Credentialing and Defining the Scope ... .au

?Canberra Hospital and Health ServicesOperational ProcedureCredentialing and Defining the Scope of Clinical Practice for Allied Health ProfessionalsContents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc453255730 \h 1Introduction PAGEREF _Toc453255731 \h 2Purpose PAGEREF _Toc453255732 \h 2Scope PAGEREF _Toc453255733 \h 2Roles and Responsibilities PAGEREF _Toc453255734 \h 3Process PAGEREF _Toc453255735 \h 51. Initial Credentialing and Scope of Clinical Practice PAGEREF _Toc453255736 \h 52. Re-credentialing and Review of Scope of Clinical Practice PAGEREF _Toc453255737 \h 8Appeals process PAGEREF _Toc453255738 \h 11Reporting PAGEREF _Toc453255739 \h 11Monitoring and Compliance PAGEREF _Toc453255740 \h 12Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc453255741 \h 13References PAGEREF _Toc453255742 \h 13Definition of Terms PAGEREF _Toc453255743 \h 14Appendices PAGEREF _Toc453255744 \h 15IntroductionACT Health is committed to the delivery of safe, appropriate and high quality allied health clinical services. This is supported through best practice credentialing and defining scope of clinical practice processes, and routine re-credentialing, by ensuring allied health professionals are appropriately qualified and experienced to perform the roles for which they are employed.The National Safety and Quality Health Service Standards provide a framework to ensure quality and safe care. Under this framework, health care organisations are to implement processes for credentialing and defining the scope of clinical practice to support safe, high quality health care as an essential component of patient safety. This procedure ensures ACT Health has a system to define and regularly review the scope of clinical practice of allied health professionals, and provides guidance on mechanisms to monitor these processes.Back to Table of ContentsPurposeThis procedure defines the process for credentialing and defining the scope of clinical practice for allied health professionals working within ACT Health facilities, and ensures that credentialing is professionally led. It provides a standardised governance process for verifying and monitoring the qualifications, experience, professional standing and other relevant professional attributes of allied health professionals, and provides that allied health professionals have a defined scope of clinical practice.Back to Table of ContentsScopeThis procedure applies to independent allied health professionals who practise within ACT Health facilities, including allied health professionals who provide direct clinical care or supervise staff providing direct clinical care. ACT Health recognises two categories of allied health professionals:Registered Allied Health ProfessionalsDental prosthetists, dental therapists, nuclear medicine technologists, occupational therapists, oral health therapists, pharmacists, physiotherapists, podiatrists, psychologists, radiation therapists and radiographers.Self-regulated Allied Health ProfessionalsAllied health assistants, art therapists, audiologists, cardiac perfusionists, cardiac scientists, counsellors, dietitians, exercise physiologists, genetic counsellors, medical physicists, neurophysiology technologists, orthoptists, prosthetists and orthotists, respiratory scientists, sleep scientists, social workers, sonographers and speech pathologists.Allied health professionals deemed out of scope for this procedure include: analytical scientists, biomedical engineers, environmental health scientists, medical laboratory scientists and public health nutritionists. However, the Profession Lead or delegate for each of these disciplines may adopt elements of this procedure that are appropriate for their particular profession. Allied health professionals engaged in research, clinical supervision, professional governance or duties involving no direct patient care or clinical responsibility are also not required to undergo this credentialing and scope of clinical practice process.Back to Table of ContentsRoles and ResponsibilitiesPositionResponsibilitiesAllied Health Profession Lead ForumProvides the governance structure for credentialing and defining the scope of clinical practice for allied health professionals.Oversees performance monitoring and reporting, ensuring that all identified allied health professionals are appropriately qualified, trained and experienced to undertake clinical services within ACT Health facilities. Allied Health Credentialing CommitteeFunctions as the appeal panel for any disputed credentialing and scope of clinical practice matters.Convened as required by the Chief Allied Health Officer.Membership includes: the Chief Allied Health Officer (Chair); a Director of Allied Health representative; a Profession Lead representative; a People and Culture Branch representative; a health care consumer representative, and co-opted subject matter experts where required. Chief Allied Health OfficerAccountable as the primary decision-maker for credentialing and defining the scope of clinical practice for allied health professionals in ACT Health, and endorses confidential tabled credentialing reports as the Chair of the Allied Health Profession Lead Forum.Ensures that systems are established, implemented, monitored and reported for the credentialing process.Delegates the role of approving credentialing and scope of clinical practice applications to the Profession Lead for each respective profession.Directors of Allied HealthResponsible for ensuring administrative compliance and accountability for credentialing and scope of clinical practice for allied health professionals within their Division.Report the outcome of the credentialing applications within their respective Division to their Executive Director as required, and to the Chief Allied Health Officer via the Allied Health Executive.Profession LeadsResponsible for ensuring administrative compliance and accountability for credentialing within their respective profession.Assesses, verifies and approves credentialing and scope of clinical practice applications and re-credentialing applications for all allied health professionals within their profession who provide direct clinical rms the applicant’s Line Manager of the outcome of the application, and of the scope of clinical practice granted.Provide status reports for credentialing and scope of clinical practice for each relevant division to the Allied Health Profession Lead Forum as required.Profession Leads may delegate the credentialing and scope of clinical practice approval process to a senior allied health professional(s) within their discipline.Provide a copy of the credentialing application to the applicant if requested.Hiring Managers/Line ManagersResponsible for supporting the credentialing and scope of clinical practice process.Ensure allied health professionals they manage adhere to the credentialing process and submit all applications and documentation on time.Overseeing the collation of all applications within