Before you complete this form, please read the application guidelines for the GP Procedural Training Support Program to ensure you are eligible for funding.

If you are eligible, please complete all sections of this form.

Mandatory Fields are indicated with a *.

1. Applicant details

Title
 
How [do/does] [you/Person's name/they] describe [your/their] gender?

Gender refers to current gender, which may be different to sex recorded at birth and may be different to what is indicated on legal documents.*
Gender: *
Citizenship: *

2. Practice address

The location and MMM classification of your principal clinical practice.

MMI classification: *

See Health Workforce Locator website.

3. Intended practice address

The location and MMM classification of the practice where you intend to use the skills of this program after completion of the Rural Generalist Anaesthesia Training Program.

MMI classification:

See Health Workforce Locator website.

4. Postal address

Address:

5. Current qualifications

Details of the qualifications on which this application is based.

6. GP description

Please mark the description that best reflects your status as a GP: *

Please note: Only those GPs who have achieved Fellowship of ACRRM or the RACGP are eligible for this program.

Please upload your evidence of Fellowship, or email it to gpptsp@acrrm.org.au.

Evidence of Fellowship

7. Rural location

Please indicate your rural location: *
Please indicate where you intend to use your skills after completion of the Advanced Rural Skills Training in Anaesthesia: *

To check the Modified Monash Model Classification (MMM) of your practice location please go to Health Workforce Locator Website.

If your intended practice location is different from your current principal practice location, please provide supporting information, such as how you will transition to a new practice.

8. Need for anaesthetics skills in your location

If your intended practice location differs from your current principal practice, please answer the questions below based on your intended location.

In your community how long does it take to access the closest maternity services by road? *

9. Provision of anaesthetic services

If your intended practice location differs from your current principal practice, please answer the questions below based on your intended location.

Are anaesthetic facilities available in your principal clinical practice? *

10. Rural Experience

11. Training

Please mark the statement that applies: *

12. Additional Information

13. Conditions associated with the GPPSTP

Should my application be successful, I understand that the following conditions will apply:

  1. I am required to complete the Rural Generalist Anaesthesia Training Program
  2. I will have six months (from the notification date) to confirm with ACRRM that I have secured a training post and registered for the Rural Generalist Anaesthesia Training Program. Failure to successfully complete the training within this time may result in a request to refund the money
  3. I will have 2 years (from the commencement of training) to complete the Advanced Rural Skills Training in Anaesthesia. Failure to successfully complete the training within this time may result in a request to refund the money
  4. I will be required to provide a progress report annually to ACRRM
  5. Successful applicants will be required to be involved in evaluations of the program (both by ACRRM and the Department of Health and Aged Care)
  6. In accordance with the requirements of the Department of Health and Aged Care, the following details will be published on the ACRRM website:
    • Program Title
    • Program Component
    • Support Recipient’s Name
    • Purpose
    • Value
    • Approval Date
    • Term
    • Location (town, region)
    • Postcode

This information will remain on the ACRRM website for at least 2 years.

14. Confidentiality

The program guidelines specify that the College must publish a list of support recipients on its website. The information you have provided will be used to assist with GPPTSP future planning. Your contact details will be kept on the GPPTSP confidential contact database, although information will also be used for administering and regulating GPPTSP. We may share or transfer information relating to you and GPPTSP, including de-identified information, to committees or management groups established for the purposes of managing, regulating or overseeing GPPTSP. This information (and the information obtained by us for GPPTSP) may be used by us in connection with GPPTSP for education and research purposes and otherwise as permitted by law.

By providing the information in this application form you are :
(Please tick each option to confirm your agreement)

Warranting that the information provided is true and correct and not misleading:
Undertaking to promptly notify GPPTSP - ACRRM in writing of any changes to the information provided:
Confirming your permission for GPPTSP - ACRRM to verify data with relevant third parties and use as described: