Application for 2008-2010 GPMHSC accreditation Focussed ...



Application for GPMHSC accreditation 2011 – 2013 triennium

FOCUSSED PSYCHOLOGICAL STRATEGIES SKILLS TRAINING

|Instructions for applicants: |

|This application form is for training providers seeking accreditation from the General Practice Mental Health Standards Collaboration (GPMHSC) for |

|education activities to be recognised as 'focussed psychological strategies skills training' |

|(FPS skills training) |

| |

|Activities require prior accreditation with the RACGP and/or ACRRM before adjudication by the GPMHSC. Training organisations can seek accreditation |

|from these organisations using this form. Applications submitted to the GPMHSC without prior accreditation with the RACGP and/or ACRRM will be |

|forwarded to the respective college. |

| |

|Training providers are strongly advised to review the GPMHSC educational standards outlined in the document 'A framework for professional development |

|in mental health for GPs' to assist in completing this form. |

| |

|Requirements for re-accreditation |

|Training providers who have had FPS skills training activities accredited with the GPMHSC in previous trienniums, will need to apply to the GPMHSC for |

|re-accreditation for the 2011 – 2013 Triennium using this form. |

| |

|Training providers seeking re-accreditation will also be required to submit with this form: |

|a covering letter outlining the changes that have been made from the original application that have been incorporated into the program that you are |

|seeking accreditation for, and; |

|a copy of an evaluation report containing aggregated data from the l activities conducted in the previous triennium. The report can be the same as what|

|is submitted to the RACGP and ACRRM. |

| |

|Please complete section 1 or 2 and sections 3 -8 of this application |

|Section 1 - Please indicate which organisation(s) you are seeking accreditation from using this form: |

| | |

|I want to use this form to seek RACGP |I want to use this form for ACRRM PD Program accreditation. |

|QI&CPD Program accreditation. |Please complete all green shaded 'ACRRM' sections. |

|Please complete all yellow shaded 'RACGP' sections. | |

|Please forward a copy of this application to the RACGP for adjudication. | |

|Please note that providers who do not have an existing ‘Provider Contract’ | |

|with the QI&CPD Program will be required to pay adjudication fees. Please | |

|complete the Tax invoice included at the back of the form. | |

|Section 2 - Please indicate if you already have accreditation and are seeking only GPMHSC accreditation: |

| I already have RACGP QI&CPD accreditation for this activity and seek | I already have ACRRM accreditation for this activity and seek GPMHSC |

|GPMHSC accreditation only. |accreditation only. |

|RACGP activity number:       | |

| |ACRRM activity number:       |

Submission process

If you require RACGP and/or ACRRM accreditation, this application must be submitted directly to the relevant College. If you already have existing accreditation for this activity with the RACGP and/or ACRRM, you may submit this application to the GPMHSC Secretariat at: gpmhscapplications@.au

|Key contact details |

|GPMHSC Secretariat |RACGP QI&CPD Program |ACRRM PD Program |

|Tel: 03 8699 0556 |Contacts for all states available: |Tel: 1800 223 226 |

|Email: gpmhscapplications@.au |.au/qicpd/contacts |Email: pdp@.au |

| | | |

|Web: .au |Web: .au/qicpd |Web: .au |

|Section 3. Organisational information |

|3.1 Education activity title: |      |

|3.2 Total number of hours of structured learning: |      (hours) |Do not include time allocated for breaks, meals, trade |

| | |displays or completion of predisposing and reflective |

| | |activities. |

|3.3 Provider/organisation: |      |

|3.4 RACGP Provider number: | |

|3.5 Organisation address: |      |

|3.6 Organisation website: |      |

|3.7 Name of Education activity developer: |      |3.8 EAR reference no:       |

|3.9 Position title: |      |

| 3.10 Telephone: |      |3.11 Fax: |      |

| 3.12 Email: |      |

| 3.13 Contact name for administration enquiries: |      |

| 3.14 Telephone: |      |3.15 Fax: |      |

| 3.16 Email: |      |

| 3.17 Sponsoring/funding organisations involved | |

|with this activity: | |

| 3.18 Other organisations involved in | |

|developing this activity: | |

|RACGP REQUIRED INFORMATION: complete only if seeking RACGP accreditation with this form. Questions relating to completion of this section should be |

|directed to the RACGP QI&CPD Office in your state (refer to .au/qicpd/contacts for contact details) |

