' is 'Yes'.

Enter the category or level of cover for your second listed medical indemnity policy. Fill only if 'Current medical indemnity insurance selection: Yes' is 'Yes'.

Provide the expiry date of your second listed medical indemnity policy. Fill only if 'Current medical indemnity insurance selection: Yes' is 'Yes'.

Check this box if the physician’s specialty/selection is Medical Oncology.

Check this box if you are selecting Neonatology and Perinatal Medicine as your area/subspecialty.

Check this box if your Neonatology and Perinatal Medicine training includes Echocardiography. Fill only if 'Neonatology and Perinatal Medicine' is 'Yes'.

Check this box if you have another Neonatology and Perinatal Medicine training option not listed and specify it in the provided space. Fill only if 'Neonatology and Perinatal Medicine' is 'Yes'.

Check this box if your Neonatology and Perinatal Medicine training includes Ultrasound. Fill only if 'Neonatology and Perinatal Medicine' is 'Yes'.

Enter the other Neonatology and Perinatal Medicine training option you completed if it is not listed (e.g., not Echocardiography or Ultrasound). Fill only if 'Neonatology and Perinatal Medicine – Other (please state)' is 'Yes'.

Check this box if you are applying under the Nephrology specialty area.

Check this box if your application includes the Renal Biopsy procedure/credentialing component.

Check this box if your application includes Peritoneal Access Placement.

Check this box if your application includes Acute Vascular Access.

Check this box if the physician’s specialty is Neurology.

Check this box if your specialty is Neurosurgery.

Check this box if you have completed post-fellowship training in Neurosurgery and will provide details in the space provided.

Enter the details of your post-fellowship training in neurosurgery (e.g., subspecialty area or program name). Fill only if 'Neurosurgery – Post Fellowship Training (please state)' is 'Yes'.

Enter the title or name of the ninth current clinical appointment.

Describe the scope of clinical practice for the ninth current appointment, including relevant duties or services provided.

Enter the Hospital and Health Service (HHS) or organisation where the ninth current appointment is held.

Check this box if the physician’s specialty is Nuclear Medicine.

Check this box if the physician performs or specializes in Positron Emission Tomography (PET).

Check this box if the physician performs or specializes in CT Coronary Angiography (CTCA).

Check this box if you are selecting Advanced Operative Laparoscopy at Level 4. Fill only if 'Obstetrics and Gynaecology' is 'Yes'.

Check this box if you are selecting Advanced Operative Laparoscopy at Level 5. Fill only if 'Obstetrics and Gynaecology' is 'Yes'.

Check this box if you are selecting Advanced Operative Laparoscopy at Level 6. Fill only if 'Obstetrics and Gynaecology' is 'Yes'.

Check this box if you are selecting the Advanced Endoscopic Surgery option. Fill only if 'Obstetrics and Gynaecology' is 'Yes'.

Check this box if you are selecting the Lower Genital Tract Laser Surgery option. Fill only if 'Obstetrics and Gynaecology' is 'Yes'.

Check this box if you are selecting the Robotic Surgery option. Fill only if 'Obstetrics and Gynaecology' is 'Yes'.

Check this box if you have completed extra training in paediatric gynaecology. Fill only if 'Obstetrics and Gynaecology' is 'Yes'.

Check this box if you have completed extra training in video colposcopy of children. Fill only if 'Obstetrics and Gynaecology' is 'Yes'.

Check this box if your Obstetrics and Gynaecology subspecialty is Gynaecological Oncology. Fill only if 'Obstetrics and Gynaecology' is 'Yes'.

Check this box if your Obstetrics and Gynaecology subspecialty is Urogynaecology. Fill only if 'Obstetrics and Gynaecology' is 'Yes'.

Check this box if your Obstetrics and Gynaecology subspecialty is Reproductive Endocrinology and Infertility. Fill only if 'Obstetrics and Gynaecology' is 'Yes'.

Check this box if your Obstetrics and Gynaecology subspecialty is Maternal-Fetal Medicine. Fill only if 'Obstetrics and Gynaecology' is 'Yes'.

