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IRB/ECT Training Information Form
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1
Course Selection
*
This field is required.
Emergency Care Training
SM IRB Drivers
IRB Crew Course
Emergency Care Training
SM IRB Drivers
IRB Crew Course
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2
ECT Course Selection
*
This field is required.
Resuscitation Certificate - HLTAID009
First Aid - HLTAID011
Advanced Resuscitation - HLTAID015
Resuscitation Certificate - HLTAID009
First Aid - HLTAID011
Advanced Resuscitation - HLTAID015
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3
Branch
*
This field is required.
North Queensland
North Barrier
Wide Bay Capricorn
Sunshine Coast
South Coast
Point Danger
Sunshine Coast
North Queensland
North Barrier
Wide Bay Capricorn
Sunshine Coast
South Coast
Point Danger
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4
Wide Bay Cap Club Name
*
This field is required.
Select your club
Branch
Moore Park
Bundaberg
Elliott Heads
Hervey Bay
Yeppoon
Emu Park
Tannum
Agnes Water
Branch
Moore Park
Bundaberg
Elliott Heads
Hervey Bay
Yeppoon
Emu Park
Tannum
Agnes Water
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5
Sunshine Coast Club Name
*
This field is required.
Select your club
Branch
Brisbane Life Saving
Noosa Heads
Rainbow Beach
Sunshine Beach
Coolum Beach
Marcoola
Mudjimba
Maroochydore
Alexandra Headland
Mooloolaba
Kawana Waters
Dicky Beach
Metropolitan Caloundra
Bribie Island
Redcliffe Peninsula
Peregian
Branch
Brisbane Life Saving
Noosa Heads
Rainbow Beach
Sunshine Beach
Coolum Beach
Marcoola
Mudjimba
Maroochydore
Alexandra Headland
Mooloolaba
Kawana Waters
Dicky Beach
Metropolitan Caloundra
Bribie Island
Redcliffe Peninsula
Peregian
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6
South Coast Club Name
*
This field is required.
Select your club
Branch
Brisbane Life Saving
Northcliffe
Broadbeach
Kurrawa
Mermaid Beach A.E.M.E
Nobbys Beach
Miami Beach
North Burleigh
Burleigh Heads Mowbray Park
Point Lookout
Coochiemudlo Island
Southport
Surfers Paradise
Branch
Brisbane Life Saving
Northcliffe
Broadbeach
Kurrawa
Mermaid Beach A.E.M.E
Nobbys Beach
Miami Beach
North Burleigh
Burleigh Heads Mowbray Park
Point Lookout
Coochiemudlo Island
Southport
Surfers Paradise
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7
Point Danger Club Name
*
This field is required.
Please Select your Club
Branch
Brisbane Life Saving
Tugun
Bilinga
North Kirra
Kirra
Coolangatta
Tweed Heads and Coolangatta
Rainbow Bay
Tallebudgera
Pacific Surf
Palm Beach
Currumbin
Branch
Brisbane Life Saving
Tugun
Bilinga
North Kirra
Kirra
Coolangatta
Tweed Heads and Coolangatta
Rainbow Bay
Tallebudgera
Pacific Surf
Palm Beach
Currumbin
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8
North Queensland Club Name
*
This field is required.
Please Select your Club
Branch
Mission Beach
Port Douglas
Ellis Beach
Cairns
Etty Bay
Branch
Mission Beach
Port Douglas
Ellis Beach
Cairns
Etty Bay
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9
North Barrier Club Name
*
This field is required.
Please Select your Club
Branch
Eimeo
Mackay
Sarina
Forrest Beach
Arcadian
Townsville Picnic Bay
Ayr
Branch
Eimeo
Mackay
Sarina
Forrest Beach
Arcadian
Townsville Picnic Bay
Ayr
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10
ECT Trainer details
*
This field is required.
Please Select
No
Yes
Please Select
Please Select
No
Yes
Do you require SLSQ to find you an ECT Trainer?
First, Last Name
Please enter your phone
Please enter your email
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11
Course Start Date
*
This field is required.
Minimum 21 Days from submission date If your course is not submitted within 21 days of the start date you will be required to provide sufficient reasoning
/
Date
Day
Month
Year
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Hour
00
15
30
45
00
15
30
45
Minutes
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12
Assessment Start Date
*
This field is required.
/
Date
Day
Month
Year
00
01
02
03
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20
21
22
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Hour
00
15
30
45
00
15
30
45
Minutes
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13
Head IRB Details
*
This field is required.
First , Last name
Phone number
Email
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14
IRB Trainers
*
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15
IRB Assessors
*
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16
List any Probationary Trainers/Assessors
Please type the probationary name and indicate if they are a Trainer (T), or Assessor (A)
First , Last name (A) / (T)
First , Last name (A) / (T)
First , Last name (A) / (T)
First , Last name (A) / (T)
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17
Direct Supervisor or IRB Trainer with TAE Cert IV
*
This field is required.
At least one IRB Trainer needs to hold a Cert IV or a Direct Supervisor must be allocated and recorded on the Course Training report.
First/ Last name
Phone number
Email
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18
Qualified IRBDs assisting (not TAF)
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19
Are you the CTO
*
This field is required.
YES
NO
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20
Personal Details
*
This field is required.
First Name
Last Name
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21
CTO Details
*
This field is required.
First , Last name
Email
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22
Approximate Number of Participants
*
This field is required.
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23
Training Details
*
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24
Alternative Training Venues
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25
Number of IRB's & Candidates
*
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26
Additional comments
If your course is submitted within 21 days of the start date please provide sufficient reasoning below
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