Mohs Surgery Training Position Application Form

Application for Accreditation of a Mohs Surgery Training Position

This form should be completed by the Supervisor of Training with reference to the Accreditation Standards for Mohs Surgery Training Positions.
TRAINING FACILITY DETAILS
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? *

Yes No
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:
CANDIDATE DETAILS
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? *

YES NO
STANDARD 1 TRAINING AND EDUCATION
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? *

YES NO
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? *

YES NO
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? *

YES NO
STANDARD 2 SUPERVISION AND COORDINATION
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? *

YES NO
17. Has the Supervisor of Training five years post Mohs training program surgery experience? *

YES NO
18. Has the Supervisor of Training completed at least 200 Mohs surgery cases in each of the two years prior to this application? *

YES NO
If yes, please provide details:
19. Is the Supervisor of Training enrolled in the RCPA QAP frozen section technical module? *

YES NO
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? *

YES NO
22. Has the Supervisor of Training attended ACD Supervisor Training within the last 5 years?

YES NO
23. Is the Supervisor of Training aware of the duties of their role as describes in the Training Program Handbook Mohs? *

YES NO
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? *

YES NO
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? *

YES NO
27. Has each Clinical Supervisor completed at least 100 Mohs cases in the years prior to this application? *

YES NO
If yes, please provide details:
28. Is each Clinical Supervisor of good standing with the AHPRA without restriction on registration? *

YES NO
29. Has each Clinical Supervisor attended ACD Supervisor Training within the last 5 years? *

YES NO
30. Is each Clinical Supervisor aware of the duties of their role as described in the Training Program Mohs Surgery? *

YES NO
31. Will all patient care at the training facility be supervised by qualified clinical supervisors?

YES NO
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? *

YES NO
STANDARD 3 EQUIPMENT AND FACILITIES
34. Will the following equipment be available to the Mohs candidate?

Select Yes/No as appropriate
Resuscitation equipment *

YES NO
Microscope *

YES NO
Cryostat *

YES NO
Electrosurgical devices *

YES NO
STANDARD 4 LEARNING AND WORK ENVIRONMENT
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? *

YES NO
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? *

YES NO
If yes, please provide details:
37. Is there an orientation package/program which will be provided to the Mohs candidate? *

YES NO
38. Is there a case review/audit system? *

YES NO
Signature of Supervisor of Training: *
Date: *
Timetable *

Cancel of
Supporting documentation 1

Cancel of
Supporting documentation 2

Cancel of
Supporting documentation 3

Cancel of

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