Foundational Emergency Medicine Training Program Enrolment Form

Foundational Emergency Medicine Training Program Enrolment Form

Please apply in the form below.
To enrol in the Foundational Emergency Medicine Training Program (FEMTP) you must meet the following criteria:*

Hold medical registration with either the Australian Medical Board (provisional, limited or general registration), the Medical Council of New Zealand (provisional or general scope registration) or or the relevant regulatory body in the jurisdiction in which you will be undertaking training.Be in post graduate year 2 or aboveHave a prospective Emergency Department term scheduled, working at least 0.25 FTE (minimum of 9.5 hours per week) - If your prospective Emergency Department training site is not listed on the FEMTP Sites List (link below), please contact EMATP@acem.org.au to determine if your hospital is an eligible training site.Completed the FEMTP Primary Supervisor formNOT be enrolled in the FACEM Training Program, IEMTP Training Program, AEMTP Training Program, or Associateship of Pre-hospital and Retrieval Medicine (PHRM) Training Program or be an ACEM SIMG undertaking a pathway to Fellowship of the College through the processes of the Medical Board of Australia (MBA) or the Medical Council of New Zealand (MCNZ).
View FEMTP Primary Supervisor Form.

Professional Details
Basic medical degree*
Year Conferred*
University*
If qualification obtained outside Australia or New Zealand, specify city and country.
Are you a Fellow of a medical College(s)?*

YesNo
Please list the medical College(s).*
Are you a current trainee in a specialist training program?*

YesNo
Please list the medical College(s).*
Select the medical board/s you are registered with:*

MCNZ RegistrationAHPRA RegistrationOther
MCNZ Registration Number*
AHPRA Registration Number*
Other Registration Number*
If you require to nominate a CPD Home, please consider ACEM:

ACEM Non-Member CPD program

ACEM Educational Affiliate

Workforce Data

The Australasian College for Emergency Medicine, in association with the Council of Presidents of Medical Colleges, is collecting workforce data to ascertain the numbers of indigenous Fellows and trainees working in Australia and New Zealand. By answering these questions, you are contributing to the collection of valuable information which will assist the College to design and implement an effective training program including designing relevant and culturally appropriate learning material. The following questions are voluntary.
Are you of Aboriginal, Torres Strait Islander and/or Māori origin? Please select all that apply.

AboriginalTorres Strait IslanderMāoriNone of the above
Are you applying for the ACEM Foundation Foundational Emergency Medicine Training Program Grant for Aboriginal, Torres Strait Islander and Māori Medical Practitioners? (See the link below for more information).

YesNo
ACEM Foundational Emergency Medicine Training Program Grant
Please upload letters of support.*

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Prospective Emergency Department Placement(s)
You must complete six Full Time Equivalent (FTE) months of emergency medicine training to complete the training time requirements of the FEMTP Program.

Please detail your prospective training time below:

Note
- Training may be undertaken at a minimum of 6 FTE weeks at a time.
- If you are training at more than one emergency department, each placement must be a minimum of 0.25 FTE (9.5 hours) per week averaged over the duration of the placement. Placements that do not meet the 0.25 FTE requirement will not be counted towards your training time requirement.
How many placements do you plan to undertake? Please note, ED placements cannot be backdated.*
Start Date*

DayMonthYear
Date
End Date*

DayMonthYear
Date
Hospital*
Hours per week*
Position*
Start Date*

DayMonthYear
Date
End Date*

DayMonthYear
Date
Hospital*
Hours per week*
Position*
Start Date*

DayMonthYear
Date
End Date*

DayMonthYear
Date
Hospital*
Hours per week*
Position*
Start Date*

DayMonthYear
Date
End Date*

DayMonthYear
Date
Hospital*
Hours per week*
Position*

FEMTP Supervisor Details
Your Primary FEMTP Supervisor must be a FACEM, an ACEM Diplomate, an ACEM Advanced Diplomate, or an ACEM Associate who has met the requirements of an FEMTP Primary Supervisor – Review the Trainee Handbook for more information.

* Please complete and upload the signed FEMTP Primary Supervisor form.
Name of Primary Supervisor*

First NameLast Name
Please upload FEMTP Supervisor form*

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Applicant Declaration
Application Declaration*

I hereby apply for enrolment in the Foundational Emergency Medicine Training Program training program of the Australasian College for Emergency Medicine. I acknowledge that I have read and understood the information provided on this enrolment form and in ACEM Regulation D FEMTP, IEMTP and AEMTP Training Programs. I declare that the information provided on this enrolment form is accurate and complete to the best of my knowledge.
View the ACEM Regulation D FEMTP, IEMTP and AEMTP Training Programs

View the FEMTP page on the ACEM Website.

View the Emergency Medicine Associateship Training Handbook.
Signature*

Clear
Date*

DayMonthYear
Date
How did you hear about the FEMTP Program?

ColleagueSupervisorConferenceOther
Please specify which conference*
Should be Empty:

Personal Information