the team they manage and submit to the Profession Lead for each respective allied health discipline.Provide advice and recommendation to the Profession Lead or delegate on the assessment and verification of the applicant’s credentials and the appropriateness of the requested scope of clinical rms the Divisional Director of Allied Health of the outcome of the application, and the scope of clinical practice granted, who is to then inform the Divisional Executive Director.Line Managers may not necessarily be from the applicant’s professional allied health discipline.Allied health professionalsEnsure all required information is submitted on time for credentials to be verified and scope of clinical practice determined.Disclose the status of registration or professional membership eligibility, including any conditions, past or present suspensions, reprimands or undertakings, limitation on scope of clinical practice by another health care facility or any other matter that could reasonably be expected to be disclosed in order to make an informed decision on credentials and scope of clinical ply with re-credentialing and review of scope of clinical practice in a timely manner.At all times act in good faith.Chief Allied Health OfficeProvide support and guidance to allied health managers and allied health professionals undertaking the credentialing and defining scope of clinical practice process.Back to Table of ContentsProcess1. Initial Credentialing and Scope of Clinical PracticeApplication by Allied Health ProfessionalStep 1 – Submission of the applicationThe Allied Health Professional applies for credentialing and a scope of clinical practice on the relevant form: Allied Health Initial Credentialing Form (for new appointments and existing allied health professionals) or Allied Health External Credentialing Form (for external allied health professionals not-employed by ACT Health). For new employees, submission of the application needs to occur before the commencement of clinical duties.The Allied Health Professional attaches a complete set of documentation (credentials) to the application. It is the obligation of the Allied Health Professional to advise the Profession Lead or delegate of any conditions, undertakings or other restrictions on registration, limitations on scope of clinical practice by another health service or any other matter that the Profession Lead or delegate could reasonably expect to be disclosed in order to make an informed decision on credentials and scope of clinical practice.Allied Health Professionals who are new appointments or external to ACT Health must submit at least one referee report from a discipline peer who is independent of the applicant, holds no conflict of interest, and who can attest to the applicant’s clinical performance within the previous two years. For new graduate applicants, the Profession Lead or delegate may use discretion as to the acceptable number and type of referees. The applicant should provide reasons if the report is not from a discipline peer. The Credentialing Referee Report template is provided in the Appendices.The Allied Health Professional forwards the completed application to their Line Manager for initial checking and onward submission to the Profession Lead or delegate for the relevant profession. For new appointments, the credentialing process will be initiated by the hiring manager in consultation with Employment Services, Canberra Hospital and Health Services. External Allied Health Professionals are to submit applications to the Line Manager who will forward to the Profession Lead or delegate for their discipline.Receipt and preparation of application by the Line ManagerStep 2 – Collation of application package for Profession LeadThe Line Manager reviews the completeness of the application package, and ensures the Allied Health Professional has submitted all material before collating and forwarding to the Profession Lead or delegate for consideration.Consideration by the Profession LeadStep 3 – Verification of credentials and essential documentationThe Profession Lead or delegate must review and verify the following:Applicant’s completed form: Initial Credentialing Form (for new appointments and existing allied health professionals) or External Allied Health Professional Credentialing Form (for external allied health professionals not-employed by ACT Health).Confirm with Employment Services, Canberra Hospital and Health Services that the applicant’s identity in accordance with a national police check (for all new appointments as part of recruitment and external allied health professionals only) has been carried out.Applicant’s registration status in the appropriate category with AHPRA for registered allied health professionals; or professional association membership eligibility for self-regulating allied health professionals. Any decision regarding the applicant’s scope of clinical practice must take into account any conditions or undertakings on their registration or eligibility for professional association membership.Note: It is the obligation of the applicant to advise the Profession Lead or delegate of any conditions, undertakings or other restrictions on registration, limitation on scope of clinical practice by another health service or any other matter that the Profession Lead or delegate could reasonably expect to be disclosed in order to make an informed decision on credentials and scope of clinical practice. This must be documented on the ‘Notification Form for Conditions on Health Practitioner Registration’.Applicant’s curriculum vitae (for new appointments and external allied health professionals only).Applicant holds the primary allied health qualification mandatory to the position. Postgraduate qualifications are required only if clinically relevant to the scope of clinical practice requested. Degree qualifications or equivalent must be sighted, with a copy for secure filing.In some cases applicants may be required to demonstrate as part of initial credentialing Continuing Professional Development (CPD) consistent with registration or professional association requirements, or evidence of a self-managed CPD portfolio consistent with professional requirements. Verification of CPD is non-punitive, and the Profession Lead or delegate may use discretion as to what is appropriate for their profession. For allied health professions that do not specify minimum CPD requirements, the Profession Lead or delegate may use discretion as to the acceptable level and type of CPD activities undertaken. For new graduates, the Profession Lead or delegate may use discretion as to what is appropriate CPD. Where evidence of CPD is required as part of initial credentialing the applicant will be notified of this. Professional Indemnity Insurance (for external allied health professionals only).Referee report (for new and external allied health professionals only; or those seeking an extended scope of clinical practice) provided by the applicant (must submit at least one credentialing