Continuing Professional Development
Accreditation Application Form

Under the auspices of the Australian Pharmacy Council (APC) The Pharmacy Guild of Australia, Queensland (Guild) may accredit Continuing Professional Development (CPD) for pharmacists that is eligible to be used as supporting evidence of continuing competence.

To complete this application, CPD providers will need to have reviewed, and referred to, the following documents:

  • CPD Accreditation Applicant Guide
  • Australian Pharmacy CouncilAccreditation Standards for CPD Activities, 1 July 2013.
  • Australian Pharmacy Council Accreditation Marketing Policy, 21 May 2015 Version 2.2.
  • PSA National Competency Standards Framework for Pharmacists (2010).
  • Australian Privacy Principles

Section 1 General Details
Activity title
Name of applicant (primary contact) / Contact Person / Phone
Organisation Name / Email
Approval status sought / New
Re-approval  existing approval reference number:
Proposed commencement date of activity / Click here to enter a date.
Requested duration of approval / once off e.g. conference
1 year / 2 years
3 years
Duration of activity (i.e. total time engaged in learning) / days or hours
Estimated number of CPD credits applying for / Group 1 ______
Group 2 ______
Group 3 ______
Activity format / Lecture
Online module
Journal article
Conference
Other
Section 2 Mandatory Requirements
What is the justification for conducting the activity?
(APC CPD Standard 2.1) / Evidence examples: explanation, needs analysis documentation, collated feedback, survey data, proposals etc.
What are the learning objective/s for the activity?
(APC CPD Standard 1.1, 3.1) / Learning Objective/s
[insert learning objective]
[insert learning objective]
[insert learning objective]
[insert learning objective]
[insert learning objective]
Competency Standards (tick the competency standard/s the activity and learning objectives addresses)
(APC CPD Standard 1.1, 3.1)
Domain 1 / Professional and ethical practice
Standard 1.1 / Practise legally
Standard 1.2 / Practise to accepted standards
Standard 1.3 / Deliver ‘patient-centred’ care
Standard 1.4 / Manage quality and safety
Standard 1.5 / Maintain and extend professional competence
Domain 2 / Communication, collaboration and self-management
Standard 2.1 / Communicate effectively
Standard 2.2 / Work to resolve problems
Standard 2.3 / Collaborate with members of the health care team
Standard 2.4 / Manage conflict
Standard 2.5 / Commitment to work and the workplace
Standard 2.6 / Plan and manage professional contribution
Standard 2.7 / Supervise personnel
Domain 3 / Leadership and management
Standard 3.1 / Provide leadership and organisational planning
Standard 3.2 / Manage and develop personnel
Standard 3.3 / Manage pharmacy infrastructure and resources
Standard 3.4 / Manage quality service delivery
Standard 3.5 / Provide a safe and secure work environment
Domain 4 / Review and supply prescribed medicines
Standard 4.1 / Undertake initial prescription assessment
Standard 4.2 / Consider the appropriateness of prescribed medicines
Standard 4.3 / Dispense prescribed medicines
/ Domain 5 / Prepare pharmaceutical products
Standard 5.1 / Consider product Performance Criteria’s
Standard 5.2 / Prepare non-sterile drug products
Standard 5.3 / Aseptically prepare sterile drug products
Standard 5.4 / Prepare cytotoxic drug products
Domain 6 / Deliver primary and preventive health care
Standard 6.1 / Assess primary health care needs
Standard 6.2 / Deliver primary health care
Standard 6.3 / Contribute to public and preventive health
Domain 7 / Promote and contribute to optimal use of medicines
Standard 7.1 / Contribute to therapeutic decision-making
Standard 7.2 / Provide ongoing medication management
Standard 7.3 / Influence patterns of medicine use
Domain 8 / Critical analysis, research and education
Standard 8.1 / Retrieve, analyse and synthesise information
Standard 8.2 / Engage in health, medicines or pharmacy practice research
Standard 8.3 / Formally educate and train students and healthcare colleagues
How will participants be able to access the learning objectives?
(APC CPD Standard 1.1) / Evidence examples: explanation, promotional material, presentation materials etc.
Please give details of authors, content developers and presenters and their involvement in the activity development.
(APC CPD Standard 2.1) / Pharmacist or Subject Matter Expert (SME) / Name / Contribution to Activity
Pharmacist
SME
Pharmacist
SME
Pharmacist
SME
Pharmacist
SME
Pharmacist
SME
Declarations of conflicts of interests and activity sponsorship
(APC CPD Standard 2.4, 3.2) /
  • Please attach a completed Conflict of Interest Declaration for each author, content developer and presenter.
  • Explanation of any activity sponsorship (if applicable)

