Applicant: Surname, First Name

The Australasian College

of Aerospace Medicine

Application for Training/Fellowship

Name:

Title:

Surname, First Name
Postal Address:
E-mail: / Email address
Phone: / Preferred contact number

If my application for Training or Fellowship is successful, I will undertake to support the objectives and aspirational goals of the Australasian College of Aerospace Medicine in promoting the discipline of aerospace medicine as a clinical entity in Australasia.

Name as Signature:

Type name here

Date of application:

dd/mm/yy

Medical Qualifications

If more than five, list the five most significant degrees or Fellowships here, and list the others in your CV.

Degree / Qualification / Institution / Year
Awarded
yyyy
yyyy
yyyy
yyyy
yyyy

Aerospace Medicine Qualifications

If more than five, list the five most significant degrees or qualifications here, and list the others in your CV.

Degree / Qualification / Institution / Year
Awarded
yyyy
yyyy
yyyy
yyyy
yyyy

Aerospace Medicine Appointments

List the organizations for which you have functioned at the level of a specialist, consultant, or subject-matter expert. If more than five, list the five most recent, and list the others in your CV.

Role / Organization / Years
yyyy - yyyy
yyyy - yyyy
yyyy - yyyy
yyyy - yyyy
yyyy - yyyy

Honours and Awards

List the honours and awards you have received in recognition for a contribution to aerospace medicine. If more than five, list the most recent here, and list the others in your CV.

Award / Institution / Year
Awarded
yyyy
yyyy
yyyy
yyyy
yyyy

Aerospace Medicine Memberships

List the Memberships you hold with aerospace medicine organizations. If more than five, list the five most significant, and list the others in your CV.

Organisation / Highest Level of Membership / Years
yyyy - yyyy
yyyy - yyyy
yyyy - yyyy
yyyy - yyyy
yyyy - yyyy

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Applicant: Surname, First Name

Continuing Professional Development: Activities

Category / Activity / Points / 2011 / 2012 / 2013
1 / Educational Development, Teaching, and Research
Activities thatfocus on developing expertise within defined scholarly activities; teacher, researcher or standard setter. Maximum 50 Category 1 points can be claimed each year.
•Author of aerospace medicine-related book (per book) / 40
•Author of peer-reviewed paper in an aerospace medicine journal (per article) / 20
•Service as Member of ACAsM Committee (per committee) / 20
•Supervision or mentoring of a Trainee (per Trainee, max 2 per year) / 20
•Examiner for FACAsM exam (per exam) / 20
•Bound volume reviewer (per volume) / 10
•Single (one-off) lecture, tutorial, or presentation to Trainees, medical students, other medical practitioners (per lecture) / 10
•Development of submission of Policy relevant to aerospace medicine (per policy). / 10
•Conduct of a Mini CEx or CBD assessment (per assessment) / 5
•Aerospace medicine presentation to Health Staff or Executive Staff (per presentation) / 5
•Review of aerospace medicine-related grant application (per hour) / 1
•Peer review of manuscript of a journal paper, book chapter, report (per hour) / 1
•Other (per hour) / 1
Category / Activity / Points / 2011 / 2012 / 2013
2 / Group Learning Activities
Formal education sessions by CPD providers e.g. universities, teaching hospitals, medical colleges, specialty societies. Maximum 50 Category 2 points can be claimed each year.
•AsMA or ICASM, Annual Scientific Meeting, attendance (per hour), / 1
•ASAM or AMSNZ Annual Scientific Meeting, attendance (per hour) / 1
•Workshop relevant to aerospace medicine (per hour) / 2
•Other meetings relevant to aerospace medicine(per hour) / 1
•Meetings largely devoted to aeromedical retrieval (per hour) / 1
•ASAM or AMSNZ Regional Meetings, attendance (per hour) / 1
•Other (per hour) / 1
3 / Self-assessment Programmes
Programs designed to assist you to identify your educational needs.
•Aviation, Space, and Environmental Medicine’s You’re the Flight Surgeon (per hour) / 1
•Other self-assessment programs as approved by ACAsM (per hour) / 1
4 / Structured Learning Projects
Activities undertaken to improve a particular aspect of your performance or practice.
•Postgraduate studies with clear relevance to aerospace medicine (per semester) / 50
•Short courses approved by ACAsM (per hour) / 1
Category / Activity / Points / 2011 / 2012 / 2013
5 / Practice Review and Appraisal
Activities that assist you to review your practice/performance.
•360-degree review (per review) / 15
•Formal appraisal by employer, must be specific to aerospace medicine (per review) / 10
•QA Initiative developed reviewed by a specialist in aerospace medicine (per hour) / 5
•Peer review group: participation as a reviewer of other Fellows (per hour) / 2
•Formative assessments: Mini-CEX, CbD (per assessment) / 2
•Audit of clinical or non-clinical practice of aerospace medicine (per hour) / 1
•Ethics Committee reviewing aerospace medicine-relevant topics (per hour) / 1
•Quality Improvement/Assurance Committee relevant to aerospace medicine (per hour) / 1
•Other (per hour) / 1
6 / Other Learning Activities
Individual or group learning activities that occur on a regular or day-to-day basis.
Maximum 50 Category 6 points can be claimed each year.
•Journalclub (per hour) / 2
•Private reading of journals (per hour) / 1
•Self-directed learning approved by ACAsM (per hour) / 1
•Preparation for teaching, publication and presentation (per hour) / 1
•Preparation for formative assessments (per hour, max 2) / 1
Total CPD Points / 2011 / 2012 / 2013

At least 50% of the points in each year were gained from activities relevant to aerospace medicine.

Printed name as signature: Name

Date: dd/mm/yy

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Applicant: Surname, First Name

Consent

IType Full Name,

consent to the senior medical representativeof the Civil Aviation Safety Authority, the Civil Aviation Authority of New Zealand, the Institute of Aviation Medicine of the Royal Australian Air Force, and the Aviation Medicine Unit of the Royal New Zealand Air Force to advise the Australasian College of Aerospace Medicine whether or not I am the subject of a current investigation, the subject of an investigation that returned a negative finding or is unresolved, or the subject of current or previous disciplinary action. I give consent on the understanding that details of the nature of any complaints, investigations, or subsequent actions will not be divulged.

I understand that this information will be used by the College to determine whether I am ‘in good standing’ with the aeromedical regulators in order determine my suitability for membership of the College. I give my consent voluntarily. I acknowledge that failure to provide consent will result in my application not being considered further, however I understand that I can re-submit an application in the future without prejudice.

Name as Signature:NameDate dd/mm/yy

Confirmation

This person is considered 'in good standing' with all aeromedical regulators.

Foundation Fellowship Committee: Initials, FFC Delegate Date dd/mm/yy

Application checklist

To enable the Education Committee to properly assess your suitability to be recognized as a Fellow of the Australasian College of Aerospace Medicine, or to determine the appropriate avenue for entry into the training programme, a copy of the following documents must accompany your application:

Done
1 / Evidence of current unconditional registration to practice medicine in Australia or New Zealand.
2 / A comprehensive curriculum vitae (CV), detailing the training, qualifications, employment, and academic activities and publications relevant for recognition as a specialist in aerospace medicine.
3 / A summary of continuing medical education activities during the last three (3) years, with specific emphasis on those activities relevant to aerospace medicine. Use the attached Continuing Professional Development (CPD) template for each of the last three years.
4 / A letter detailing how you meet the core competencies required of a Fellow (if applicable).
5 / Two written references.
6 / Application form, completed.
7 / Application fee, paid.

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