referee report from a discipline peer who is independent of the applicant, holds no conflict of interest, and who can attest to the applicant’s clinical performance within the previous two years). For new graduate applicants, the Profession Lead or delegate may use discretion as to the acceptable number and type of referees. The applicant should provide reasons if the report is not from a discipline peer. The Credentialing Referee Report template is provided in the Appendices.A Working with Vulnerable People Check for self-regulated applicants where the positions requires it.Other licensing requirements or credentials as determined by the Profession Lead or delegate (for example, a radiation licence for relevant professions).Applicants are required to sign a completed declaration regarding employment, registration and membership restrictions, and the accuracy of information provided.Step 4 – Profession Lead approval of initial credentialing and scope of clinical practiceThe Profession Lead or delegate should request further information from the applicant where there is insufficient information to support the requested scope of clinical practice.The Profession Lead or delegate considers all aspects of the application, and if satisfied, the applicant’s credentials and requested scope of clinical practice will be approved in relation to:Scope of Clinical PracticeThe approval must reflect any conditions or undertakings imposed on the applicant by AHPRA, or by the relevant professional association.Duration of Scope of Clinical PracticeThe approval must include a specified period for the scope of clinical practice of not more than eighteen months and with a defined end date.Variation recommended by the Profession LeadWhere the Profession Lead or delegate proposes to make a recommendation that a scope of clinical practice is to be changed from that applied for and the change is likely to be detrimental to the Allied Health Professional, the Profession Lead or delegate will provide to the applicant, in writing if requested, the reasons for the proposed change and afford them the opportunity to make a submission within fourteen (14) days about the proposed change.The Profession Lead or delegate should establish appropriate processes to maintain relevant credentialing data and accurate file records for information management, retrieval and auditing purposes.The Profession Lead or delegate must notify the Chief Allied Health Officer and the applicant’s Line Manager of the decision in relation to the outcome of initial credentialing and scope of clinical practice. The Line Manager will then notify the Divisional Director of Allied Health, who will notify the Divisional Executive Director of the credentialing outcome as and when required.The Profession Lead or delegate will table credentialing and scope of clinical practice application approvals at the Allied Health Profession Lead Forum for endorsement. This will include any proposed limitations (such as supervision requirements, conditions or undertakings on registration or professional membership eligibility) and will specify the period until planned re-credentialing and review of scope of clinical practice is due.Credentialing applications for Profession Leads and for allied health professionals who are sole practitioners within their discipline will be administered through the Chief Allied Health Office. The Chief Allied Health Officer or their delegate will source a suitable discipline-specific senior allied health professional to undertake the assessment of credentials and determine scope of clinical practice. Where necessary, an external profession-specific senior allied health professional may be approached to undertake the assessment of credentials.2. Re-credentialing and Review of Scope of Clinical PracticePlanned re-credentialing and review of scope of clinical practice for allied health professionals occurs annually. Re-credentialing for registered allied health professionals occurs in November each year in line with the Annual Renewal of Registration for allied health professionals covered by the National Registration and Accreditation Scheme. For self-regulated allied health professionals, re-credentialing occurs in May. Re-credentialing and review of scope of clinical practice provides that the credentials for each allied health professional remains current and relevant and that the Allied Health Professional remains competent to provide the defined scope of clinical practice.Notification by the Profession Lead of Planned Re-credentialing DateStep 1 – Reminder to the Allied Health ProfessionalEight (8) weeks prior to the planned re-credentialing date, the Profession Lead or delegate notifies the Allied Health Professional of the date by which planned re-credentialing is to be completed.Allied Health Professional applies for re-credentialing and review of scope of clinical practiceStep 2 – Submission of applicationThe Allied Health Professional applies for re-credentialing and review of scope of clinical practice on the form: Allied Health Re-credentialing Application Form (for existing allied health professionals previously credentialed). External Allied Health Professionals are to use the Allied Health External Application Form.The planned re-credentialing application must be fully completed, signed and include current evidence of CPD as well as any other information pertinent to review of credentials.Non-compliance with planned re-credentialing and review of scope of clinical practice will be referred to the Chief Allied Health Officer. For the purpose of this procedure, non-compliance is defined as: no response within thirty (30) days past the scheduled review date.The Allied Health Professional forwards the completed application to their Line Manager for initial checking and onward submission to the Profession Lead or delegate for the relevant profession. External Allied Health Professionals are to submit applications to the Line Manager who will forward to the Profession Lead or delegate for their discipline.Receipt and preparation of application by the Line ManagerStep 3 – Collation of application package for Profession LeadThe Line Manager reviews the completeness of the application package, and ensures the Allied Health Professional has submitted all material before collating and forwarding to the Profession Lead or delegate for consideration.Consideration by the Profession LeadStep 4 – Re-credentialingThe Profession Lead must review and verify the following:Applicant’s completed form: Allied Health Re-credentialing Application Form (for existing allied health professionals) or Allied Health External Application Form (for external allied health professionals not employed by ACT Health).Applicant’s registration status in the appropriate category with AHPRA for registered allied health professions; or professional association membership eligibility for self-regulated allied health professions. Any decision regarding the applicant’s scope of clinical practice must take into