|3.19 Name of GP on planning committee: |      |RACGP QI&CPD Number:       |

|3.20 Qualification(s): |      |

|3.21 Contact number: |      |Contact email:       |

|3.22 Delivery options: |

|One off event (run once only) |

|A repeated activity (identical activity repeated at different times and/or locations) |

|Continuous education (e.g. online) |

| |

|Calendar of events: All accredited activities will be advertised on the QI&CPD Calendar. |

|Please select one below: Please select one below: |

|By invitation only GPs |

|Only available to members GPs and practice team |

|All attendees welcome |

|3.24 Select the domains of | | | | | |

|general practice covered: |Communication skills |Professional knowledge|Population health |Professional & |Organisational & legal |

| | | | |ethical role |issues |

|3.25 If this module includes components covering basic CPR|Consistent with Australian Resuscitation Council ARC | Yes |

|training skills to be adjudicated for GPs' CPR |guidelines? |No |

|requirements: |Total time allocated to CPR (min 1hr)       |Not applicable |

|3.26 Specific interest requirements & training grants: | Medical acupuncture | Women's health |

|Indicate if you want this application to be adjudicated |Anaesthetics |Surgery |

|for points in a specific interest area (in addition to |Diagnostic radiology |Procedural skills training* |

|mental health) and attach all relevant materials. Content |Breast medicine |Emergency medicine* |

|must represent more than 50% of the total activity to be |[X] FPS skills training |* Training grant eligibility. Must be a |

|eligible | |minimum of 6 hours |

|3.27 The main aim of this activity is: | |

| |Non-medical/ clinical education |

| |Medical/clinical education ( COMPLETE SECTION 0 |

|3.28 ICPC codes: For medical/clinical education please |CODE |Description |

|provide up to three ICPC codes and descriptions of the | | |

|medical /clinical issues covered by your activity. It is | | |

|the responsibility of the GP on your planning committee to| | |

|identify the ICPC codes and classification areas. | | |

| |1.       |1.       |

| |2.       |2.       |

| |3.       |3.       |

| |Refer to for list of ICPC codes |

| |and classifications. |

| 3.29 How many GPs do you anticipate will attend?      |3.29 How many facilitators will assist?       |

|3.30 Needs assessment: |All needs assessments need to be supported by current and clinical evidence based |

| |references, in accordance with the RACGP guidelines for QI&CPD, demonstrating that this |

| |activity is valid to GP needs. |

| | |

| |The needs assessment for this activity may include information from one or more of the |

| |following: |

| |information from expert bodies including references to peer reviewed medical literature |

| |and/or recognised health organisation documentation |

| |references to federal and/or state government policy; relevant guidelines, reports and |

| |initiatives |

| |GP perspective, e.g. formal GP participant survey - Note: anecdotes, informal surveys, |

| |personal opinions and single ‘expressions of interest’ are not valid |

| |community perspective, e.g. information from community groups, other health professionals, |

| |GP divisions and consumer groups. |

| |[pic]Attach a copy of your needs assessment including references |

| | |

| |

|ACRRM REQUIRED INFORMATION: complete only if seeking ACRRM accreditation with this form. Questions relating to completion of this section should be |

|directed to the ACRRM PD Program (refer to .au for contact details). |

|3.31 Activity type: |

| Conference | Skills based training (inc simulator training) |

|Workshop |In practice visit |

|Satellite broadcast (inc web casts) |Other – please specify:       |

|Group seminar | |

|3.32 Curriculum area(s) & Educational Domain(s) |

| | |Educational Domains |

| |Please mark with a X the curriculum |Core clinical knowledge & |Extended clinical practice |

| |area(s) relevant to the activity mapped |skills | |

| |against the relevant educational | | |

| |domain(s) | | |

|3.34 Do you require this activity to be assessed for Rural and | | | | |

|Remote Procedural GP's Program Incentive? If YES, indicate |Anaesthetics |Obstetrics |Surgery |Emergency Medicine |

|relevant discipline: | | | | |

|Section 4. Training activity details |

|4.1 Minimum number of enrolments: |      |4.2 Maximum number of enrolments: |      |

|4.3 Please detail any prerequisites or entry requirements: |      |

|4.4 Scheduled date(s) and time(s): |      |

|4.5 Venue(s) for activity (include full street address and postcode): |      |

|4.6 Please indicate how this activity will be funded, and the anticipated cost to |      |

|general practitioners: | |

|4.7 Please tick this box if you do not consent to the GPMHSC advertising your activity on the GPMHSC | |

