Special Approved Placements Program Request - Coversheet and Checklist

Personal details
Full name
(Please provide name as stated on AHPRA public record)
Medical registration number and category
Australian residency status
Existing Medicare provider number (if held, first six digits only)
Contact number (business hours)
Application
Requested practice location(s)
(Please provide full name and street address) / 1.
2.
3.
Reason for applying for approved placement
Tick only one /  Category A – Exceptional circumstance claim
 Category B – Removed from other full-time program
 Category C – Removed from RLRP 2 Year Program
 Category D – Aus trained doc seeking experience
 Category E – OTD with limited med reg
 Category F – Emergency respondent
Request type /  New placement request
 Request for extension of placement
 Add location
 Change location
Current/Prior SAPP placements (if applicable)
Approved practice location(s)
(Please provide full name and street address) / 1.
2.
3.
Expiry date of placement
(DD/MM/YYYY)
Supporting evidence checklist
Current medical registration / Attached (compulsory)
Employment contract /  Attached (compulsory)
GP experience assessment /  Attached Not attached
Reason if experience assessment not provided
 I am applying for SAPP because of exceptional circumstances and do not have an experience assessment
I have provided prior FRACGP/FACRRM exam results instead of an experience assessment
 I am applying for SAPP to respond to a declared emergency, disaster or pandemic
Other:
Category A Applicants
Documentary evidence of exceptional circumstances / Attached Not applicable to my application
If yes
 Documentation is from a health professional who is registered in Australia and who does not have a personal or employment relationship with my prospective employer. The document demonstrates why the medical condition requires treatment in a specific location
 I give permission for this evidence to be referred to Health’s Medical Advisor for comment (compulsory declaration for all exceptional circumstance claims.
Category B Applicants
Evidence of removal/pending removal from alternate full-time general practice program / Attached
Prior FRACGP/FACRRM assessment results /  Attached
Assessments show successful completion of at least one assessment component
 Yes No
Evidence of enrolment for outstanding assessment components / Attached Not attached
If not attached:
 Statutory declaration confirming intent to enrol and re-take outstanding assessment components when available
Category C Applicants
Evidence of removal/pending removal from RLRP 2 year program / Attached(compulsory)
Statutory declaration confirming intent to re-enrol for general practice training when available /  Attached (compulsory)
Evidence that supervisor is a vocationally recognised GP / Attached (compulsory - tick appropriate option below)
 FRACGP FACRRM Dual Qualification
 Vocationally Registered by DHS
Category D Applicants
Documentation confirming primary medical degree / Attached (compulsory)
Evidence that supervisor is a vocationally recognised GP /  Attached (compulsory - tick appropriate option below)
 FRACGP FACRRM Dual Qualification
 Vocationally Registered by DHS
Evidence that the employing practice is an accredited general practice / Attached (compulsory)
Statutory declaration confirming intent to transition to an alternate program within two years / Attached(compulsory)
Category E Applicants
Previous AMC Exam results /  Attached (compulsory)
Evidence of enrolment for future AMC Clinical Exam / Attached Not attached
If not attached:
 Statutory declaration confirming intent to enrol in AMC clinical exam when available
Statement confirming preparatory activities for AMC Clinical Exam / Attached  Not attached
Category F Applicants
Statement confirming engagement to assist response to emergency, disaster or pandemic. / Attached(compulsory)

Printed name:______

Signature:______

Date:______

Please submit your completed application form and supporting documentation to .