ANZAN Site Accreditation and Re-accreditation Form

Site Accreditation and Re-accreditation Form
APPLICATION FOR RE-ACCREDITATION OF CORE TRAINING POSITION(S) IN NEUROLOGY
Hospital Details
Hospital
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Department & Positions
Head of Neurology Department

First NameLast Name
Head of Department email
example@example.com
Number of accredited core positions
Number of position(s) to be re-accredited
Supervisors
Please list ALL Potential supervisors of AT's (this section continues on following page)
Probable Supervisor #1

First NameLast Name

FTE
Date last attended RACP Supervisor Workshop

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Indicate which RACP training modules have been undertaken?
Probable Supervisor #2

First NameLast Name
FTE
Date last attended RACP Supervisor Workshop

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Indicate which RACP training modules have been undertaken?
Separately list ALL potential Advanced Trainee Supervisors
Neurology Consultant Staff
List all neurology consultant staff. Indicate FTE – Staff or VMO, indicate who has undertaken the RACP training modules and which ones
A. Dr John Brown - consultant, 0.4 FTE, RACP Modules 1, 2, 3
Total FTE for the Unit:

EMG Supervisor
EMG Supervisor *

First NameLast Name
EMG Level *
Hours spent supervising (Please include EMG Supervisor Logbook with this application)
EEG Supervisor
EEG Supervisor *

First NameLast Name
EEG Level *
Hours spent supervising (Please include EEG Supervisor Logbook with this application)
Please list all Consultants who are accredited by ANZAN for NCS/EMG & EEG – at which Level
eg: Dr xxx - EMG Level 2
Please list ALL junior medical staff working on the unit
a. Include the position (ie Intern, SMO, BPT, Fellow etc) and FTE devoted to the Unit.
b. How staff are covered for their ambulatory clinics including EMG sessions and
teaching sessions such as Brain School
c. The on call roster for each AT

General Timetable for the Neurology & Stroke Unit:

Fellows
Please list all Fellows currently working within the Department (including sub-specialty, e.g. Neurophysiology):
Please attach a timetable separately for ALL Fellows working within the Department, especially Neurophysiology

Consults registrar (AT1):

	MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY
AM	Consults Alt week Case based EMG & EEG teaching (Dr)	Neuro- immunology/General clinic (Dr)	Consults	Consults NCS/EMG clinic (Dr)	Consults
PM	Consults	Movement Disorders clinic (Dr)	Grand Round - LMH EEG Tutorial (Dr) Brain school every month	Neurology Clinical Case Meeting Discharge Audit meeting	Neuro radiology meeting- Neurology Clinical Case/neuropath -

Ward registrar (AT2):

Rows	MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY
AM
PM

Unit Information
Number of inpatient beds
Quality assurance program? * (Attach files to application)
No. of Ambulatory Care (outpatients) Clinics/Week
Average no. of inpatient consultations/week
Number of Part-time Neurologists in the Department?
Number of Full-time Neurologists in the Department?
On-Call Arrangements for Advanced Trainees (AT)
Please provide further detail on the on-call arrangements for Advanced Trainees at this site, in addition to the on-call information provided earlier in this form.
What is the on-call arrangement for an AT?
Evening on-call - what time does it finish?
Overnight on-call - how often does this occur?
Is there a room and facilities available if an AT has to stay overnight in the hospital?
If yes, please provide details (location, facilities):
Is there a logbook in place to ensure normal training activities are not affected by on -call duties?

Location of video-conferencing facilities at hospital: (including contact details of technical support person):
Will Hospital or Area Health Authority allow access to these facilities at no cost to trainee:
Other sub-specialty training available? If yes nominate specialties
Please indicate any changes in resources since the last accreditation:
Thank You for Completing This Form
Name

First NameLast Name
Signature *
Please upload your files in the File Upload box below, or send the attachments to anzan@anzan.org.au
File Upload

Cancelof
Should be Empty:

Site Accreditation and Re-accreditation Form