Emergency Care Advanced Clinical Practitioner Credentialing
Initial Application Form
· This form must be typed. A hand written application will not be accepted
· An electronic signature will be accepted
· Please return your completed application form to and CC in
Personal Details
1. Your full name
Mr ☐ Mrs ☐ Ms ☐ Miss ☐
Other ☐
Please specify - ______
Surname – Enter text here
First given name – Enter text here
Other given names - Enter text here
2. Gender
Male ☐ Female ☐
3. Your address
Address
Enter text here
Postcode
Enter text here
County
Enter text here
4. Do you have an alternative postal address?
☐ No (go to next question)
☐ Yes (Give details below)
Address
Enter text here
Postcode
Enter text here
County
Enter text here
Personal Details (continued)
5. Contact Details
Home telephone number (Area code and number)
Enter text here
Mobile telephone number
Enter text here
Work telephone number (Area code and number)
Enter text here
Email address
Enter text here
6. Are you currently a registered nurse?
☐ Yes
☐ No
7. Are you currently a registered paramedic?
☐ Yes
☐ No
8. Are you registered with any other professional body?
☐ Yes (Please provide details below)
☐ No
Details of professional body _ Enter text here______
9. Professional registration number in relation to questions 6, 7 or 8_ Enter text here______
Employment Details
10. Primary Employer (employer is defined as the organisation where you hold a contract of employment)
Name
Enter text here
Address
Enter text here
Postcode
Enter text here
County
Enter text here
Phone number (Area code and number)
Enter text here
11. Where do you currently conduct the majority of your clinical practice? (If your work base is different from your primary employer as per point 10, please state below.)
Name
Enter text here
Address
Enter text here
Postcode
Enter text here
County
Enter text here
Phone number (Area code and number)
Enter text here
12. Do you conduct work with any other organisations? If so, please list below.
E-portfolio Access/Payment Details
By completing this application form, you have expressed your formal interest in the ACP credentialing process and will therefore need to gain access to the Royal College of Emergency Medicine (RCEM) e-portfolio. Please complete the info below to aid account set up:
E-portfolio user name (if already issued)ACP training year / ☐ Year 1
☐ Year 2
☐ Year 3
ACP training route / ☐ Adult
☐ Paediatric
☐ Adult and Paediatric
ACP Post location / Trust:
Hospital:
1. Supervisor / Full Name:
Email:
Registration number:
2. Supervisor / Full Name:
Email:
Registration number:
For the credentialing process, it is a requirement to sign up for RCEM membership. From 1 January 2017 access to ePortfolio will be a membership benefit and no separate charge will be made.
Schedule of fees (inc. tax)
Associate membership (ACP) of the Royal College of Emergency Medicine for 3 years. 2017 subscription rate is £109.00 – pro-rated depending on application date.To apply for membership and access to the ePortfolio for ACPs please follow the link below:
http://www.rcem.ac.uk/rcem/Create_an_Account/RCEM/Create_an_Account.aspx
Refund Policy
These fees are non-refundable.
Please select the region you work in?
Health Education East Midlands ☐ / Health Education East of England ☐ / Health Education Kent, Surrey and Sussex ☐Health Education North Central and East London ☐ / Health Education North East ☐ / Health Education North West ☐
Health Education North West London ☐ / Health Education South London ☐ / Health Education South West ☐
Health Education Thames Valley ☐ / Health Education Wessex ☐ / Health Education West Midlands ☐
Health Education Yorkshire and the Humber ☐ / Scotland ☐ / Wales ☐
Northern Ireland ☐ / Republic of Ireland ☐
ACP Credentialing
13. When do you anticipate you will be ready for credentialing?
Please state: ______
14. Do you have your employer’s support to undertake Emergency Care ACP credentialing?
Yes ☐
No ☐
Applicant Declaration
I declare that:
· The information I have provided in this application is accurate and true at the time of completion
· I agree to honour the payment method I have selected
· I agree to abide by the requirements and regulations of the online E-portfolio system
I agree that:
· My data will be shared and stored securely by Health Education England and associated Local Education and Training Boards, and the Royal College of Emergency Medicine. My data may also be shared with parties involved with the evaluation of the implementation of Emergency Care ACP credentialing.
· I will ensure no patient identifiable data is entered into the E-Portfolio.
· I will honour the payment method I have selected
· I will abide by the requirements and regulations of the online E-portfolio system
Applicant’s signature _____ Enter text here______
Date ______Enter text here______
Please return your completed application form to and CC in
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