Application for Accreditation of a Mohs Surgery Training Position Application Form

1. Training Facility where the training position will be principally based:*

Address:*

Suburb:*

State:*

Postcode:*

Contact name:*

Telephone:

Email*

2. Will any part of the training position be undertaken at satellite facilities?*

YesNo

If yes, please provide details of each satellite facility and how much time is spent at each during the week, e.g. 0.2FTE:

Satellite Facility 1:

Satellite Facility 2:

3. Name of Candidate currently in position:*

N/A

4. Name of previous Candidate in position:*

N/A

5. Name of proposed Candidate (for future position):*

N/A

6. Date when Candidate commenced/proposed date of commencement of Training Position:*

7. Duration of proposed training:*

8. Is the training position full-time?*

YESNO

9. Mohs candidate timetable (Attachment 1)

Please append a weekly timetable for the Mohs candidate at your facility:

The timetable should include all clinic, surgery sessions, dermatopathology instruction sessions, and educational activities. Each clinic entry should specify the type of clinic and the name of the Clinical Supervisor/s. Insert 'Unsupervised' in lieu of Clinic Supervisor's name or 'Observer', if the candidate will not actively participate in the clinic.

Please attach multiple weekly tables if the candidate will have a ortnightly or monthly timetable.

10. Please outline the learning experiences (such as lectures, tutorials, seminars, peer review conferences) which will be provided to the Mohs candidate:*

11. Will the Mohs candidate be able to participate in at least 500 Mohs surgery cases each year, and be the primary surgeon in at least 200 of these cases?*

YESNO

12. Will the Mohs candidate be able to participate in at least 50 Mohs cases each year which are referrals from other medical and surgical specialists?*

YESNO

13. Please outline the opportunities for research/scholarly activities which will be available to the Mohs candidate:*

14. Will the Mohs candidate have one session each month of protected study/research time?*

YESNO

15. Name and Qualifications of Supervisor of Training (SoT)*

Name of SoT:*

Qualification of SoT:*

16. Has the Supervisor of Training been approved for inclusion on the ACD Approved Mohs Surgeons Register?*

YESNO

17. Has the Supervisor of Training five years post Mohs training program surgery experience?*

YESNO

18. Has the Supervisor of Training completed at least 200 Mohs surgery cases in each of the two years prior to this application?*

YESNO

If yes, please provide details:

19. Is the Supervisor of Training enrolled in the RCPA QAP frozen section technical module?*

YESNO

20. Please outline the Supervisor of Training's dermatological teaching experience:*

21. Is the Supervisor of Training of good standing with the AHPRA without restrictions on registration?*

YESNO

22. Has the Supervisor of Training attended ACD Supervisor Training within the last 5 years?

YESNO

23. Is the Supervisor of Training aware of the duties of their role as describes in the Training Program Handbook Mohs?*

YESNO

24. Does the Supervisor of Training agree to submit their annual logbooks to satisfy the Mohs committee that they are teaching and supervising within the expected professional standards?*

YESNO

25. Name and qualifications of Clinical Supervisors (CS)

Name of CS1:*

Qualifications:*

Name of CS2:*

Qualifications:*

Name of CS3:

Qualifications:

26. Has each Clinical Supervisor been approved for inclusion on the ACD Approved Mohs Surgeons Register?*

YESNO

27. Has each Clinical Supervisor completed at least 100 Mohs cases in the years prior to this application?*

YESNO

If yes, please provide details:

28. Is each Clinical Supervisor of good standing with the AHPRA without restriction on registration?*

YESNO

29. Has each Clinical Supervisor attended ACD Supervisor Training within the last 5 years?*

YESNO

30. Is each Clinical Supervisor aware of the duties of their role as described in the Training Program Mohs Surgery?*

YESNO

31. Will all patient care at the training facility be supervised by qualified clinical supervisors?

YESNO

32. Please outline the systems which are in place to ensure that the Candidate can rapidly and reliably communicate with Clinical Supervisors when necessary:*

33. Do you acknowledge that the Mohs candidate must undertake a program of formative and summative assessments as outlined in the Mohs Surgery Training Program Curriculum, and that the Supervisor of Training and Clinical Supervisors must be involved in these?*

YESNO

34. Will the following equipment be available to the Mohs candidate?

Select Yes/No as appropriate

Resuscitation equipment*

YESNO

Microscope*

YESNO

Cryostat*

YESNO

Electrosurgical devices*

YESNO

35. Can the training facility demonstrate sufficient case load to enable the Mohs candidate to obtain the breadth and depth of experience defined by the curriculum?*

YESNO

If yes, please provide evidence that demonstrates that in the two years preceding the application a faculty of at least two with a total Mohs case load of at least 700 existed at the primary teaching site (including any satellite facilities.) A minimum of 90% of these Mohs cases should have occurred on the head, neck, lower leg (including feet), hands, digits or anogenital:

36. Is the training facility a licensed day surgery that has achieved accreditation to NSQHS standards?*

YESNO

If yes, please provide details:

37. Is there an orientation package/program which will be provided to the Mohs candidate?*

YESNO

38. Is there a case review/audit system?*

YESNO

Signature of Supervisor of Training:*

Date:*

Timetable*

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Supporting documentation 1

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Supporting documentation 2

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Supporting documentation 3

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Application for Accreditation of a Mohs Surgery Training Position

TRAINING FACILITY DETAILS

CANDIDATE DETAILS

STANDARD 1 TRAINING AND EDUCATION

STANDARD 2 SUPERVISION AND COORDINATION

STANDARD 3 EQUIPMENT AND FACILITIES

STANDARD 4 LEARNING AND WORK ENVIRONMENT