PHRM Training Program Enrolment Form

Prospective PHRM Training Site Placements
You must complete at least 6 FTE months of training time to meet your PHRM Training Program requirements.

Please detail your prospective training time below.

Note:
- Training may be undertaken in blocks of not less than 3 months FTE at a time.
- You must complete 6 FTE months of PHRM training time within 3 years of your enrolment date.
- If your nominated site is only accredited for the Pre-Hospital component of the PHRM Training Program, then you must also complete time at a site accredited for the Retrieval component of training.
- If your nominated site is only accredited for the Retrieval component of the PHRM Training Program, then you must also complete time at a site accredited for the Pre-Hospital component of training.
How many placements do you plan to undertake?*
Position One
Start Date*

DayMonthYear
Date
End Date*

DayMonthYear
Date
Site Name*
Hours per week*
FTE*
Position*
Position Two
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Site Name*
Hours per week*
FTE*
Position*
Position Three
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Site Name*
Hours per week*
FTE*
Position*
Position Four
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Site Name*
Hours per week*
FTE*
Position*
I acknowledge that it is my responsibility to ensure I am aware of my chosen training site’s ACEM PHRM accreditation status – pre-hospital only, retrieval only, or full accreditation - prior to enrolling in the PHRM Training Program.*
I understand that I may be required to complete a longer placement, or an additional placement at another CCPHRM-accredited site to ensure all components of the PHRM Training Program can be completed.*

PHRM Placement and Training Supervisor Details
Evidence of a confirmed training position at a site accredited by the Conjoint Committee of Pre-Hospital and Retrieval Medicine (CCPHRM) for PHRM training is required. This evidence must also specify the name of your PHRM Training Supervisor. Your primary supervisor must be a Fellow of ACEM, ACRRM, ANZCA,CICM or RACGP who is an approved PHRM Training Supervisor. This evidence can be provided in the following formats; letter from empoyer, letter from PHRM Training Supervisor, or completed CCPHRM-approved pro-forma letter. Please upload this evidence.
Please upload evidence of a confirmed position at a CCPHRM-accredited site.*

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PHRM Training Program Enrolment Form

Professional Details

Prospective PHRM Training Site Placements

Position One

Position Two

Position Three

Position Four

PHRM Placement and Training Supervisor Details

Enrolment Fee and Applicant Declaration