Check this box if your Obstetrics and Gynaecology subspecialty is Obstetrics and Gynaecological Ultrasound. Fill only if 'Obstetrics and Gynaecology' is 'Yes'.

Check this box if you are selecting Occupational & Environmental Medicine as the applicable specialty/area for this form.

Check this box if you are selecting Ophthalmology as the specialty for this section.

Check this box if you have completed post-fellowship training in Ophthalmology and will specify the training in the provided text line.

Enter the details of any post-fellowship ophthalmology training you have completed. Fill only if 'Post Fellowship Training (please state)' is 'Yes'.

Check this box if you are selecting Oral and Maxillofacial Surgery as your specialty.

Check this box if Orthopaedic Surgery is your specialty.

Check this box if you have completed post-fellowship training in Orthopaedic Surgery and will provide the training details in the space provided.

Enter the details of your post-fellowship training in orthopaedic surgery (e.g., subspecialty or fellowship program name). Fill only if 'Orthopaedic Surgery – Post Fellowship Training (please state)' is 'Yes'.

Check this box if you are applying under the “Other Postgraduate Programs” category.

Check this box if you are applying for the Clinical Pathology postgraduate program. Fill only if 'Other Postgraduate Programs' is 'Yes'.

Check this box if you are applying for the Genetic Pathology postgraduate program. Fill only if 'Other Postgraduate Programs' is 'Yes'.

Check this box if you are applying for the Molecular Pathology postgraduate program. Fill only if 'Other Postgraduate Programs' is 'Yes'.

Check this box if you are applying for the Paediatric Pathology postgraduate program. Fill only if 'Other Postgraduate Programs' is 'Yes'.

Check this box if you are applying for the Neuropathology postgraduate program. Fill only if 'Other Postgraduate Programs' is 'Yes'.

Check this box if your specialty is Otolaryngology – Head and Neck Surgery.

Check this box if you have completed post-fellowship training in Otolaryngology – Head and Neck Surgery and will provide the training details in the space provided.

Enter the details of your post-fellowship training in Otolaryngology – Head and Neck Surgery (e.g., subspecialty area or program name). Fill only if 'Otolaryngology – Head and Neck Surgery: Post Fellowship Training (please state)' is 'Yes'.

Check this box if you are selecting Paediatric Cardiology as the relevant training area/specialty for this section.

Check this box if you have training/competency or are seeking recognition in transthoracic echocardiography within paediatric cardiology. Fill only if 'Paediatric Cardiology' is 'Yes'.

Check this box if you have training/competency or are seeking recognition in fetal echocardiography. Fill only if 'Paediatric Cardiology' is 'Yes'.

Check this box if you have training/competency or are seeking recognition for paediatric cardiac catheterisation at Level 1 procedures. Fill only if 'Paediatric Cardiology' is 'Yes'.

Check this box if you have training/competency or are seeking recognition for paediatric cardiac catheterisation at Level 2 procedures. Fill only if 'Paediatric Cardiology' is 'Yes'.

Check this box if you have training/competency or are seeking recognition for paediatric cardiac catheterisation at Level 3 procedures. Fill only if 'Paediatric Cardiology' is 'Yes'.

Check this box if you have training/competency or are seeking recognition for paediatric cardiac catheterisation at Level 4 procedures. Fill only if 'Paediatric Cardiology' is 'Yes'.

Check this box if you have training/competency or are seeking recognition in transoesophageal echocardiography within paediatric cardiology. Fill only if 'Paediatric Cardiology' is 'Yes'.

Check this box if you are selecting Paediatric Clinical Pharmacology as your specialty/subspecialty area.

Check this box if you have training, certification, or a specialty/subspecialty focus in paediatric emergency medicine.

Check this box if the applicant’s specialty/area of practice is Paediatric Endocrinology.

Check this box if you are selecting Paediatric Endocrinology and Chemical Pathology as your Paediatrics and Child Health specialty/subspecialty option.

Check this box if you are selecting Paediatric Gastroenterology and Hepatology as the relevant paediatric specialty for this application.

