Credentialing & Scope of Practice Application & Renewal Form – Supporting Personnel

Application Type*

New Application

Renewal Application

Personal and Contact Information

Name*

Given Names Surname

Preferred Title*

Prefix

(e.g. Dr, Mr, A/Prof; Prof)

Preferred Name

Any former names including maiden name

Date of Birth*

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address

Same as Home Address

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile Phone Number*

Mobile Phone

Other Phone Numbers

Home Phone Fax

Email Address*

Personal Business

Emergency Contact Person

Emergency Contact*

Name Relationship Mobile Phone Email

Other Phone Numbers

Home Phone Work Phone

Name of Partner/Spouse*

(for Hospital invitation list)

Professional Practice Details

Practice Name (1)*

Business Address (Primary Consulting Room)*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Fax

Practice Name (2)

Business Address (Other Consulting Rooms)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Fax

Professional Registration Details

Please attach a copy of your Registration certificate*

Max. file size: 512 MB.

Registration Details*

Registration Number Category of Registration Expiry Date

Are there any conditions or undertakings currently attached to this registration?*

Yes

If yes, please give details

Have you ever been subject to an adverse finding or had conditions or undertakings attached to your registration by a medical board, dental board, or other registration board (as appropriate)?*

Yes

If yes, please give details of the restriction and what period during which the restrictions apply/applied.

Professional Indemnity

Please attach a copy of your Professional Indemnity Certificate*

Max. file size: 512 MB.

Indemnity Insurance*

Indemnity Insurance Number Category of Coverage Insurer Name Expiry Date

Does your membership fully cover the scope of clinical practice you have applied for?*

Yes

Has your medical defence insurer or any medical defence insurer or fund of which you have been a member ever applied conditions or refused to renew your cover or membership (in part or in full)?*

Yes

If yes, please provide details

Are there any current claims against you with your insurer, Medical Board (or other Registration Board) or Office of the Health Ombudsman (OHO)?*

Yes

If yes, please provide details

Medico Legal*

* This information is required to assess an application for scope of clinical practice and will only be used by Townsville Day Surgery for such purposes. Information provided will not be disclosed otherwise.

Have there ever been any adverse findings made against you which would be relevant to your appointment (for example: breach of insurance/medical laws, professional misconduct, sexual assaults or assault) by the OHO, a Medical or Registration Board, a Health Care Complaints Commission/Body, a Coroner, a Court or any other negligence, professional, disciplinary or similar body?*

Yes

Criminal Record Check – Have you been convicted of, or pleaded guilty to a criminal offence including a serious sex or violence offence or an offence involving dishonesty or drugs (other than a spent conviction)?*

Yes

If yes, and if not prevented by confidentiality agreements, could you please provide a brief description of each adverse judgement or settlement, and the year in which the event occurred?

Immunisation History Check – Townsville Day Surgery requires each new applicant to provide a copy of their Immunisation History Statement (or alternatively Serology results).

Max. file size: 512 MB.

(Please attach copy of your Immunisation History Statement)

Clinical Practice sought in the following category(s)*

Dental Assistant (No Admitting Privileges)

Supporting Personnel

Registered Nurse (Employed by VMO)

Registered Nurse (Working in Specialised Area)

Priveleges Sought*

Nursing Assessment & Patient Education

Surgical Assist – Registered Nurse

Supporting Personnel – IVF Scientist

Supporting Personnel – Medical Scribe

Primary Undergraduate Qualification

(Please list below or attach CV at the end of this form)

Please list Name of University/Institution, Degree/s, Graduation Year/s*

List one qualification per line

Postgraduate Qualifications, Degrees, Diplomas, College or Professional Qualifications

(Please list below or attach CV and copies of qualification/s at the end of this form)

Please list Qualification, Date Obtained and Accredited Training Organisation

List one qualification per line

Professional development over past 3 years

(Please list below or attach CV at the end of this form)

Please include any research activities, funded projects and quality assurance activity.

List one qualification per line

Current Public Hospital Appointments

(Please list below or attach CV at the end of this form)

Please list Hospital Name & Appointment/s below

List one per line

Have you previously been refused clinical privileges at another health care facility?*

Yes

If yes, please provide the name of the facility and rationale for refusal. Please note a Hospital Management member may contact the facility.

Has your scope of clinical practice and/or appointment at any Hospital or Day Procedure Centre ever been reduced, suspended or revoked (including if done by mutual agreement) or have you had conditions attached to that appointment for any reason?*

Yes

If yes, please give dates and particulars. Please note a Hospital Management member may contact the facility.

Have you ever been disciplined, undergone or been required to take (remedial or otherwise) a program, course or therapy for workforce, professional or personal behaviour related to your practice, or to your credentials at a health facility?*

Yes

If yes, please give dates and particulars. Please note a Hospital Management member may contact the facility.

Details of all Health Care related employment within the last 10 years

(Please list below or attach CV at the end of this form)

Please list Hospital Name/s & Appointment/s below*

List one per line

NOTE - COPIES OF THE FOLLOWING MUST ACCOMPANY THIS APPLICATION

Please upload required documents below. If you have already upload the file listed in the above sections of this form, please disregard that line.