account any conditions or undertakings on their registration or eligibility for professional association membership.Note: It is the obligation of the applicant to advise the Profession Lead or delegate of any conditions, undertakings or other restrictions on registration, limitation on scope of clinical practice by another health service or any other matter that the Profession Lead or delegate could reasonably expect to be disclosed in order to make an informed decision on credentials and scope of clinical practice. This must be documented on the “Conditions or Undertakings on Practice Notification Report”.Applicant is to demonstrate Continuing Professional Development (CPD) consistent with registration or professional association requirements, or evidence of a self-managed CPD portfolio consistent with professional requirements. Verification of CPD is non-punitive, and the Profession Lead or delegate may use discretion as to what is appropriate for their profession. For allied health professions that do not specify minimum CPD requirements, the Profession Lead or delegate may use discretion as to the acceptable level and type of CPD activities undertaken.Professional Indemnity Insurance (for external allied health professionals only).A Working with Vulnerable People Check for self-regulated applicants where the positions requires it.Other licensing requirements or credentials as required and determined by the Profession Lead or delegate (for example, current radiation licence for the relevant professions).Applicants are required to sign a completed declaration regarding employment, registration and membership restrictions, and the accuracy of information provided.Note: Applicant’s curriculum vitae, post graduate qualification(s) gained or referee reports are only required at re-credentialing if a change to scope of clinical practice is requested (for example, an application for extended scope of clinical practice).Step 5 – Profession Lead approval of re-credentialing and review of scope of clinical practiceThe Profession Lead or delegate should request further information from the applicant where there is insufficient information to support the requested scope of clinical practice.The Profession Lead or delegate considers all aspects of the re-credentialing application, and if satisfied, the applicant’s re-credentialing and requested scope of clinical practice will be approved in relation to:Scope of Clinical PracticeThe approval must reflect any conditions or undertakings imposed on the applicant by AHPRA, or by the relevant professional association.Duration of Scope of Clinical PracticeThe approval must include a specified period for the scope of clinical practice of not more than one (1) year with a defined end date.Variation recommended by the Profession LeadWhere the Profession Lead or delegate proposes to make a recommendation that a scope of clinical practice is to be changed from that applied for and the change is likely to be detrimental to the Allied Health Professional, the Profession Lead or delegate will provide to the applicant, in writing if requested, the reasons for the proposed change and afford them the opportunity to make a submission within fourteen (14) days about the proposed change.The Profession Lead or delegate should maintain relevant re-credentialing data and accurate file records for information management, retrieval and auditing purposes.The Profession Lead or delegate must notify the Chief Allied Health Officer and the applicant’s Line Manager of the decision in relation to the outcome of re-credentialing and review of scope of clinical practice. The Line Manager will then notify the Divisional Director of Allied Health, who will notify the Divisional Executive Director of the credentialing outcome as and when required.The Profession Lead or delegate will table re-credentialing and review of scope of clinical practice application approvals at the Allied Health Profession Lead Forum for endorsement. This will include any proposed limitations (such as supervision requirements, conditions or undertakings on registration or professional membership eligibility) and will specify the period until planned re-credentialing and review of scope of clinical practice is due.Credentialing applications for Profession Leads and for allied health professionals who are sole practitioners within their discipline will be administered through the Chief Allied Health Office. The Chief Allied Health Officer or their delegate will source a suitable discipline-specific senior allied health professional to undertake the assessment of credentials and determine scope of clinical practice. Where necessary, an external profession-specific senior allied health professional may be approached to undertake the assessment of credentials.Back to Table of ContentsAppeals process An Allied Health Professional who has had their credentialing and scope of clinical practice declined, withheld or varied from the original request, has a right to request a review of the decision in writing to the Chief Allied Health Officer within fourteen (14) days of receipt of the decision. The Allied Health Professional will be given the opportunity to provide further information that was not previously submitted for consideration which may be relevant to the decision. The Chief Allied Health Officer will convene an Allied Health Credentialing (Appeal) Committee as required to hear the appeal. The appeal process will allow for reconsideration of any decision previously made.Back to Table of ContentsImplementation and ReportingThis procedure will be implemented in a staged fashion. The procedure will be rolled out in the following order – credentialing for:new allied health employees being employed into Canberra Hospital and Health Services; existing allied health staff from non AHPRA registered groups; existing allied health staff from AHPRA registered groups; andexternal allied health professionals. The Chief Allied Health Office is responsible for communicating about the progress of the implementation of this procedure to the allied health workforce and to the Deputy Director-General, Canberra Hospital and Health Services. The Chief Allied Health Officer via the Allied Health Profession Lead Forum will oversee the monitoring and reporting of credentialing and scope of clinical practice processes. The Profession Lead or delegate for each discipline will provide credentialing status updates for their profession through confidential written reports to the Chief Allied Health Officer for endorsement via the Allied Health Profession Lead Forum, having established appropriate processes to demonstrate accountability for ensuring systems are in place for credentialing and scope of clinical practice across the divisions in which their profession is represented.Following implementation, the Chief Allied Health Officer will provide written advice to the Deputy Director-General, Canberra Hospital and Health Services no later than 5 working days after 30 June outlining the