Check this box if Liver Biopsy is a procedure option you perform or are requesting recognition/training for within Paediatric Gastroenterology and Hepatology. Fill only if 'Paediatric Gastroenterology and Hepatology' is 'Yes'.

Check this box if Gastroscopy is a procedure option you perform or are requesting recognition/training for within Paediatric Gastroenterology and Hepatology. Fill only if 'Paediatric Gastroenterology and Hepatology' is 'Yes'.

Check this box if Colonoscopy is a procedure option you perform or are requesting recognition/training for within Paediatric Gastroenterology and Hepatology. Fill only if 'Paediatric Gastroenterology and Hepatology' is 'Yes'.

Check this box if Capsule endoscopy is a procedure option you perform or are requesting recognition/training for within Paediatric Gastroenterology and Hepatology. Fill only if 'Paediatric Gastroenterology and Hepatology' is 'Yes'.

Check this box if ERCP is a procedure option you perform or are requesting recognition/training for within Paediatric Gastroenterology and Hepatology. Fill only if 'Paediatric Gastroenterology and Hepatology' is 'Yes'.

Check this box if EUS is a procedure option you perform or are requesting recognition/training for within Paediatric Gastroenterology and Hepatology. Fill only if 'Paediatric Gastroenterology and Hepatology' is 'Yes'.

Check this box if you have another endoscopy procedure not listed here and you will specify it in the space provided. Fill only if 'Paediatric Gastroenterology and Hepatology' is 'Yes'.

Enter the name or details of any other endoscopy procedure performed in paediatric gastroenterology and hepatology that is not listed on the form. Fill only if 'Other endoscopy (please state)' is 'Yes'.

Check this box if the service/claim relates to Paediatric Nephrology.

Check this box if a renal (kidney) biopsy procedure was performed. Fill only if 'Paediatric Nephrology' is 'Yes'.

Check this box if peritoneal access was placed (e.g., peritoneal dialysis catheter placement). Fill only if 'Paediatric Nephrology' is 'Yes'.

Check this box if acute vascular access was inserted or established for treatment. Fill only if 'Paediatric Nephrology' is 'Yes'.

Check this box if the referral/request is for the Paediatric Respiratory and Sleep Medicine service.

Check this box if the referral/request is specifically for a paediatric bronchoscopy under Paediatric Respiratory and Sleep Medicine. Fill only if 'Paediatric Respiratory and Sleep Medicine' is 'Yes'.

Check this box if you want to select Paediatric Surgery as your surgery specialty.

Check this box if you are selecting Paediatric Haematology as your Paediatrics and Child Health specialty option.

Check this box if you are selecting Paediatric Haematology and Pathology as your Paediatrics and Child Health specialty option.

Check this box if you are selecting Paediatric Immunology and Allergy as your Paediatrics and Child Health specialty option.

Check this box if you are selecting Paediatric Immunology, Allergy and Immunopathology as your Paediatrics and Child Health specialty option.

Check this box if you are selecting Paediatric Infectious Diseases as your Paediatrics and Child Health specialty option.

Check this box if you are selecting Paediatric Infectious Diseases and Microbiology as your Paediatrics and Child Health specialty option.

Check this box if you are selecting Paediatric Intensive Care Medicine as your Paediatrics and Child Health specialty option.

Check this box if you are selecting Paediatric Medical Oncology as your Paediatrics and Child Health specialty option.

Check this box if you are selecting Paediatric Neurology as your Paediatrics and Child Health specialty option.

Check this box if you are selecting Paediatric Nuclear Medicine as your Paediatrics and Child Health specialty option.

Check this box if you are selecting Paediatric Palliative Medicine as your Paediatrics and Child Health specialty option.

Check this box if you are selecting Paediatric Rehabilitation Medicine as your Paediatrics and Child Health specialty option.

Check this box if you are selecting Paediatric Rheumatology as your Paediatrics and Child Health specialty option.

Check this box if the selected specialty/service is Pain Medicine.

Check this box to indicate you are selecting Palliative Medicine as the relevant specialty/area.