|webpage: (Please note, if you do not tick this box, your activity will automatically be added to the ‘find | |

|mental health training’ webpage | |

|[pic]Attach a copy of advertising material/program flyer |

|[pic] Attach a detailed program timetable or outline |

|Section 5. Overview of activity |OFFICE USE ONLY |

|Responses to the following points should incorporate clear examples from the program development process and/or | |

|content where appropriate and relevant. The overall educational goal of FPS skills training is to provide GPs with | |

|quality training in the provision of focussed psychological strategies (FPS) for the treatment of common mental | |

|disorders. | |

|5.1 Please give an overview and summary of the activity (please note; this section may be used as a publishable |[ ] Criterion Met |

|summary of your activity if accredited) |[ ] Criterion Not Met |

| |      | |

|5.2 Please detail the specific learning objectives for this activity. |[ ] Criterion Met |

|Please note for RACGP applications you must include at least one learning objective that addresses patient |[ ] Criterion Not Met |

|safety using a systems based approach. | |

| |      | |

|5.3 GP participants may have various levels of prior knowledge and expertise. Please provide details of how this |[ ] Criterion Met |

|activity is adaptable to diversity in participants' existing knowledge and skills. |[ ] Criterion Not Met |

| |      | |

|5.4 FPS skills training must include at least 20 hours of interactive, structured learning. Describe the duration and format of the activity, including|

|the different learning methodologies that will be utilised, opportunities for participant interaction etc. |

|The 20 hours must contain a minimum of 12 hours of face to face contact time, plus a further 8 hours of interactive, structured learning activities. |

|Meal breaks, predisposing and reinforcing activities such as pre/post tests do not contribute to the 20 hour minimum total training. |

|Your response should demonstrate a high level of interactivity, with a focus on participant engagement and active learning, including opportunities |

|for: |

|scripting and rehearsal |

|demonstration of techniques |

|supervised practice of skills |

|case based discussion |

| |      |

| | |

|5.5 Describe how participants are given the opportunity to prepare for the activity and set their own goals (i.e. a |[ ] Criterion Met |

|predisposing activity)? |[ ] Criterion Not Met |

| |      | |

| | | |

| |[pic]Attach a copy of predisposing activity material | |

|5.6 Describe how participants are given the opportunity for reflection to ensure learning is reinforced/strengthened|[ ] Criterion Met |

|back into practice (i.e. a reinforcing activity)? |[ ] Criterion Not Met |

| |      | |

| | | |

| |[pic]Attach a copy of reinforcing activity material | |

|5.7 Describe how the activity will be evaluated. |[ ] Criterion Met |

| |[ ] Criterion Not Met |

|RACGP REQUIRED INFORMATION: Applicants for RACGP QI&CPD accreditation must include three mandatory questions within post program evaluations. These |

|are: 1.To what degree were the learning objectives met (each LO listed) 2. To what degree were your learning needs met, and 3. Rate to what degree |

|this activity was relevant to your' practice. |

| |      | |

| | | |

| |[pic]Attach a copy of all evaluation material | |

|5.8 Describe the active involvement of general practitioners in program planning, development, review and delivery. |[ ] Criterion Met |

|Provide the name, and organisational affiliation of the general practitioners involved. |[ ] Criterion Not Met |

| |      | |

| |Name | |

| | | |

| |Organisational affiliations | |

| | | |

| |Involvement in planning | |

| | | |

| |Involvement in development | |

| | | |

| |Involvement in delivery | |

| | | |

| |Involvement in review | |

|5.9 The perspectives of consumers and carers are frequently different; both must be addressed within FPS skills |[ ] Criterion Met |

|training |[ ] Criterion Not Met |

|Describe the active involvement of mental health consumers within program | |

|Planning (required); | |

|Development (required); | |

|Delivery (required); and | |

|Review (required). | |

|Please also briefly detail consumers' organisational affiliations (e.g. with recognised advocacy groups) and past| |

|experience in similar roles. | |

|For information on consumer and carer participation, refer to Section 7 within the document ‘A framework for | |

|professional development in mental health for GPs’, available at .au | |

| |Name(s) of consumer(s) | |

| | | |

| |Involvement in planning | |

| | | |

| |Involvement in development | |

| | | |

| |Involvement in delivery | |

| | | |

| |Involvement in review | |

| | | |

| |Organisational affiliations | |

| | | |

| |Past experience | |

|5.10 The perspectives of consumers and carers are frequently different and both must be addressed within FPS skills |[ ] Criterion Met |