credentialing status of self-regulated allied health professionals; and no later than 5 working days after 30 December outlining the credentialing and registration status of registered allied health professionals.Back to Table of ContentsMonitoring and ComplianceOutcome MeasureAll identified allied health professionals providing direct clinical care are credentialed and hold an appropriate scope of clinical practice at initial appointment, and through planned re-credentialing.MethodThe Chief Allied Health Officer will ensure processes are established and implemented to examine, record and review the credentials of allied health professionals providing direct clinical care to patients and consumers.Regular reports will be utilised by the Chief Allied Health Officer to review compliance with this procedure and any recommendations for improvement.There will be an annual report of allied health credentialing and scope of clinical practice performance and outcomes. This will include:Total number of registered allied health professionals with annually authenticated credentials by 30 November each year.Total number of self-regulated allied health professionals with annually authenticated credentials by 30 May each plianceAll independent Allied Health Professionals providing direct clinical care to patients and consumers in ACT Health are to have undergone the credentialing process and have a defined scope of clinical practice. Where an allied health professional refuses to comply with this procedure, the Profession Lead or delegate will advise the Chief Allied Health Officer in writing. The Chief Allied Health Officer will formally write to the applicant requesting submission of their application. The Allied Health Professional will have fourteen (14) days to respond to this request.If the response is considered unsatisfactory, the Chief Allied Health Officer may recommend to the Deputy Director-General, Canberra Hospital and Health Services, restriction or suspension of the Allied Health Professional’s scope of clinical practice until the necessary documentation is provided. The Chief Allied Health Officer will inform the Allied Health Professional in writing of the determination and of the appropriate Appeals Process.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationLegislationAustralian Capital Territory Health Professionals Act 2004Australian Human Rights Commission Act 1986Discrimination Act 1991Health Practitioner Regulation National Law 2010 (ACT)Health Practitioner Regulation National Law Act 2009Public Sector Management Act 1994PoliciesAnnual Renewal of Professional Registration – Allied Health Standard Operating ProcedureAnnual Renewal of Professional Registration PolicyAppeal Mechanism Standard Operating ProcedureConditions or Undertakings on Practice Notification Report FormIntroduction of New Technology PolicyReview of Credentials and Defining of Scope of Clinical Practice prior to the Introduction of New Health Technologies Standard Operating ProcedureStandards Australian Council on Safety and Quality in Health Care, Standard for Credentialing and Defining the Scope of Clinical Practice 2004Public Sector Management Standards 2006Certified AgreementsACT Public Sector Health Professionals Enterprise Agreement 2013-2017Back to Table of ContentsReferencesAustralian Commission of Safety and Quality in Health Care, Safety and Quality Improvement Guideline October 2012, Standard 1: Governance for Safety and Quality in Health Service Organisations.National Standard for Credentialing and Scope of Clinical Practice. Australian Council on Safety and Quality in Health Care, 2004.Standard Operating Procedure (SOP): Credentialing and Defining the Scope of Clinical Practice for Senior Medical and Dental Practitioners.Back to Table of ContentsDefinition of Terms In this procedure, unless otherwise indicated:Appointment – the employment or engagement of an allied health professional to provide services within an organisation according to conditions defined by general law and supplemented by contract.Allied Health Professional – this procedure applies to the following allied health professionals who provide direct clinical care within ACT Health facilities. Registered Allied Health Professionals: dental prosthetists, dental therapists, nuclear medicine technologists, oral health therapists, occupational therapists, pharmacists, physiotherapists, podiatrists, psychologists, radiation therapists and radiographers. Self-regulated Allied Health Professionals: Allied health assistants, art therapists, audiologists, cardiac perfusionists, cardiac technologists, counsellors, dietitians, exercise physiologists, genetic counsellors, neurophysiologists, orthoptists, prosthetists and orthotists, respiratory scientists, sleep scientists, social workers, sonographers and speech pathologists. Note: the following ACT Health allied health professional disciplines are outside the scope of the procedure: allied health assistants, analytical scientists, biomedical engineers, environmental health scientists, medical laboratory scientists, medical physicists and public health nutritionists. Clinical Practice – the professional activity undertaken by allied health professionals for the purposes of investigating patient symptoms and preventing and/or managing illness, together with associated professional activities related to patient care.Clinician – a healthcare provider, trained as a health professional. Clinicians include registered and non-registered practitioners, or a team of health professionals providing health care who spend the majority of their time providing direct clinical care.Credentialing – the formal process used to verify the qualifications, experience, professional standing and other relevant professional attributes of an allied health professional for the purposes of forming a view about the competence, performance and professional suitability of the allied health professional to provide safe, high quality health care services within a specific organisational environment.Credentials – the qualifications, professional training, clinical experience, research, education, communication and teamwork that contribute to an allied health professionals competence, performance and professional suitability to provide safe, high quality health care services. For the purposes of this procedure, an allied health professional’s history of, and current status with respect to, professional registration, disciplinary actions, indemnity insurance and criminal record are also regarded as relevant to their credentials.Delegate – is a representative(s) of the Profession Lead’s own choosing, who is authorised to verify and approve the credentials and defined scope of clinical practice of allied health professionals in their own discipline.Defining the Scope of Clinical Practice – delineating the extent of an individual allied health professionals clinical practice within a particular organisation based on the individuals credentials, competence, performance and