ACEM Intermediate Emergency Medicine Training Program Enrolment Form

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*
Alternative Contact Number
Email*
example@example.com

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*

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 Advanced Diplomate 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*

Browse Files

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Applicant Declaration
Applicant Declaration*

I hereby apply for enrolment in the Emergency Medicine Diploma 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 EMC, EMD and EMAD 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*

Clear
Date*

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

Completed the EMCColleagueSupervisorConferenceOther
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