|training |[ ] Criterion Not Met |

|Describe the active involvement of mental health carers within program | |

|Planning (required); | |

|Development (required); | |

|Delivery (required); and | |

|Review (required). | |

|Please also briefly detail carer's organisational affiliations (e.g. with recognised advocacy groups) and past | |

|experience in similar roles. | |

|For information on consumer and carer participation, refer to Section 7 within the document A framework for | |

|professional development in mental health for GPs, available at .au | |

| |Name(s) of carer(s) | |

| | | |

| |Involvement in planning | |

| | | |

| |Involvement in development | |

| | | |

| |Involvement in delivery | |

| | | |

| |Involvement in review | |

| | | |

| |Organisational affiliations | |

| | | |

| |Past experience | |

|5.11 Describe the active involvement of appropriately trained mental health professionals in program planning, |[ ] Criterion Met |

|development, delivery and review. Please provide their name, qualifications, experience in providing FPS as well as |[ ] Criterion Not Met |

|their teaching experience. | |

| |Name of mental health professionals | |

| | | |

| |Qualifications | |

| | | |

| |Experience in provision of FPS | |

| | | |

| |Teaching experience | |

| | | |

| |Involvement in planning | |

| | | |

| |Involvement in development | |

| | | |

| |Involvement in delivery | |

| | | |

| |Involvement in review | |

| | | |

| |Organisational affiliations | |

|Section 6. Content area: focussed psychological strategies | |

|Not all approved FPS are expected to be addressed within a 20 hour program. | |

|The GPMHSC has endorsed two program variations: | |

|Programs which are based on |Programs which are based on |

|cognitive behaviour therapy (CBT) |interpersonal therapy (IPT) |

|Programs predominantly based on CBT must provide skills orientated training|Programs predominantly based on IPT must at a minimum provide skills |

|in 1, 2, 3, 4 (4.1), 5 (5.1) and any one strategy from 6 or 7, from the |orientated training in the areas listed below. |

|list below. |1. Psycho-education |

|1. Psycho-education |2. Motivational interviewing |

|2. Motivational interviewing |3. Theory and principles underlying IPT |

|3. Theory and principles underlying CBT |Mental disorders linked to 4 types of relationship difficulties (loss, role|

|4. Behavioural interventions |disputes, role transitions and interpersonal deficits) |

|4.1 Essential: behaviour modification |4. IPT training |

|4.2 Optional: activity scheduling |Exploration of patient’s perceptions, expectations of others and |

|4.3 Optional: exposure techniques |relationships |

|5. Cognitive Interventions |Identification of problems with relationships |

|5.1 Essential: Cognitive analysis, thought challenging & cognitive |Use of affect to bring about change |

|restructuring |Problem-solve to get resolution of relationship issues |

|5.2 Optional: self instructional training, attention regulation and control|Communication analysis and training |

|6. Relaxation strategies |Role-play changed behaviour |

|7. Skills training (problem-solving, communication training, parent |Use of the therapeutic relationship |

|management training, stress management) | |

|6.1 Is this program a CBT based program, or an IPT based program? |

| |CBT based program ( Complete sections 6.2 , 6.3 and 6.5 to 6.11 |

| |IPT based program ( Complete section 6.2, 6.4 and 6.5 to 6.11 |

|Responses to the following points should incorporate brief but clear examples from program content where each |OFFICE USE ONLY |

|learning outcome is addressed: | |

|6.2 Learning outcome: demonstrate an understanding of the range of evidence based FPS and the rationale for their |[ ] Criterion Met |

|use in different clinical circumstances. |[ ] Criterion Not Met |

| |      | |

|6.3 Learning outcome: be able to provide CBT based FPS to consumers as part of a treatment plan for common mental |[ ] Criterion Met |

|disorders |[ ] Criterion Not Met |

|CBT based programs: Please provide details of the where and how this learning outcome is addressed within the | |

|program for each focussed psychological strategy. | |

| |1. Psycho-education | |

| |      | |

| | | |

| |2. Motivational interviewing | |

| |      | |

| | | |

| |3. Theory and principles underlying CBT | |

| |      | |

| | | |

| |4. Behavioural interventions | |

| |      | |

| | | |

| |4.1 Essential: behaviour modification | |

| |      | |

| | | |

| |4.2 Optional: activity scheduling | |

| |      | |

| | | |

| |4.3 Optional: exposure techniques | |

| |      | |

| | | |

| |5. Cognitive Interventions | |

| |      | |

| | | |

| |5.1 Essential: Cognitive analysis, thought challenging & cognitive restructuring | |