professional suitability, and the needs and capability of the organisation to support the allied health professional’s scope of clinical practice.Extended Scope of Clinical Practice – is the range of evidence-based roles and tasks that maximise the health professional’s scope of clinical practice, involving extending the scope of clinical practice of specific professions; it describes a discrete knowledge and skill base in addition to the recognised core scope of a profession and the regulatory context of a particular jurisdiction.Professional Standing – is the recognition of a health practitioner to be of good professional repute and character; practicing a high degree of ethical conduct; widely respected by peers; and demonstrates a commitment to continuing professional development and clinical practice advancement.Re-credentialing – the formal process used to reconfirm the qualifications, experience and professional standing (including history of current status with respect to professional registration, professional association eligibility, disciplinary actions, indemnity insurance and criminal record) of allied health professionals, for the purpose of forming a view about their ongoing competence, performance and professional suitability to provide safe, high quality health care services within specific organisational environments.Scope of Clinical Practice – the authorised extent of an individual allied health professional’s clinical practice within a particular organisation based on the individual’s credentials, competence, performance and professional suitability and the needs and capability of the organisation to support the clinician’s scope of clinical practice.Back to Table of ContentsAppendicesAppendix 1: Initial Application FormAppendix 2: Re-credentialing Application FormAppendix 3: External Application FormAppendix 4: Credentialing Referee ReportDisclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Date AmendedSection AmendedApproved By25 Oct 2016Appendices – Alert Added noting the forms are currently under reviewManager – Policy, Data and Quality Assurance Team11 Dec 2017Minor updatesJo Morris, Ag Chief Allied Health OfficerAppendix 1ACT HEALTH ALLIED HEALTH PROFESSIONALSCredentialing and Scope of Clinical Practice – Initial Application FormPlease note that this form is a sample only. Please contact AHCredentialing@.au for the latest version of the allied health credentialing form that is relevant to your individual circumstances. Application for new appointments and existing Allied Health Professionals within ACT HealthThe ACT Health Procedure for Credentialing and Defining the Scope of Clinical Practice for Allied Health Professionals recognises two categories of Allied Health Professionals that are required to complete the application process for initial credentialing and scope of clinical practice:1. Registered Allied Health Professionals must satisfy the requirements of a National Board to practise clinically or provide clinical supervision. The relevant ACT Health Allied Health Professions include: Dental Prosthetics, Dental Therapy, Nuclear Medicine Technology, Occupational Therapy, Oral Health Therapy, Pharmacy, Physiotherapy, Podiatry, Psychology, Radiation Therapy and Radiography.2. Self-Regulated Allied Health Professionals hold a relevant allied health qualification providing eligibility for membership of a Professional Association. The relevant ACT Health Allied Health Professions include: Art Therapy, Audiology, Cardiac Science, Counselling, Dietetics, Exercise Physiology, Genetic Counselling, Neurophysiology Technology, Orthoptics, Prosthetics and Orthotics, Respiratory Science, Sleep Science, Social Work, Sonography and Speech Pathology.OFFICE USE ONLYApplication recorded: Yes FORMCHECKBOX No FORMCHECKBOX Date: / /Name: Position:Signature:SECTIONS 1 – 7: TO BE COMPLETED BY THE APPLICANTSECTION 1 – APPLICANT’S DETAILSNote: Please ensure that your name(s) reflects that which is published on any national register for your profession.SurnameGiven name(s)Previous name(s)Date of birthPlace of birthPostal addressPhoneMobileEmail SECTION 2 – PRE-EMPLOYMENT CHECKS AND QUALIFICATIONSConfirmProvidedNational Police Check: (For new appointments only)Application made as part of recruitment process: FORMCHECKBOX Application not yet made: FORMCHECKBOX Working with Vulnerable People Check: (Where required for self-regulated professions)Application made as part of recruitment process: FORMCHECKBOX Application not yet made: FORMCHECKBOX Evidence of qualifications* Certified copy of primary allied health qualification or equivalent (if not previously provided) and postgraduate qualifications (where relevant).*For new graduates who have not yet graduated, a letter from your academic institution is required confirming that you have satisfied all requirements for the award for which you studied. FORMCHECKBOX N/A FORMCHECKBOX N/A FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX NON-AUSTRALIAN RESIDENTS ONLY: Do you require a Work Visa to practise in Australia? FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX Yes SCOPE OF CLINICAL PRACTICEPlease list the profession(s) in which you are seeking core scope of clinical practice:____________________________________________________________________________________________________________________________________________________________________________________________________ REGISTRATION OR PROFESSIONAL ASSOCIATION MEMBERSHIP ELIGIBILITY: FORMCHECKBOX Registered Profession(s): _________________________________________________________________Registration Number: ___________________ Registration Type: ________________________Expiry Date: / / Endorsements: __________________________FOR MEDICAL RADIATION/DENTAL/SONOGRAPHY PROFESSIONS: Location Specific Practice Number recorded: __________________Current radiation licence number: __________________________Australian Sonographer Accreditation Registry (ASAR) registration number: ________________ FORMCHECKBOX Self-Regulated Profession(s): _______________________________________________________________Professional Association: ______________________________________________________Eligible for Membership: Yes FORMCHECKBOX No: FORMCHECKBOX Membership Number (if a member): ____________________________________________Expiry Date: / / Are you accredited with a professional association: FORMCHECKBOX Yes FORMCHECKBOX No (Please specify): ______________________________________________________________________________________________________________________________________Expiry Date: / / SECTION 3 - ADDITIONAL INFORMATIONConfirmProvidedCurrent Practising Status:Does your position or the position for which you have applied include any clinical responsibility (e.g. direct patient care or clinical supervision)? FORMCHECKBOX Yes FORMCHECKBOX NoCurriculum Vitae: (For new appointments only if not previously provided) FORMCHECKBOX N/A FORMCHECKBOX Continuing Professional Development:Please provide evidence of completed CPD over the past 12 