Paediatric Certification Application Form

Application Form for Certified Advanced Paediatric Audiologist - Case-by-case Pathway
Please note: The document titled 'Essential Information for Applicants - Case-by-case Pathway' offers instructions and guidelines that you must consult prior to commencing your application, and as you work through it. You must refer to the Essential Information, and any documents it directs you to, for each section of the application form.

The Essential Information for Applicants - Case-by-case Pathway can be accessed here.

Unsubmitted drafts:

Kindly note that according to Jotform's policy, any unsubmitted drafts will be removed after 2 months of saving it as a draft. Therefore, we recommend completing and submitting your draft application within this timeframe. It is advisable to gather all necessary information beforehand and then proceed to fill out the form as one of the final steps of your application submission.

If you encounter any issues completing this application form, please contact us at certification@audiology.asn.au
Application Summary

The application covers the following:
- Name, AudA membership number, contact details
- Case-by-case Pathway eligibility criteria and declaration
- Declarations and responses to the competencies of the Paediatric Audiologist area of the Paediatric Competency Standards for Audiologists
- CV & Summary table of paediatric experience
- Online interview availability
- Referee details
- Payment details

Full Name*

Given NameFamily Name
Preferred Given Name
AudA Membership Number*
E-mail*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState

Post CodeCountry

Eligibility Criteria and Declaration for Case-by-case Pathway

Refer to 'Essential Information for Applicants' before completing this section

The applicant:
- Must be an Audiology Australia Accredited Audiologist
- Must have completed their Clinical Internship
- Is required to demonstrate they meet all competencies described in the Paediatric Audiologist area in the Paediatric Competency Standards for Audiologists (see Response to Competencies below)
The applicant must meet the following degree and recency of experience requirements:
- Details of at least some current and recent experience in paediatric clinical activities and an estimation of how much it is below that of the requirements of either Pathway A or Pathway B
- This experience must be gained after completion of Clinical Internship, and can include practice undertaken overseas
Please note:
- You must attach the Experience calculator and/or the Experience table to show how you calculated your hours
Accredited Audiologist Declaration*

I declare that I am an AudA Accredited Audiologist
I have attached the Experience calculator*

YesNo
AND/OR
I have attached the Experience table*

YesNo
Attach Experience calculator and/or Experience table here *

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Case-by-case Pathway Declaration (select one only)*

I declare that I am closest to meeting the degree and recency of experience requirements of Pathway AI declare that I am closest to meeting the degree and recency of experience requirements of Pathway B
Enter an estimation of how much the amount of your relevant experience is below the requirements of Pathway A or Pathway B*
Extenuating circumstances and explanation*

I have entered below details of any extenuating circumstances, and an explanation for why I believe I should be awarded certification.
Please enter your details here*
I have also chosen to attach further details or supporting documents of extenuating circumstances
Cancelof

Response to Competencies

Refer to 'Essential Information for Applicants' before completing this section

Paediatric Competency Standards for Audiologists – Paediatric Audiologist

The competencies in the Paediatric Audiologist area of practice are grouped into the following sections:
1. Fundamental knowledge and principles
2. Legal requirements
3. Communications
4. Cultural
5. Appointment planning, service delivery and environment
6. Paediatric hearing assessment

Paediatric Competency Standards for Audiologists Paediatric Audiologist
II. Legal Requirements
1. Demonstrates awareness of and complies with the Commonwealth, State and Territory legislation and regulations relevant to the delivery of audiology services to children.*

I declare that I meet this competency
2. Demonstrates awareness of the rights of the child, and the age and capability requirements, including relevant legislation, that allows them to make decisions, maintain privacy if they choose, and provide their own informed consent.*

I declare that I meet this competency
3. Demonstrates understanding of mandatory reporting obligations under the legislation applicable to the relevant jurisdiction.*

I declare that I meet this competency
4. Demonstrates understanding of and works in accordance with family court directives pertaining to custody arrangements, information sharing and consent.*

I declare that I meet this competency
5. Demonstrates awareness of ethical and legal obligations, and respects the rights and choices of child/family/carer, with regards to involvement in research.*

I declare that I meet this competency
Your response to 'Legal requirements' *

Paediatric Competency Standards for Audiologists Paediatric Audiologist
III. Communications
1. Establishes and addresses the communication needs of the child/family/carer, including working effectively with professional interpreters when required.*

I declare that I meet this competency
2. Builds rapport with the child/family/carer, to develop trust, respect, and effective communication.*

I declare that I meet this competency
3. Works with child/family/carer to establish a shared understanding of goals for appointment and ongoing paediatric management.*

I declare that I meet this competency
4. Communicates clearly and fully with child/family/carer in a manner that is sensitive and considers the family’s health literacy level to:

i. Set context and expectations, explain own role and that of other personnel or services who may be involved

ii. Provide information throughout appointments on procedures being undertaken

iii. Explain results, relating them to the child’s developmental level and age

iv. Establish their understanding of test results and the implications for the child, and provide further information as required

v. Include child in appointment decisions and discussions as appropriate to the age and abilities of the child.
Please provide your declaration for competency 4 here:*

I declare that I meet this competency
5. Manages case discussions with discernment, including with whom they should occur.*

I declare that I meet this competency
6. Encourages child/family/carer to ask questions and seek clarification and further information as required and encourages shared decision making.*

