ASVCP Tobacco Treatment Specialist Credential Application
APSAD Smoking and Vaping Cessation Professionals Special Interest Group (ASVCP-SIG) Tobacco Treatment Specialist (TTS) Credential application form
INFORMATION & PROFESSIONAL EXPERIENCE
Name
*
Prefix
First Name
Last Name
Email
*
Confirmation Email
confirm your email address
Phone Number
*
-
Country Code
-
Area Code
Phone Number
Workplace
*
Your place of employment
Current Position
*
Current position held
Enter the name/s of other professional bodies you are a member of
Skip to next question if none.
How many tobacco treatment related clinical hours do you currently work per month?
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A minimum of 16 hours per month is required. Smoking cessation-related work can include research, education, training, or treatment
Provide a brief summary of your smoking cessation work.
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List the details for any smoking cessation training courses and activities you have completed in the past 12 months
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If it has been more than 12 months since your last course and/or training, you must complete the ASVCP-SIG CPD form and submit it with your application. Download the CPD form.
Provide evidence for any smoking cessation training courses and activities you have completed
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I practice evidence-based smoking cessation interventions as recognised by the APSAD Smoking & Vaping Cessation Special Interest Group. The Smoking & Vaping Cessation Special Interest Group recognises the RACGP Smoking cessation guidelines for Australian general practice.
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I Agree
REFEREE INFORMATION
Provide the details for one referee. Your nominated referee will be contacted by an APSAD representative and asked to comment on your professional competency and experience in smoking cessation. It is desirable that the referee currently works in the profession in either the clinical or research area for smoking cessation.
Referee's Name
*
Prefix
First Name
Last Name
Referee's Phone
*
Please enter a valid phone number.
Email
*
Confirmation Email
example@example.edu.au
Referee's Workplace
*
Referee's Current Position
*
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TOBACCO TREATMENT SPECIALIST FINDER
If your application for a APSAD Smoking Cessation Professionals Tobacco Treatment Specialist Credential is successful, you have the option of being listed in the Tobacco Treatment Specialist Finder on the APSAD website so smokers and health professionals can find you. Please note APSAD does not provide advice on insurance and has no responsibility for any additional insurance requirements or costs. Applicants should seek independent advice regarding any professional indemnity insurance.
I would like to listed on the TTS Finder on the APSAD website.
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Yes - Complete My Contact details for the APSAD TTS Finder
No - Continue to next page and the Declaration
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Contact details for the APSAD TTS Finder
The information you provide in this section will be included on the TTS Finder. Any details you DO NOT want shared with the public on the TTS Finder, leave your response blank.
Name
*
Prefix
First Name
Last Name
Suffix
Clinic / Hospital / Organisation
Speciality
*
Contact Details to be listed on TTS Finder
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Email
Phone
Website
Address
Email
Confirmation Email
Confirm your email address
Website
add your website if you want this listed on the TTS Finder
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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DECLARATION
I declare I am not working or affiliated with any tobacco organisations or their subsidiaries AND I hereby declare the information completed by me in this form is true and accurate.
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I Agree
I Disagree
Submit
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