| |      | |

| | | |

| |5.2 Optional: self instructional training, attention regulation and control | |

| |      | |

| | | |

| |6. Relaxation strategies | |

| |      | |

| | | |

| |7. Skills training (problem-solving, communication training, parent management training) | |

| |      | |

|6.4 Learning outcome: be able to provide IPT based FPS to consumers as part of a treatment plan for common mental |[ ] Criterion Met |

|disorders |[ ] Criterion Not Met |

|IPT based programs: Please provide details of the where and how this learning outcome is addressed within the | |

|program for each FPS. | |

| |1. Psycho-education | |

| |      | |

| | | |

| |2. Motivational interviewing | |

| |      | |

| | | |

| |3. Theory and principles underlying IPT | |

| |      | |

| | | |

| |4. IPT training | |

| |      | |

|6.5 Outline several mental health conditions and the related FPS/ treatment models which are covered within your |[ ] Criterion Met |

|program (e.g. graded exposure / phobic disorders). |[ ] Criterion Not Met |

| |      | |

|6.6 Are the skills taught in this program transferable? Please provide clear examples where possible. |[ ] Criterion Met |

| |[ ] Criterion Not Met |

| |      | |

|6.7 Where and how does the program explain aetiology and epidemiology of the conditions covered? |[ ] Criterion Met |

| |[ ] Criterion Not Met |

| |      | |

|6.8 Where and how does the program cover integrated FPS and medication? |[ ] Criterion Met |

| |[ ] Criterion Not Met |

| |      | |

|6.9 Where and how are modes of assessment explained within the program? |[ ] Criterion Met |

| |[ ] Criterion Not Met |

| |      | |

|6.10 Where and how does the program discuss progress review? |[ ] Criterion Met |

| |[ ] Criterion Not Met |

| |      | |

|6.11 Where and how are issues of closure covered in the program? |[ ] Criterion Met |

| |[ ] Criterion Not Met |

| |      | |

|Section 7. Content area: Additional learning objectives |OFFICE USE ONLY |

|Responses to the following points should incorporate brief but clear examples from program content where each | |

|learning outcome is addressed: | |

|7.1 Learning outcome: demonstrate a greater understanding of practice systems (and other issues) which decrease or |[ ] Criterion Met |

|safeguard patient safety in providing mental health care |[ ] Criterion Not Met |

| |      | |

|7.2 Learning outcome: demonstrate a greater understanding of the experience of mental disorder from the perspective |[ ] Criterion Met |

|of consumers and their families, friends and/or other carers |[ ] Criterion Not Met |

| |      | |

|7.3 Learning outcome: demonstrate an understanding of the value of supervision and other professional development to|[ ] Criterion Met |

|maintain and extend skills in the provision of FPS over time |[ ] Criterion Not Met |

| |      | |

|7.4 Learning outcome: demonstrate a working knowledge of the Medicare Benefits Schedule item numbers for provision |[ ] Criterion Met |

|of FPS by GPs |[ ] Criterion Not Met |

| |      | |

|Section 8. Attachments and declarations |

|8.1 Please ensure that your have attached all relevant documentation, including copies of all resources and materials provided to participants. Please |

|list all attachments provided below: |

| |[pic]Attachment checklist: |

| |advertising material/program flyer |

| |detailed program agenda or outline |

| |predisposing activity material |

| |reinforcing activity material |

| |evaluation material |

| |participant resources/workbooks |

| |needs assessment (RACGP QI&CPD Program applicants) |

| |a letter from MHCA (if required) and 3 copies of DVDs if you are unable to source consumers and carers for the delivery (refer to|

| |Section 7 within the document ‘A framework for professional development in mental health for GP’s’, available at .au) |

| |If applying for re-accreditation : |

| |a covering letter outlining the changes that have been made to the original application |

| |evaluation reports containing aggregated data from the original activities conducted |

|8.2 Acknowledgement of responsibilities |

|Providers of accredited FPS skills training are required to: |

|notify the GPMHSC if any changes to the activity will be made such as, content and speakers, that differ from this application during the 2011 – 2013 |