I declare that I meet this competency
7. Determines when written communication may be required to support the child’s management, and prepares and distributes accurate, clear and relevant reports according to the needs of the recipient/s.*

I declare that I meet this competency
8. Supports the child’s care by providing individualised information, advice, and education to all identified stakeholders involved in the child’s program.*

I declare that I meet this competency
Your response to 'Communications' *

Paediatric Competency Standards for Audiologists Paediatric Audiologist
IV. Cultural
1. Demonstrates understanding of and is sensitive to the needs of children/families/carers from culturally and linguistically diverse backgrounds.*

I declare that I meet this competency
2. Partners with other professionals such as interpreters, social workers and cultural liaison officers, to help understand different cultural perspectives and assist with planning and support for child/family/carer.*

I declare that I meet this competency
3. Adapts service delivery and resources to provide a safe environment that meets the cultural and linguistic needs of the child/family/carer.*

I declare that I meet this competency
4. Demonstrates sensitivity to cultural beliefs which may impact on how results or recommendations are received and provides information about support options available.*

I declare that I meet this competency
5. Demonstrates awareness of the Deaf community, its unique cultural identity and the integration of related Deaf organisations and stakeholders involved in planning and delivering paediatric services.*

I declare that I meet this competency
6. Demonstrates awareness of the role of Aboriginal and Torres Strait Islander communities and affiliated organisations in the planning and delivery of services to clients who identify as Aboriginal and Torres Strait Islander.*

I declare that I meet this competency
7. Engages and consults with Aboriginal and Torres Strait Islander communities and affiliated organisations when planning and delivering services to Aboriginal and Torres trait Islander clients.*

I declare that I meet this competency
8. Demonstrates understanding of culturally safe practice that includes recognition of the distinct needs of Aboriginal and Torres Strait Islander peoples in relation to hearing health care for children.*

I declare that I meet this competency
Your response to 'Cultural' *

Paediatric Competency Standards for Audiologists Paediatric Audiologist
V. Appointment Planning, Service Delivery and Environment
1. Determines plan for the appointment/s and procedures according to the clinical information and observations, child/family/carer’s goals and choices, and the child’s individual needs.*

I declare that I meet this competency
2. Modifies approach as required to meet the needs of the child/family/caregiver, including coordination of appointments, mode of service delivery and provision of additional resources or support.*

I declare that I meet this competency
3. Ensures that child/family/carer is provided with sufficient information to adequately prepare them for the appointment.*

I declare that I meet this competency
4. Adjusts environment, access and room configuration to suit the age, culture, developmental stage and needs of the child, including their sensory and physical needs, and those of the family/carer.*

I declare that I meet this competency
5. Ensures test modifications, mode of service delivery or environmental factors that impact appointment outcomes are documented in clinical notes and/or reports.*

I declare that I meet this competency
Your response to 'Appointment planning, service delivery and environment' *

CV & Summary Table of Paediatric Experience - Refer to 'Essential Information for Applicants' before completing this section*

I have attached a CV belowI have attached a summary table below
Attach your CV here:*

Cancelof
Attach your summary table here:*

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Online interview availability- Refer to 'Essential Information for Applicants' before completing this section*

I have provided my preferred days and times for an interview, below
Enter your preferred days of the week and times (including your timezone) here:*
If your application is successful, would you like to have your contact details shared with the other Certified Advanced Paediatric Audiologists for networking purposes?*
If your application is successful, would you like to be considered to act as an assessor for other applications in future?*

Referee form - Refer to 'Essential Information for Applicants' before completing this section. Please select only one*

I have a referee who is an AudA Accredited Audiologist, AND I have attached the referee form on the next pageI have an alternate referee who is not an AudA Accredited Audiologist, AND I have provided justification below for using this referee AND have attached the referee form on the next page
Please provide any justification/more information here

Refer to 'Essential Information for Applicants' before completing this section. The Print button is at the end of this page. Attach your Referee form (you may attach more than one)

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Fees & Payment

The application fee required for submission of this form is $200.00

Payment can be done via electronic bank transfer, details are:
Account Name: Audiology Australia
BSB: 083 054
Account Number: 883994167
Payment reference: Your AudA member number CAPA Application, E.g: 1234 CAPA Application

If you prefer payment by credit card, please contact us on certification@audiology.asn.au and we will contact you via phone to take your payment details. Once payment information is provided you can submit this form.
Declaration & submission*

I declare that all the information provided in this application is true and accurate to the best of my knowledge and I have paid my application fee to Audiology Australia.
Date of Application Submission

DayMonthYear
If you encounter any issues completing this application form, please contact us at certification@audiology.asn.au
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Application Form for Certified Advanced Paediatric Audiologist - Case-by-case Pathway

Paediatric Competency Standards for Audiologists Paediatric Audiologist

I. Fundamental knowledge and principles

Paediatric Competency Standards for Audiologists Paediatric Audiologist

II. Legal Requirements

Paediatric Competency Standards for Audiologists Paediatric Audiologist

III. Communications

Paediatric Competency Standards for Audiologists Paediatric Audiologist

IV. Cultural

Paediatric Competency Standards for Audiologists Paediatric Audiologist

V. Appointment Planning, Service Delivery and Environment

Paediatric Competency Standards for Audiologists Paediatric Audiologist

VI. Paediatric Hearing Assessment