ACEM Intermediate Emergency Medicine Training Program Enrolment Form

ACEM Intermediate Emergency Medicine Training Program Enrolment Form

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

Hold General medical registration with the Australian Medical Board, or General Scope medical registration with the Medical Council of New Zealand, or the appropriate registration with the relevant regulatory body in the jurisdiction where you will be undertaking training.Have a prospective Emergency Department term scheduled, working at least 0.25 Full Time Equivalent (FTE) (minimum of 9.5 hours per week). If your prospective Emergency Department training site is not listed on the IEMTP Sites List, please contact EMATP@acem.org.au to determine if your hospital is an eligible training site.Completed the Primary Supervisor Form.Not be enrolled in the FACEM Training Program, Foundational Emergency Medicine Training Program, Advanced Emergency Medicine Training Program, Pre-Hospital and Retrieval Medicine Training Program (PHRMTP) 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 Primary Supervisor Form.

FACEM Trainees who wish to enrol in the Intermediate Emergency Medicine Training Program must first terminate their participation on the FACEM Training Program as they cannot be enrolled in both programs at the same time.
You must meet ONE of the Entry Pathway Requirements*

IEMTP Entry Pathway 1 – Twelve (12) Full Time Equivalent (FTE) months of emergency medicine training - you must be in post graduate year 2 or above.IEMTP Entry Pathway 2 – Six (6) FTE months of emergency medicine training - you must be in post graduate year 2 or above.
You must also have met ONE of the following Requirements*

Have successfully completed the ACEM Emergency Medicine Certificate (EMC) / Foundational Emergency Medicine Training Program (FEMTP) .Approved for Direct Entry into the IEMTP.
Please attach a copy of your certificate*

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Personal Information
Have you previously been registered with ACEM?*

YesNo
ACEM ID*
Name*

TitleFirst NameMiddle NameLast Name
Is this your preferred first name?*

YesNo
Preferred First Name *
Date of Birth*

DayMonthYear
Date
Gender*

MaleFemaleIndeterminate/Intersex/Unspecified
Home Address*

Street Address

Street Address Line 2

CityState

Post Code
Is your postal address the same as above?*

YesNo
Postal Address*

Street Address

Street Address Line 2

CityState

Post Code
Preferred Contact Number*
Format: (000) 000-0000.
Alternative Contact Number
Format: (000) 000-0000.
Email*
example@example.com

Professional Details
Basic medical degree*
Year Conferred*
Format: (000) 000-0000.
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*
Format: (000) 000-0000.
AHPRA Registration Number*
Format: (000) 000-0000.
Other Registration Number*
Format: (000) 000-0000.
If you require to nominate a CPD Home, please consider ACEM:

ACEM Non-Member CPD program

ACEM Educaitonal Affliliate

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

Emergency Medicine Placement Information
For IEMTP Entry Pathway 1 - You must complete 12 FTE months of emergency medicine training to complete the training time requirements of the IEMTP.

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.
For IEMTP Entry Pathway 2 - You must complete 6 FTE months of emergency medicine training to complete the training time requirements of the IEMTP Program.

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 back dated.*
Start Date*

DayMonthYear
Date
End Date*

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

MonthDayYear
Date
End Date*

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

MonthDayYear
Date
End Date*

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

MonthDayYear
Date
End Date*

MonthDayYear
Date
Hospital*
Hours per week*
Position*

Primary Supervisor Details
Your Primary Supervisor must be a FACEM or an ACEM Associate (Adv) who has met the requirements of an EMD Primary Supervisor – Review the Trainee Handbook for more information.

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

First NameLast Name
Please upload Supervisor form*

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Applicant Declaration
Applicant Declaration*

I hereby apply for enrolment in the Associateship in Intermediate Emergency Medicine 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 Associateship 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

View the IEMTP page on the ACEM Website.

View the Training Handbook.
Signature*
Date*

DayMonthYear
Date
How did you hear about the IEMTP Program?*

Completed the EMC/FEMTPColleagueSupervisorConferenceOther
Please specify which conference*
Should be Empty:

ACEM Intermediate Emergency Medicine Training Program Enrolment Form

Personal Information

Professional Details

Workforce Data

Emergency Medicine Placement Information

Primary Supervisor Details

Applicant Declaration