months as part of registration requirements, professional association requirements, or as part of a self-managed CPD portfolio consistent with professional requirements. FORMCHECKBOX Credentialing Referee Report (For new appointments only; or those seeking extended scope of clinical practice)Please attach a credentialing referee report from a discipline peer as part of your application.Attached: Yes FORMCHECKBOX No FORMCHECKBOX Comments: _____________________________________________ FORMCHECKBOX N/A FORMCHECKBOX FORMCHECKBOX SECTION 4 – EXTENDED SCOPE OF CLINICAL PRACTICEOnly include details of clinical practice specific to extended scope of clinical practice that you are qualified to perform (provide copies qualifications where relevant). FORMCHECKBOX N/AAreas of clinical practiceQualification completedDatecompletedCopy provided FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX SECTION 5 – LIMITED SCOPE OF CLINICAL PRACTICEHas your scope of clinical practice been limited, or do you wish to limit your scope of clinical practice for any reason? If yes, please specify why: FORMCHECKBOX Yes FORMCHECKBOX NoSECTION 6 – CONFIDENTIAL PROFESSIONAL INFORMATIONHave you ever been denied registration or professional association membership? Are there any restrictions or special conditions placed on your registration or professional association membership? Have any claims, investigation or lawsuits for malpractice been made against you? Has your scope of clinical practice or appointment at any health service been reduced, suspended or revoked, or have you had any conditions attached to your previous appointments for any reason? Is there any other information regarding your ability to practise that should be declared? If yes to any of the above, please attach details. FORMCHECKBOX FORMCHECKBOX Yes FORMCHECKBOX Yes FORMCHECKBOX Yes FORMCHECKBOX Yes FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX NoSECTION 7 – DECLARATION BY APPLICANTTo the best of my knowledge, the information provided in this application is true and correct. I understand that any incorrect statement may result in refusal in granting or the withdrawal of existing credentials. I authorise my Profession Lead or delegate to seek information relating to my credentials and experience as relevant to my application.I agree to inform ACT Health of any complaint made about my professional conduct or of any change in my registration or professional membership eligibility status.I understand that the information referred to in this application will be securely stored, and can be accessed as required by the Profession Lead and Chief Allied Health Officer or nominated delegates.Signature: ________________________________________Date: / /Name: ___________________________________________Position: _________________________________________SECTIONS 8 – 9: TO BE COMPLETED BY PROFESSION LEAD OR DELEGATESECTION 8 – CONFIRMATION OF CREDENTIALSConfirmReceivedRegistered ProfessionsCopy of relevant qualifications receivedNational Board registration confirmed on AHPRA website:Date of sighting: / / Has the National Board placed any restrictions on the applicant’s practice or registration?If yes, provide details:________________________________________________________________________________________________________________FOR MEDICAL RADIATION/DENTAL/SONOGRAPHY PROFESSIONS:Location Specific Practice Number recordedCurrent radiation licence sighted and number recordedAustralian Sonographer Accreditation Registry (ASAR) registration number recorded FORMCHECKBOX FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Self-regulating professionsCopy of relevant qualifications receivedEligible for Professional MembershipProfessional Membership details received FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX N/AContinuing Professional DevelopmentHas the applicant demonstrated CPD as part of their registration requirements, professional association requirements, or as part of a self-managed CPD portfolio consistent with professional ments:___________________________________________________________________________________________________________________________ FORMCHECKBOX FORMCHECKBOX Yes FORMCHECKBOX NoCredentialing Referee Report (For new appointments; and those seeking extended scope of clinical practice)A credentialing referee report has been received from the applicant’s referee. FORMCHECKBOX FORMCHECKBOX PART 9 - APPROVAL BY PROFESSION LEAD OR DELEGATEOn completion of all aspects of the Procedure for Credentialing and Defining the Scope of Clinical Practice for Allied Health Professionals, I am satisfied that the applicant has the appropriate credentials and registration or professional membership eligibility to undertake the scope of clinical practice for the position for which they are being employed or are currently employed within ACT Health. YES FORMCHECKBOX NO FORMCHECKBOX (If no, provide details) __________________________________________________________The scope of clinical practice requested is granted for: 1 YEAR FORMCHECKBOX LESS THAN 1 YEAR FORMCHECKBOX (Specify) ______ monthsApproved by the Profession Lead or delegate: YES FORMCHECKBOX NO FORMCHECKBOX Signed: ___________________________________________Date: / /Name: ____________________________________________Position: __________________________________________Note: The duration of the credentialing and scope of clinical practice approval is one year, subject to satisfactory renewal of registration or professional membership eligibility where appropriate, or a lesser time as determined by the Profession Leador delegate.DATE DUE FOR RE-CREDENTIALING: / /A copy of the application is to be provided to the applicant on request. The original application and associated documents are either to be kept on secure paper file or electronically scanned for monitoring and reporting.Appendix 2ACT HEALTH ALLIED HEALTH PROFESSIONALSCredentialing and Scope of Clinical Practice – Re-credentialing Application FormPlease note that this form is a sample only. Please contact AHCredentialing@.au for the latest version of the allied health credentialing form that is relevant to your individual circumstancesApplication for re-credentialing of allied health professionalsThe ACT Health Procedure for Credentialing and Defining the Scope of Clinical Practice for Allied Health Professionals recognises two categories of Allied Health Professionals that are required to complete the application process for re-credentialing:1. Registered Allied Health Professionals must satisfy the requirements of a National Board to practise clinically or provide clinical supervision. The relevant ACT Health Allied Health Professions include: Dental Prosthetics, Dental Therapy, Nuclear Medicine Technology, Occupational Therapy, Oral Health Therapy, Pharmacy, Physiotherapy, Podiatry, Psychology, Radiation Therapy and Radiography.2. Self-Regulated Allied Health Professionals hold a relevant allied health qualification providing eligibility for membership of a Professional