PHRM RPL/RPE Application Form

Please indicate below the details of the training and/or experience for which you are applying for recognition.
Placement 1.
Start Date*

DayMonthYear
Date
End Date*

DayMonthYear
Date
Name of Training Site*
Role (Registrar, etc.)*
FTE*
Placement 2.
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Name of Training Site
Role (Registrar, etc.)
FTE
Placement 3.
Start Date

DayMonthYear
Date
End Date

DayMonthYear
Date
Name of Training Site
Role (Registrar, etc.)
FTE

Please upload a certified copy of any in-training assessments relevant to the application. All assessments should clearly show the name and signature of the Supervisor of Training, details of the term and site.

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Please upload evidence of competency in the learning outcomes as set out in the PHRM curriculum and a summary of training undertaken, including relevant dates, supervisors, and sites.

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Please provide details of relevant training course/program, if applicable, including the objectives, content, and outcomes of the associated curriculum.

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Please provide a statement of supervision that confirms your ability to perform in the role of a trainee at a level consistent with the learning outcomes of the PHRM.

Must be issued by a specialist doctor at a level equivalent to a PHRM Consultant.
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Please upload a logbook of cases undertaken during the relevant training term/s using the CCPHRM-approved Excel template.*

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Please provide evidence of completed CPD activities that are directly relevant to PHRM

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Please upload a copy of your current Curriculum Vitae*

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