How will conflicts of interests be made available to participants?
(APC CPD Standard 3.2) / Evidence examples: explanation, presentation, handouts, website etc.
Is the activity free of commercial bias and promotional language?
(APC CPD Standard 2.5) / Yes No
Do limitations on information or referencing exist?
  • content should be based on critical evaluation of relevant literatureand/or practice-based professional evidence(and referenced accordingly).
(APC CPD Standard 2.3) / Yes No
If yes, please give details:
Evidence examples:
-Activity content in which ideally references are < 5 years old.
-Explanation of lack of evidence available or lack of change in evidence available and how this will be addressed must be explained.
What has been done to ensure the content relates to contemporary pharmacy practice?
(APC CPD Standard 2.1)
Methods of delivery must promote effective adult learning
(APC CPD Standard 4.1, 4.2) / Evidence examples: details of learning activities, details of assessments used, instructional material, presenters brief defining the role of the facilitator in monitoring discussions etc.
Where consideration of Group 2 CPD is requested and there is an assessment component, please nominate (and attach) what assessment is required.
  • must evaluate a participant’s achievement of all of the learning outcome objectives
(APC CPD Standard 4.3, 4.4) / Multiple choice questions (MCQs)
  • minimum of 5 MCQs per 1 hour of learning
  • sufficient technical difficulty
Short answer questions
Interactive workshop
  • minimum of two thirds of workshop must be interactive
  • ratio of facilitator to participants should be no more than 1:20
Other – please specify
For the assessment above, please indicate how it will be marked and any other relevant information.
  • a maximum of two attempts per assessment is allowed
  • participants can only be provided with answers to the questions of each attempt if the two attempts does not repeat any of the same questions
  • pass mark for all assessments must be equal to or greater than 75%
(APC CPD Standard 4.3)
Is consideration of Group 3 CPD requested?
(APC CPD Standard 4.4) / Yes No
If YES please attach an outline of how each participant will complete the pre and post activity reflective learning activity – the CPD Panel may also seek additional information to support a Group 3 application.
Does the promotional material for the activity comply with the APC Accreditation Marketing Policy?
(APC CPD Standard 5.1) / Evidence examples: promotional/advertising material
Describe how participants will be given the opportunity to evaluate the activity including:
  • achievement of learning outcome objectives
  • relevance of activity and content to practice
  • overall satisfaction
  • suitability of delivery?
How will the participants be notified of when and how they can complete the evaluations and provide feedback?
(APC CPD Standard 6.1) / Evidence examples: explanation, copy of the evaluation form (i.e. survey) etc.
If the activity has been designed for repeated delivery, explain how will the activity will be reviewed and modified over time?
(APC CPD Standard 6.3) / Evidence examples: explanation, content and assessment review policy and procedures etc.
Section 3 Attachments to be lodged with application form (if applicable)
Attachments included with the application form / Session plan
Justification for activity - supporting documentation
Completed Conflict of Interest Declaration for each author, content developer and presenter (including Bio or CV)
Copy of content/instructional materials
Group 2 applications – assessment tool
Group 3 applications – reflective tool
Promotional materials
Copy of participant evaluation form
Other:
Section 4 Declaration
Declaration
(APC CPD Standards - 3.4, 5.1, 6.2) / I declare as a provider of the educational activity that we will ensure that:
  • The activity will be delivered in accordance with the application as approved.
  • The Guild CPD Accreditation Review Panel will be notified of and provided with all amendments/ alterations prior to delivery of the activity.
  • The APC Accreditation Marketing Policy is complied with in all relevant material.
  • National Privacy Principles – Principle 2 will be complied with for all relevant material and storage of participant information.
  • We will provide the Guild with a summary of the participant evaluations annually.
  • We understand the Guild may (at any time) request appropriate information on the conduct of their activities, the number of participants attending, assessment results and any other information as required. This information will be used only for the purposes of monitoring the quality of Guild accredited CPD activities.
  • We understand that the Guild will monitor the ongoing performance of providers of accredited activities, which may include observation of accredited activities by a delegate(s) of the CPD Accreditation Review Panel.
  • We understand that the Guild reserves the right to revoke the accreditation of any activity, should it fail to comply with the application as approved or the ongoing conditions for approval.
  • This activity is free of commercial bias and acknowledge the use of any promotional language is strictly prohibited
  • Contribution to the content for this activity is based on critical evaluation of relevant literature and/or practice based professional evidence. When using SME / author’s experiences to discuss a topic, they will disclose potential limitations of the evidence to the audience.
Signature: ______
Print Name:
Date:Click here to enter a date.
I have completed this document with the full understanding of my responsibilities in relation to delivering a CPD accredited activity and my typed name acts as my signature.
Application Lodgement / Please forward your application and all supporting documentation to
Section 5 Billing Details
These details will be used to generate an invoice for payment of the application fee
Invoice / Receipt to / ABN
Contact Person
Postal Address / Address
Suburb / State / Postcode
Telephone / Email
Payment Method / Please circle : Visa / MasterCard / Amex / Cheque
Card No. / Expiry
Name on card / Signature
EFT Transfer / Bank - National Australia Bank
Account Name - The Pharmacy Guild of Australia
BSB - 084 004
Account Number - 608 350 148

Please make cheque/money order payable to: The Pharmacy Guild of Australia, Queensland Branch

Note: Please ensure that you include your invoice number in the reference field so we can identify your payment.

Payment Terms and Agreement

Accreditation fees are not transferable.

Prices are subject to change.

The final accreditation application outcome will not be finalised until full payment is received.

Contact Us
The Pharmacy Guild of Australia, Queensland Branch
CPD Accreditation
Phone: 07 3831 3788
Fax: 07 3832 0871
E-mail:
Web:

Q.CPD.F8.V4: CPD Accreditation Application Form – 13/02/2017

Print Date: 08/11/2018Page 1 of 7