Check this box if paracentesis and/or thoracocentesis is a procedure you perform or are indicating under Palliative Medicine. Fill only if 'Palliative Medicine' is 'Yes'.

Check this box if you are selecting General Pathology as your pathology specialty option.

Check this box if you are selecting Anatomical Pathology as your pathology specialty option.

Check this box if you are selecting Anatomical Pathology and Cytopathology as your pathology specialty option.

Check this box if you are selecting Chemical Pathology as your pathology specialty option.

Check this box if you are selecting Haematology as your pathology specialty option.

Check this box if you are selecting Immunology as your pathology specialty option.

Check this box if you are selecting Microbiology as your pathology specialty option.

Check this box if you are selecting Forensic Pathology as your pathology specialty option.

Enter your legal first (given) name.

Enter your middle name(s), if applicable.

Enter your legal last name (family/surname).

Enter the name you prefer to be known by.

Enter any previous name you have used that may appear on certificates or official documents.

Enter your date of birth.

Check this box if the applicant's gender is Female.

Check this box if the applicant's gender is Male.

Check this box if your surgical specialty is Plastic Surgery.

Check this box if you have completed post-fellowship training in Plastic Surgery and will provide details in the space provided.

Enter the details of your post-fellowship training in plastic surgery (e.g., subspecialty area, program or institution). Fill only if 'Plastic Surgery Post Fellowship Training (please state)' is 'Yes'.

Check this box if you want correspondence to be sent to your practice address.

Enter the full practice mailing address to be used as the preferred address for correspondence.

Check this box if you are applying/declaring the Psychiatry specialty.

Check this box if you are qualified to administer electroconvulsive therapy (ECT) and want to list this capability.

Check this box if you hold an advanced psychiatry-related certification and will provide its details in the space provided.

Enter the name of any advanced psychiatry certification you hold. Fill only if 'Advanced certification (please state)' is 'Yes'.

Check this box if you provide Psychiatry for Court Liaison Service under the Regional Scope of Clinical Practice (SoCP).

Check this box if you are selecting the Public Health Medicine specialty under the Regional SoCP option.

Check this box if you have ever had an adverse finding made against you by a medical/dental registration authority or any other professional, disciplinary or similar body (including outside Australia).

Check this box if you have never had an adverse finding made against you by a medical/dental registration authority or any other professional, disciplinary or similar body (including outside Australia).

Check this box if you have ever had conditions or undertakings attached to your registration, or if your registration has been suspended or cancelled by a medical/dental registration authority or similar body (including overseas).

Check this box if you have never had conditions or undertakings attached to your registration and your registration has never been suspended or cancelled by a medical/dental registration authority or similar body (including overseas).

Check this box if you are currently under investigation by a medical registration authority, other regulatory authority, or a health facility in Australia or overseas.

Check this box if you are not currently under investigation by a medical registration authority, other regulatory authority, or a health facility in Australia or overseas.

Check this box if your right to practice and/or scope of clinical practice has ever been denied, restricted, suspended, terminated, or otherwise modified by any relevant organisation or authority.

Check this box if your right to practice and/or scope of clinical practice has never been denied, restricted, suspended, terminated, or otherwise modified by any relevant organisation or authority.

Check this box if a medical defence insurer you have been a member of has ever applied conditions or refused to renew your cover or membership in Australia or overseas.

Check this box if no medical defence insurer you have been a member of has ever applied conditions or refused to renew your cover or membership in Australia or overseas.

Check this box if you have any physical or other medical conditions (including substance abuse) that may limit your ability to exercise the scope of clinical practice for which you have applied.

Check this box if you do not have any physical or other medical conditions (including substance abuse) that may limit your ability to exercise the scope of clinical practice for which you have applied.

Check this box if you have any disclosable criminal convictions (adult convictions that are part of your criminal history and have not been rehabilitated under the Criminal Law (Rehabilitation of Offenders) Act 1986).

Check this box if you do not have any disclosable criminal convictions.

Check this box if the physician’s specialty selection is Radiation Oncology.

Check this box if you are selecting Nuclear Medicine under the Radiology section.

Enter the full name of Referee 1.

