Nicotine Treatment Specialist Credential Application

Nicotine Treatment Specialist Credential Application

APSAD Smoking & Vaping Cessation Professionals Special Interest Group
INFORMATION & PROFESSIONAL EXPERIENCE
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Email*

Confirmation Emailconfirm your email address
Phone Number*

Country CodeArea CodePhone 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 nicotine treatment related clinical hours do you currently work per month? *
A minimum of 16 hours per month is required. Nicotine cessation related work can include research, education, training, or treatment
Provide a brief summary of your nicotine and/or smoking cessation work.*
Detail the work you do around nicotine and/or smoking cessation
List the details for any nicotine and/or smoking cessation training courses and activities you have completed in the past 12 months*
If it has been more than 12 months since your last course and/or training, you must complete the APSAD Smoking and Vaping Cessation Professionals CPD form and submit it with your application.
Provide evidence for any nicotine and/or smoking cessation training courses and activities you have completed*

Upload your file/certificates.
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The Smoking & Vaping Cessation Special Interest Group recognises the RACGP Smoking Cessation Guidelines for Australian General Practice.
I practice evidence-based nicotine and/or smoking cessation interventions as recognised by the APSAD Smoking & Vaping Cessation Special Interest Group.*

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 nicotine and/or smoking cessation treatment. It is desirable that the referee currently works in the profession in either the clinical or research area for nicotine and/or smoking cessation.
Referee's Name*

PrefixFirst NameLast Name
Email*

Confirmation EmailConfirm the referee's email
Referee's Phone *
Please enter a valid phone number.
Referee's Workplace*
Referee's Current Position*

NICOTINE TREATMENT SPECIALIST FINDER

If your APSAD Smoking and Vaping Cessation Professionals Nicotine Treatment Specialist credential application is successful, you have the option of being listed in the Nicotine 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 NTS Finder on the APSAD website.*

Yes - Complete My Contact details for the APSAD NTS FinderNo - Continue to Declaration

Nicotine Treatment Specialist Finder Contact Details

The information you provide in this section will be included on the Nicotine Treatment Specialist Finder. Any details you do NOT want shared on the Nicotine Treatment Specialist Finder, leave blank.
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Clinic / Hospital / Organisation*
Speciality*
Phone Number*

Area CodePhone Number
Email*

Confirmation EmailConfirm your email address
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website*
add your website for the NTS Finder
Contact Details to be listed on NTS Finder (tick all that apply)*

EmailPhoneWebsiteAddress

DECLARATION
I declare I am not working or aﬃliated with any tobacco/vaping organisations or their subsidiaries AND I hereby declare the information completed by me in this form is true and accurate.*

I AgreeI Disagree
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Nicotine Treatment Specialist Credential Application

INFORMATION & PROFESSIONAL EXPERIENCE

REFEREE INFORMATION

NICOTINE TREATMENT SPECIALIST FINDER

Nicotine Treatment Specialist Finder Contact Details

DECLARATION