Notification of Program Completion Form - Emergency Medicine Certificate and Associateship Training Programs

Notification of Program Completion Form - Emergency Medicine Certificate and Associateship Training Programs
Complete the following form to declare that you have completed the requirements of your training program as outlined in ACEM Regulation D.

Note: Please download all WBAs and meeting documentation from your Assessment Summary that you wish to keep, as once this form is submitted you will no longer have access.
Your Name*

First NameLast Name
ACEM ID*
Select the training program that you are enrolled in.*

EMCIEMTP (Formerly EMD) Entry Pathway 1IEMTP (Formerly EMD) Entry Pathway 2AEMTP (Formerly EMAD) Entry Pathway 1AEMTP (Formerly EMAD) Entry Pathway 2AEMTP (Formerly EMAD) Entry Pathway 3
EMC 2011 - 2020 Assessments*

5 Mini-CEX6 DOPS2 CbD10 Written Case ReflectionsEMC 2011 - 2020 Procedural ChecklistBLS CertificationALS Certification
EMC 2011 – 2020 Training Time*

I confirm that I have completed 6 full time equivalent months of emergency medicine training time.
EMC 2011 - 2020 Online MCQ Examination*

I confirm that I have passed the EMC Online MCQ Examination.
Final Declaration*

I confirm that I have completed all requirements, and all my assessment have been entered into my Online Assessment Portal for the EMC 2011 - 2020 Training Program.
EMC Assessments*

5 Mini-CEX6 DOPS2 CbDEMC Procedural ChecklistASL2 Certification (or NZ equivalent)Indigenous Health & Cultural Competency Modules
EMC Training Time. I confirm that I have completed:*

6 full time equivalent months of emergency medicine training time.The required Start of Placement and Reflection Meetings as indicated by the College.
EMC Online MCQ Examination*

I confirm that I have passed the EMC Online MCQ Examination.
EMC Graduate Survey*

I can confirm that I have completed and submitted the EMC Graduate Survey.
EMC Graduate Survey
Final Declaration*

I confirm that I have completed all requirements, and all my assessments have been entered onto my Assessment Summary site for the EMC Training Program.
IEMTP (Formerly EMD) Entry Pathway 1 Assessments*

10 Mini-CEX11 DOPS4 CbDEMC Procedural ChecklistEMD Procedural ChecklistASL2 Certification (or NZ equivalent)APLS CertificationEMST or ETM CertificationIndigenous Health & Cultural Competency Modules
IEMTP (Formerly EMD) Entry Pathway 1 Training Time. I confirm that I have completed:*

12 full time equivalent months of emergency medicine training time.The required Start of Placement and Reflection Meetings as indicated by the College.
IEMTP (Formerly EMD) Entry Pathway 1 Online MCQ Examinations. I confirm that I have passed the:*

EMC Online MCQ ExaminationEMD Online MCQ Examination
IEMTP Graduate Survey*

I can confirm that I have completed and submitted the IEMTP Graduate Survey.
IEMTP Graduate Survey
Final Declaration*

I confirm that I have completed all requirements, and all my assessments have been entered onto my Assessment Summary site for the IEMTP (Formerly EMD) Entry Pathway 1 Training Program.
IEMTP (Formerly EMD) Entry Pathway 2 Assessments*

5 Mini-CEX5 DOPS2 CbDEMD Procedural ChecklistAPLS CertificationEMST or ETM CertificationIndigenous Health & Cultural Competency Modules
IEMTP (Formerly EMD) Entry Pathway 2 Training Time. I confirm that I have completed:*

6 full time equivalent months of emergency medicine training time.The required Start of Placement and Reflection Meetings as indicated by the College.
IEMTP (Formerly EMD) Entry Pathway 2 Online MCQ Examination*

I confirm that I have passed the EMD Online MCQ Examination.
IEMTP Graduate Survey*

I can confirm that I have completed and submitted the IEMTP Graduate Survey.
IEMTP Graduate Survey
Final Declaration*

