Hospital Authority
HA Accreditation of “Care-related Support Worker Training”

醫護支援人員(臨床病人服務)課程認證計劃

Application Form

* Please tick the appropriate box

** Please delete as appropriate

Part A: Organization and Coordinator Information
/ Name of Organization (Course Provider) / (Chinese) / :
(English) / :
/ Office Address / :
/ Program Coordinator/ in-charge:
Name / : / Post / :
Office Telephone / : / Fax / :
Email / :
/ The Organization Registered under the * - (Please provide a copy of the registration document(s))
 / Societies Ordinance (Certificate of Registration of a Society issued by the Hong Kong Police Force)
 / Companies Ordinance
 / Limited Company (Memorandum and Articles of Association)
 / Unlimited Company (Business Registration Certificate)
 / Other regulations, such as registered schools (Registration Certificate / Exemption From Registration Certificate)
/ Name of Chief Executive Officer or Director / :
(Prof. / Dr / Mr. / Ms / Miss) **
/ Registered Office Address / :
/ Office Address (If different from registered) / :
/ Your organization has * - (Please provide a copy of the relevant document(s))
 become an appointed training body under Employees Retraining Board (ERB)
Date of gazette: ______(dd/mm/yy)
 completed Stage 1 (i.e. Initial Evaluation, IE) and Stage 2 (i.e. Learning Programme Accreditation, LPA) under the Quality Assurance Process for the organization and CRSW course conducted by the Hong Kong Council for Accreditation of Academic & Vocational Qualifications (HKCAAVQ)
Date of completion (IE): ______and valid until: ______(dd/mm/yy)
Date of completion (LPA): ______and valid until: ______(dd/mm/yy)
Part B: Details of Course Applied

Course applied* (Either one or both) /  “Certificate in CRSW Training” to be funded by Employees Retraining Board (i.e. ERB Course) /  Self-financed CRSW Training to be funded by your organisation
(i.e. Non-ERB Course)
a) Course Title / ______(Chinese)
______(English) / ______(Chinese)
______(English)
(Please attach 1) course outline with course title, objectives, course structure, content/target participant and 2) a copy of course handout/materials)
b) Name of Course Instructor(s)
(Please attach the details of academic achievement, professional qualification and relevant working and training experience of all the instructors)
c) Course Duration (No of Contact Hours) / Lecture: ______
Classroom Practicum:______
Total: ______/ Lecture: ______
Classroom Practicum:______
Total: ______
d) Entry Requirements:
e) Number of Participants/ Class:
f) Number of Class to be conducted/ Year:
g) Mode of training provision** : / Full-time / Part-time / Full-time / Part-time
h) Course Fee Per Trainee : / HK$______/ HK$______
i) Course Assessment and Quality Assurance*: /  Written Examination
 Classroom Clinical Assessment
Others: ______/  Written Examination
 Classroom Clinical Assessment
Others: ______
(Please attach a set of sample of the examination paper and assessment mechanism)
Part C: Experience on Health Care Training Provision
(Please specify the health-care vocational training provision of your organization in the past 5 years)
/ Course Title / Year Commenced / Mode of Study (Full-time/ Part-time) / Course duration (No. of hours) / No of Classes conducted / No. of Graduates
If the above course(s) has/ have been recognized in the relevant industry sectors, please indicate the relevant recognition in the following table  (Please provide copies of relevant documents)
/ Course Title / Professional Bodies/ Authorized Bodies / Year Awarded / Title of Qualification Awarded

Part D: Manpower, Training Venue and Equipment

a) Manpower of the Organization

12.Total Staff Strength

Staff Grade / Number
Management
Clerical / Supporting
Course Instructor
Total :

13.Instructor - Trainee Ratio in the Classroom Practicum

Number of Course Instructors / Number of Trainees
14. Highest Relevant Qualification of Course Instructor of the Course Applied
Name of Instructor / Full Time / Part Time / ^ Highest Relevant Qualification
(i.e. in healthcare / nursing)
Please tick the appropriate box / Years of experience educational / vocational training
A / B / C / D / E (Pls specify)
^ Remarks for Qualification
A : Master Degree or above
B : Degree
C : High Diploma / Diploma
D : Professional Qualification(s)
E : Others
b) Training Venue of the Course Applied
15. / Number of Training Rooms Available / :
(Please attach photos of the lecture room and mock area for Classroom practicum/ demonstration)
Maximum No. of Participants in Each Room / :
District of the above Training Venue(s) / :
c) Equipment of the Course Applied
16. / Training Equipment for this Course Applied: (Please attach photos of the related facilities and equipment)
Facilities
Equipment

Part E: Declaration by the Applicant

I declare that –

(a) I have the responsibility for coordinating and delivering ALL aspects of the course under application and have no partnership or collaboration in any form with other course providers in the course provision both administratively and operationally, AND

(b) All information given in this application form is correct, complete and true to the best of my knowledge and belief.

Signature / : / Name / :
Post / : / Department / :
Company Chop / : / Date applied / :

The completed application form with supporting documents should be sent to -

Room 408S, 4/F., Training & Development Team, Human Resources Division, Head Office, Hospital Authority (Attention to: Ms Felice LAI).

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HA CRSW Course Accreditation – Application Form (Version April 2019)