Enter Referee 1’s current job title or role.

Enter Referee 1’s mailing or work address.

Enter Referee 1’s work phone number.

Enter Referee 1’s mobile phone number.

Enter Referee 1’s email address.

Enter the full name of your second referee.

Enter your second referee’s current job title or role.

Enter the business or postal address for your second referee.

Enter your second referee’s work phone number.

Enter your second referee’s mobile phone number.

Enter the email address for your second referee.

Enter the full name of Referee 3.

Enter Referee 3's current job title or role.

Enter Referee 3's postal address.

Enter Referee 3's work telephone number.

Enter Referee 3's mobile phone number.

Enter Referee 3's email address.

Check this box if the physician’s specialty selection is Rehabilitation Medicine.

Check this box if you are selecting Respiratory as the specialty area for this physician.

Check this box if you are selecting Sleep Medicine as the specialty area for this physician.

Check this box if the physician performs flexible bronchoscopy.

Check this box if the physician places or manages endobronchial stents.

Check this box if the physician performs endobronchial ultrasound-guided transbronchial needle aspiration (EBUS TBNA).

Check this box if the physician performs endobronchial ultrasound-guided transbronchial needle aspiration (EBUS) using a guide sheath.

Check this box if the physician performs medical thoracoscopy.

Check this box if the physician performs endobronchial electrosurgery.

Check this box if the physician performs rigid bronchoscopy.

Check this box if the physician performs autofluorescence bronchoscopy.

Check this box if the physician performs laser bronchoscopy.

Check this box if you are selecting the Retrieval Services specialty of Medical Coordination.

Check this box if you are selecting the Retrieval Services specialty of Pre-hospital and Retrieval Medicine.

Check this box if you are selecting the Retrieval Services specialty of Retrieval Medicine (Paediatric).

Check this box if you are selecting the Retrieval Services specialty of Retrieval Medicine (Neonatal).

Check this box if your physician specialty is Rheumatology.

Check this box if you perform biopsies of relevant tissues and organs as part of your rheumatology practice.

Check this box if you provide musculoskeletal ultrasound services in your rheumatology practice.

Check this box if you perform arthroscopy procedures as part of your rheumatology practice.

Check this box if you perform injections using imaging guidance (e.g., ultrasound or fluoroscopy) in your rheumatology practice.

Check this box if you perform radioactive or chemical synovectomy procedures in your rheumatology practice.

Check this box if you are requesting a scope of clinical practice in Addiction Medicine.

Check this box if you are requesting a scope of clinical practice in Anaesthesia.

Check this box if you are requesting a scope of practice in Intensive Care for Anaesthetists.

Check this box if you are requesting a scope of practice to perform diagnostic perioperative adult transoesophageal echocardiography (TOE).

Check this box if you are requesting a scope of practice in Extracorporeal Perfusion (ECP).

Check this box if you are requesting a neonatal anaesthesia scope of practice.

Check this box if you are requesting an anaesthesia scope of practice for transplant cases.

Check this box if you are requesting an anaesthesia-related scope not listed above and provide the details in the space provided.

Enter the other anaesthesia scope/subspecialty being requested if it is not listed in the options above. Fill only if 'Other (please state)' is 'Yes'.

Check this box if you are requesting a scope of clinical practice in Breast Medicine.

Check this box if you are requesting scope to interpret screening and diagnostic mammography.

Check this box if you are requesting scope to perform and interpret breast ultrasound.

Check this box if you are requesting scope to perform image-guided interventional procedures.

Check this box if you are requesting approval to undertake permanent teeth extractions in your Dental Therapist scope.

Check this box if you are requesting approval to undertake orthodontic procedures in your Dental Therapist scope.

Check this box if you are requesting approval to undertake dental treatment under general anaesthesia in your Dental Therapist scope.

Check this box if you are requesting scope of clinical practice as a Dental Therapist.

Check this box if you are requesting a scope of clinical practice in Dermatology.

Check this box if you are requesting a scope of clinical practice in Emergency Medicine.

Check this box if you are requesting the scope of clinical practice for the Forensic Medical Officer role.