Current CV

Max. file size: 512 MB.

Registration Certificate

Max. file size: 512 MB.

Indemnity Insurance

Max. file size: 512 MB.

Covid Vaccination Statement

Max. file size: 512 MB.

(if applicable)

Immunisation History Statement

Max. file size: 512 MB.

Evidence of Qualifications and Participation in Continuing Medical Education

Max. file size: 512 MB.

Executed copy of the Clinicians Code of Conduct

Max. file size: 512 MB.

(if applicable)

Copy of Hand Hygiene Certificate

Max. file size: 512 MB.

Hand Hygiene: https://nhhi.southrock.com/cgi-bin-secure/Home.cgi

(Certificate from another hospital or education program acceptable)

Additional Documents, Certificates or Statements

Max. file size: 512 MB.

Declaration and Authority

I authorise the Townsville Day Surgery to release my contact details, including mobile phone number, to other VMO’s that currently hold clinical privileges at Townsville Day Surgery:*

Yes

I authorise Townsville Day Surgery Pty Ltd (‘Townsville Day Surgery’), its employees, officers and the Medical Advisory Committee, to obtain information on an annual, or as necessary, basis from the registration body/indemnity insurance organisation as nominated in this application, regarding the currency of my registration/membership of that body/organisation.
I authorise Townsville Day Surgery to conduct a criminal record check in respect of my history including information relevant to the provision of services to children and I agree to notify the Facility Manager or duly authorised person if I am convicted of a sex or violence offence or any other offence relevant to my practice as a Medical Practitioner.
I authorise Townsville Day Surgery, its officers and the Medical Advisory Committee to verify with relevant individuals, external organisations, and nominated referees the validity of all claims, including complaints made, including explicit consent for the organisation to verify my declaration regarding health status, professional registration history, claims and legal proceedings.
I declare that I have no physical or mental condition or substance abuse problem that could affect my ability to exercise the scope of clinical practice requested or that would require any special assistance in order to enable me to exercise that scope of clinical practice safely and competently. I undertake to notify Townsville Day Surgery if this statement becomes incorrect in the future.
I declare that my medical indemnity/professional indemnity cover is adequate and appropriate for the Clinical Privileges and activity which is the subject of this application.
I declare that I am the person named in this application and that the information provided by me in this application and in connection with this application is accurate and complete and is not misleading or deceiving or likely to mislead or deceive. I understand that if I have provided misleading or deceptive information, or information which is likely to mislead or deceive, that the Townsville Day Surgery Board may (in its absolute discretion) consider that I do not have ‘current fitness’ under the Medical Practitioners By-Laws.
I declare that my personal immunisation status is current for preventable diseases. I declare that I will continue to maintain the appropriate immunisation status for the duration of my clinical privileges.
In applying for appointment I acknowledge that I have been provided with, and read, a copy of the Medical Practitioners By-Laws and if appointed, agree to abide by the Medical Practitioners By-Laws and policies of the Townsville Day Surgery, including any annexure or variation to the Medical Practitioners By-Laws during the tenure of my appointment, all relevant legislative requirements (including compliance with Health Ombudsman Standards) and any terms and conditions which are attached to my appointment by the Board/Licensee. I understand that non-compliance with the Medical Practitioners By-Laws may be grounds for suspension, termination or imposition of conditions on my clinical privileges.
I undertake to notify Townsville Day Surgery promptly and in writing, if my scope of clinical practice is altered in any way at any other hospital or day procedure centre.
I agree to attend committee and clinical meetings at the facility to support my discipline within the facility, and to participate in any clinical quality assurance activity including submitting my practice to clinical audit and peer review, in conjunction with the hospital, the Medical Advisory Committee or clinical specialty committees if required by Townsville Day Surgery.
I undertake to notify Townsville Day Surgery should any information provided in this application for appointment vary in any way.
I acknowledge and agree to release and indemnify Townsville Day Surgery from and against all claims, including legal costs, out of a decision to suspend or terminate my accreditation or to not re-appoint me in circumstances set out in the Medical Practitioners By-Laws.
In the event of myself or the aforementioned practitioner(s) being unavailable in the case of an emergency, I am agreeable to the facility seeking urgent alternative assistance with authority to be exercised only after consultation with the Facility Manager or duly authorised person.
I understand that my Appointment will be reviewed in three (3) years or earlier if considered necessary.

Name*

First Last Date

Witness Name*

First Last Date

Credentialing and Scope of Practice Application Form - Supporting Personnel

Personal and Contact Information

Emergency Contact Person

Professional Practice Details

Professional Registration Details

Professional Indemnity

Medico Legal*

Primary Undergraduate Qualification

Postgraduate Qualifications, Degrees, Diplomas, College or Professional Qualifications

Professional development over past 3 years

Current Public Hospital Appointments

Details of all Health Care related employment within the last 10 years

NOTE - COPIES OF THE FOLLOWING MUST ACCOMPANY THIS APPLICATION

Declaration and Authority