|triennium |

|submit to the GPMHSC an activity report which includes the aggregated evaluative data within 4 weeks of completion of the training activity training |

|event. This can be the same report provided to the RACGP and/or ACRRM. |

|Please indicate your acceptance of these requirements. |

| |I,      agree to comply with the requirements outlined above for |

| |providers of FPS skills training |

Additional information for RACGP & ACRRM

|RACGP REQUIRED INFORMATION: complete only if seeking RACGP accreditation with this form. Questions relating to completion of this section should be |

|directed to the RACGP QI&CPD Office in your state (refer to .au/qicpd/contacts for contact details) |

|8.3 Shared information consent: Do you give permission for program information to be shared with researchers and interested GPs | Yes |

|for continuing education purposes at the discretion of the RACGP QI&CPD Program. The RACGP may use the information in this |No |

|application for its own research and evaluation. | |

|Declaration: |

|I declare that: |

|I have read, understood and agree to abide by the RACGP QI&CPD Program educational criteria and requirements for the development, delivery and conduct |

|of RACGP QI&CPD Program approved education activities |

|I understand that all activities allocated points within the RACGP QI&CPD Program are subject to the quality review process and future applications may|

|not be considered from Providers whose activities are not developed, delivered and conducted in accordance with the aims and objectives of the RACGP |

|QI&CPD Program |

|the information provided in this document is accurate and complete |

|I will provide GPs who participate in this activity with a written record of their participation and provide a list of all GPs who participated in the |

|activity to the RACGP QI&CPD Program within one month of the activity being completed. Attendance lists will be submitted to the RACGP QI&CPD Program |

|electronically and in the correct format |

|the activity will be evaluated in accordance with the guidelines for activity evaluation and an activity report will be submitted to the RACGP QI&CPD |

|Program within the scheduled timeframe |

|a GP Adverse Experience Feedback form will be made available to all GPs who participate in this activity as part of the ongoing quality review process.|

|Activity developers full name: |      |Date: |      |

|Signature: | |

|ACRRM REQUIRED INFORMATION: complete only if seeking ACRRM accreditation with this form. Questions relating to completion of this section should be |

|directed to the ACRRM PD Program (refer to .au for contact details). |

|8.4 By submission of this application you agree to provide ACRRM with the following: |

|With this application attached in electronic file format: |

|A copy of your activity / program / course especially outlining any “skills” activities. |

|Any other relevant documentation such as pre-reading, assessment instruments, evaluation forms or promotional flyers. |

|One month following the educational event in electronic file format: |

|Attendance list/s complete with all attending ACRRM Member’s details and ACRRM membership numbers. |

|A summary of the event evaluation results including relevant assessment details (e.g. completion rates, assessment results etc.) |

|Name of contact person for providing documentation: |      |

|Position: |      |

|Telephone: |      |Email: |      |

Adjudication payments are not applicable for provider organisations that have purchased a ‘Provider Package’ (products and services agreement) with the RACGP QI&CPD program.

Tax invoice

Please photocopy this document and maintain for your records. It becomes a tax invoice for GST purposes upon payment. Please sign and date below. ABN 34 000 223 807

Adjudication fees: $253.00 (incl $23.00 GST) for each Category 1 adjudication.

The fee for applicants based in countries other than Australia where the course/proposal being adjudicated will be occurring outside Australia is $230.00 (no GST).

Payable by cheque or credit card.

Cheque payment. Please make cheques payable in Australian dollars to:

The Royal Australian College of General Practitioners

Credit card payment

|Please circle one of the debit my (circle one): | |

|BANKCARD / MASTERCARD / VISA / AMEX |CARD HOLDER NAME:      |

| | |

|NO.      /     /      /       |TELEPHONE NO: (       )       |

| | |

|EXPIRY DATE:       /       |SIGNATURE: |

| | |

|AMOUNT: $      |DATE:      /      /       |

Name of contact person and telephone number:     

Name of organisation or RACGP provider number:      

Please submit your application and payment with this invoice to your QI&CPD Unit.

RACGP QI&CPD Unit contact details:

VIC vic.qicpd@.au (03) 8699 0483

SA/NT sant.qicpd@.au (08) 8267 8330

QLD qld.qicpd@.au (07) 3456 8944

WA wa.qicpd@.au (08) 9489 9555

NSW/ACT nswact.qicpd@.au (02) 9886 4700

TAS tas.qicpd@.au (03) 6278 1644

Postal addresses and fax numbers are available at .au/QICPD

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