Check this box if you are requesting the scope of clinical practice for the Government Medical Officer role.

Check this box to request a Scope of Clinical Practice in General Dental Practice.

Check this box if you are requesting approval to provide dental treatment under general anaesthesia in a hospital operating theatre.

Check this box if you are requesting approval to provide relative analgesia using nitrous oxide and oxygen.

Check this box if you are requesting approval to provide dental treatment using intravenous sedation.

Check this box if the scope of clinical practice you are requesting is as an Oral Health Therapist.

Check this box if you are requesting a scope of clinical practice under Specialist Dental Practice.

Check this box if you are requesting a Specialist Dental Practice scope in Endodontics.

Check this box if you are requesting a Specialist Dental Practice scope in Public Health Dentistry.

Check this box if you are requesting a Specialist Dental Practice scope in Oral Pathology.

Check this box if you are requesting a Specialist Dental Practice scope in Dento-Maxillofacial Radiology.

Check this box if you are requesting a Specialist Dental Practice scope in Periodontics.

Check this box if you are requesting a Specialist Dental Practice scope in Prosthodontics.

Check this box if you are requesting a Specialist Dental Practice scope in Oral Medicine.

Check this box if you are requesting a Specialist Dental Practice scope in Forensic Odontology.

Check this box if you are requesting a Specialist Dental Practice scope in Orthodontics.

Check this box if you are requesting a Specialist Dental Practice scope in Oral and Maxillofacial Surgery.

Check this box if you are requesting a Specialist Dental Practice scope in Special Needs Dentistry.

Check this box if you are requesting a Specialist Dental Practice scope in Oral Surgery.

Check this box if you are requesting a Specialist Dental Practice scope in Paediatric Dentistry.

Enter the title or position name of the second current clinical appointment.

Describe the scope of clinical practice for the second current appointment.

Enter the HHS or organisation where the second current appointment is held.

Enter the title or role name of your seventh current clinical appointment that will be held concurrently.

Describe the scope of clinical practice for this seventh appointment, including the types of clinical duties performed.

Enter the name of the Hospital and Health Service (HHS) or organisation where this seventh appointment is held.

Check this box if you are selecting Sexual Health Medicine as the specialty.

Enter the title or role name of the sixth current clinical appointment.

Describe the scope of clinical practice associated with the sixth current clinical appointment.

Enter the Hospital and Health Service (HHS) or organisation where the sixth current clinical appointment is held.

Check this box if you are selecting Sports Medicine as your specialty.

Check this box if you are providing the supporting information by referring the reviewer to your CV instead of entering details in this section.

Enter the title or name of your tenth current clinical appointment.

Describe the scope of clinical practice associated with your tenth current clinical appointment.

Enter the Hospital and Health Service (HHS) or organisation for your tenth current clinical appointment.

Enter the title or name of your third current clinical appointment.

Describe the scope of clinical practice for your third current appointment.

Enter the Hospital and Health Service (HHS) or organisation where your third current appointment is held.

Check this box if you are submitting a new application for Scope of Clinical Practice (SoCP).

Check this box if you are applying to add to or change your existing Scope of Clinical Practice (SoCP).

Check this box if you are submitting a renewal application for your Scope of Clinical Practice (SoCP).

Check this box if your specialty is Urology.

Check this box if you have completed post fellowship training in Urology and will provide the details in the space provided.

Enter the details of your post-fellowship training in urology (e.g., subspecialty area and/or program name). Fill only if 'Urology – Post Fellowship Training (please state)' is 'Yes'.

Check this box if you are selecting Vascular Medicine as the specialty.

Check this box if you practice or are credentialed in Vascular Surgery as a specialty.

Check this box if you have training/competency in Peripheral Endovascular Therapy as part of your vascular practice.

Check this box if you have completed post-fellowship training related to vascular surgery and will provide the details in the space provided.

Enter the details of any post-fellowship training you have completed in vascular surgery. Fill only if 'Post Fellowship Training (please state)' is 'Yes'.

Enter the witness’s full name as it should appear in print.

Enter the date on which the witness signs this declaration.