I confirm that I have completed all requirements, and all my assessments have been entered onto my Assessment Summary site for the IEMTP (Formerly EMD) Entry Pathway 2 Training Program.
AEMTP (Formerly EMAD) Entry Pathway 1 Assessments*

13 Mini-CEX14 DOPS4 CbD1 Direct Observation of Communication Skills2 Clinical Lead Shift Reports1 Quality Assurance Improvement ActivityEMC Procedural ChecklistEMD Procedural ChecklistEMAD Procedural ChecklistASL2 Certification (or NZ equivalent)APLS CertificationEMST or ETM CertificationUltrasound CourseACEM Clinical Supervision CourseIndigenous Health & Cultural Competency Modules
AEMTP (Formerly EMAD) Entry Pathway 1 Training Time. I confirm that I have completed:*

18 full time equivalent months of emergency medicine training time.At least 320 hours in a multi-FACEM site.The required Start of Placement and Reflection Meetings as indicated by the College.
AEMTP (Formerly EMAD) Entry Pathway 1 Online MCQ Examinations. I confirm that I have passed the:*

EMC Online MCQ ExaminationIEMTP (Formerly EMD) Online MCQ ExaminationAEMTP (Formerly EMAD) Online MCQ Examination
AEMTP Graduate Survey*

I can confirm that I have completed and submitted the AEMTP Graduate Survey.
AEMTP Graduate Survey
Final Declaration*

I confirm that I have completed all requirements, and all my assessments have been entered onto my Assessment Summary site for the AEMTP (Formerly EMAD) Entry Pathway 1 Training Program.
AEMTP (Formerly EMAD) Entry Pathway 2 Assessments*

8 Mini-CEX8 DOPS2 CbD1 Direct Observation of Communication Skills2 Clinical Lead Shift Reports1 Quality Assurance Improvement ActivityEMD Procedural ChecklistEMAD Procedural ChecklistAPLS CertificationEMST or ETM CertificationUltrasound CourseACEM Clinical Supervision CourseIndigenous Health & Cultural Competency Modules
AEMTP (Formerly EMAD) Entry Pathway 2 Training Time. I confirm that I have completed:*

12 full time equivalent months of emergency medicine training time.At least 320 hours in a multi-FACEM site.The required Start of Placement and Reflection Meetings as indicated by the College.
AEMTP (Formerly EMAD) Entry Pathway 2 Online MCQ Examinations. I confirm that I have passed the:*

EMD Online MCQ ExaminationEMAD Online MCQ Examination
AEMTP Graduate Survey*

I can confirm that I have completed and submitted the AEMTP Graduate Survey.
AEMTP Graduate Survey
Final Declaration*

I confirm that I have completed all requirements, and all my assessments have been entered onto my Assessment Summary site for the AEMTP (Formerly EMAD) Entry Pathway 2 Training Program.
AEMTP (Formerly EMAD) Entry Pathway 3 Assessments*

3 Mini-CEX3 DOPS1 Direct Observation of Communication Skills2 Clinical Lead Shift Reports1 Quality Assurance Improvement ActivityEMAD Procedural ChecklistUltrasound CourseACEM Clinical Supervision CourseIndigenous Health & Cultural Competency Modules
AEMTP (Formerly EMAD) Entry Pathway 3 Training Time. I confirm that I have completed:*

6 full time equivalent months of emergency medicine training time.At least 320 hours in a multi-FACEM site.The required Start of Placement and Reflection Meetings as indicated by the College.
AEMTP (Formerly EMAD) Entry Pathway 3 Online MCQ Examinations*

I confirm that I have passed the AEMTP (Formerly EMAD) Online MCQ Examination.
AEMTP Graduate Survey*

I can confirm that I have completed and submitted the AEMTP Graduate Survey.
AEMTP Graduate Survey
Final Declaration*

I confirm that I have completed all requirements, and all my assessments have been entered onto my Assessment Summary site for the AEMTP (Formerly EMAD) Entry Pathway 3 Training Program.
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