Appendix 3: Application form for upgrade, re-credentialing or initial assessment of prescriber level for experienced clinicians
CPD summary portfolio, declaration and application
Prescriber name and number
/ Click or tap here to enter text.Prescriber profession
/ Click or tap here to enter text.NB: All professions are to complete the CPD point summary below except Orthotists/ Prosthetists, Oxygen Prescribers or Category 1 Registered Lymphoedema Therapists (NLPR)
AHPRA registration number (if applicable)
/ Click or tap here to enter text.Date of application
/ Click or tap here to enter text.Assistive technology categoriesapplying for (number and title)and prescriber level requested for each AT category
/ Click or tap here to enter text.[please list each AT category and the prescriber level being requested]
- If you are a new inexperienced prescriber please apply via
- If you are applying for an initial assessment of prescriber status as an experienced clinician you will need to complete this form and attach a detailed CV and cover letter outlining your training and experience in the requested AT categories (refer to Table 3, Application Type 2)
- Please indicate which type of application and pathway you are applying for in the table below(for further details on application types and pathways, refer to tables 2 and 3 in The Standard)
Application type
/Pathway 1
/Pathway 2
Application type 1:Upgrade prescriber level (indicate)☐Green to Amber ☐Amber to Red / ☐ / ☐
Application type 1 :Re-credentialing (indicate)
☐Green ☐ Amber ☐ Red / ☐ / ☐
Application type 2:Initial assessment of prescriber, based on a skills recognition process for experienced clinicians
NB: Prescribers to use this application pathwaywhen adding additional AT Categories to registration / ☐
Declaration
For your application to be complete you will need to declare that you have met the requirements of the standard for your application and pathway type.
In completing this form, I declare and agree that:Click or tap here to enter text.
I have met the minimum requirements of the standard for my application type and pathway including the relevant number of scripts (via SWEP or an equivalent prescription outside SWEP) and having accrued the 30 prescriber CPD points in AT in accordance with the CPD accrual rules
I will participate in any Prescription review process or audits as determined by SWEP
All the information I have given in this declaration is true and correct
I have the necessary forms and documentation to support this declaration
For the purposes of verification of compliance with the requirements of the standard I agree to supply forms and documentation as requested by SWEP
I am aware if any of the above information is found to be false or unsupported I may not be eligible to continue prescribing or may need to participate in further assessment as determined by SWEP.
CPD point summary
All application types are to complete the CPD point summary below except Orthotists/ Prosthetists, Oxygen Prescribers or Lymphoedema Therapists (Category 1 registered practitioners)
- Orthotists required to provide proof of full membership with AOPA
- Oxygen Prescribers required to provide AHPRA registration and evidence of prescriber requirements as defined in The Framework, Appendix 3 for AT Categories 21 & 22.
- Lymphoedema Therapists provide proof of Level 1 practitioner registration with the ALA National Lymphoedema Practitioners Register (NLPR)
- Please specify the number of points accrued for CPD prescriber activity types in the table below
- For further details, refer to the CPD activity guidelines The Standard, Appendix 2
- Attach documentary evidence as indicated
- Other documentary evidence (such as Appendix 4, CPD portfolio) should NOT be submitted with this application form, unless requested by SWEP
CPD prescriber activity type
/CPD points accrued
/Maximum allowed
Category 1: Specific to AT category(s)
/Minimum of 15 points required
- CQU or nationally accredited program or equivalent
2. SWEP endorsed training program
Attach certificate of completion from organiser / Click Here / 30-point max. (point value stated on certificate)
- Attendance at a workshop
- Receiving clinical supervision/ instruction
State name(s) and prescriber no. / Click Here / 5-point maximum
- Receiving clinical supervision/ instruction
State name(s) and prescriber no. / Click Here / 10-point maximum
- Independent study
- Giving clinical supervision/ instruction
SUBTOTAL of Category 1 CPD prescriber points / Click Here:Subtotal
Category 2: General
/15 point maximum permitted
- Attendance at conferences, seminars and expos
- Participation in professional association activity and/ or special interest group
- Presentation/ teaching
- External study
- Research/ quality improvement
- Journal subscription
Partial exemption of points requested, state reason for absence from practice: Attach statutory declaration/ evidence in support of request / Click Here / (maximum points as per standard)
SUBTOTAL of Category 2 CPD prescriber points / Click HereSubtotal
TOTAL: I hereby declare that I have met the requirements of the standard for my application and pathway type and that I have accrued a point value of:
Signed:______
E-Signature: Click or tap here to enter text. / Click Here Total points
Type 2 applications: attach detailed CV and cover letter for initial assessment or prescriber registration
NB: For requests to add additional AT categories to an existing registration, please provide a statement below detailing your relevant skills and experience in this AT category.
©2017