Association. The relevant ACT Health Allied Health Professions include: Art Therapy, Audiology, Cardiac Science, Counselling, Dietetics, Exercise Physiology, Genetic Counselling, Neurophysiology Technology, Orthoptics, Prosthetics and Orthotics, Respiratory Science, Sleep Science, Social Work, Sonography and Speech Pathology.OFFICE USE ONLYApplication recorded: Yes FORMCHECKBOX No FORMCHECKBOX Date: / /Name: Position:Signature:SECTIONS 1 – 7: TO BE COMPLETED BY THE APPLICANTSECTION 1 – APPLICANT’S DETAILSNote: Please ensure that your name(s) reflects that which is published on any national register for your profession.SurnameGiven name/sPrevious name/sDate of birthPlace of birthPostal addressPhoneMobileEmail address SECTION 2 – RE-CREDENTIALING DETAILSConfirmProvidedPREVIOUSLY CREDENTIALED: Yes FORMCHECKBOX No FORMCHECKBOX (Complete the Initial Application Form) Date of previous approval: / /NATURE OF RE-CREDENTIALINGI wish to re-apply for the defined scope of clinical practice that I was previously granted with no changesORI wish to apply for an extended scope of clinical practice to that which I was previously granted ORI wish to limit the scope of clinical practice that I was previously granted.Current Practising StatusDoes your position or the position for which you have applied include any clinical responsibility (e.g. direct patient care or clinical supervision)? Working with Vulnerable People Check (Where required for self-regulated professions)Issued: FORMCHECKBOX Date of issue: / / Current: Yes FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A SCOPE OF CLINICAL PRACTICEPlease list the profession(s) in which you are seeking core scope of clinical practice:____________________________________________________________________________________________________________________________________________________________________________________________________ REGISTRATION OR PROFESSIONAL ASSOCIATION MEMBERSHIP ELIGIBILITY: FORMCHECKBOX Registered Profession(s): _________________________________________________________________Registration Number: ___________________ Registration Type:________________________ Expiry Date: / / Endorsements: __________________________FOR MEDICAL RADIATION/DENTAL/SONOGRAPHY PROFESSIONS: Location Specific Practice Number recorded: __________________Current radiation licence number: __________________________Australian Sonographer Accreditation Registry (ASAR) registration number: ________________ FORMCHECKBOX Self-Regulated Profession(s): _______________________________________________________________Professional Association: ______________________________________________________Eligible for Membership: Yes FORMCHECKBOX No: FORMCHECKBOX Membership Number (if a member): ____________________________________________Expiry Date: / / Are you accredited with a professional association: FORMCHECKBOX Yes FORMCHECKBOX No (Please specify): ______________________________________________________________________________________________________________________________________Expiry Date: / / SECTION 3 – ADDITIONAL INFORMATIONConfirmProvidedCurriculum Vitae (only required if requesting a change to scope of clinical practice) FORMCHECKBOX Continuing Professional DevelopmentPlease provide evidence of completed CPD over the past 12 months as part of registration requirements, professional association requirements, or as part of a self-managed CPD portfolio consistent with professional requirements. FORMCHECKBOX Credentialing Referee Report (For those seeking extended scope of clinical practice only)Please attach a credentialing referee report from a discipline peer as part of your application.Attached: Yes FORMCHECKBOX No FORMCHECKBOX Comments: _____________________________________________ FORMCHECKBOX N/A FORMCHECKBOX FORMCHECKBOX SECTION 4 – EXTENDED SCOPE OF CLINICAL PRACTICEInclude only details of clinical practice that you are qualified to perform beyond your primary allied health qualification, this includes advanced and extended scopes of clinical practice (provide copies qualifications/training where relevant).Areas of clinical practiceQualification or training completedDateCompletedCopy provided FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX SECTION 5 – LIMITED SCOPE OF CLINICAL PRACTICEHas your scope of clinical practice been limited, or do you wish to limit your scope of clinical practice for any reason? If yes, please specify why: FORMCHECKBOX Yes FORMCHECKBOX NoSECTION 6 – CONFIDENTIAL PROFESSIONAL INFORMATIONHave you ever been denied registration or professional association membership? Are there any restrictions or special conditions placed on your registration or professional association membership? Have any claims, investigation or lawsuits for malpractice been made against you? Has your scope of clinical practice or appointment at any health service been reduced, suspended or revoked, or have you had any conditions attached to your previous appointments for any reason? Is there any other information regarding your ability to practise that should be declared? If yes to any of the above, please attach details. FORMCHECKBOX FORMCHECKBOX Yes FORMCHECKBOX Yes FORMCHECKBOX Yes FORMCHECKBOX Yes FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX NoSECTION 7 – DECLARATION BY APPLICANTTo the best of my knowledge, the information provided in this application is true and correct. I understand that any incorrect statement may result in refusal in granting or the withdrawal of existing credentials. I authorise my Profession Lead or delegate to seek information relating to my credentials and experience as relevant to my application.I agree to inform ACT Health of any complaint made about my professional conduct or of any change in my registration or professional membership eligibility status.I understand that the information referred to in this application will be securely stored, and can be accessed as required by the Profession Lead and Chief Allied Health Officer or nominated delegates.Signature: ________________________________________Date: / /Name: ___________________________________________Position: _________________________________________SECTIONS 8 – 9: TO BE COMPLETED BY PROFESSION LEAD OR DELEGATESECTION 8 – CONFIRMATION OF CREDENTIALSConfirmReceivedRegistered Professions National Board registration confirmed on AHPRA website:Date of sighting: / / Has the National Board placed any restrictions on the applicant’s practice or registration?If yes, provide details:________________________________________________________________________________________________________________FOR MEDICAL RADIATION/DENTAL/SONOGRAPHY PROFESSIONS:Location Specific Practice Number recordedCurrent radiation licence sighted and number recordedAustralian Sonographer Accreditation Registry (ASAR) registration number recorded FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Self-regulating professionsEligible for Professional Membership:Professional Membership details received: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX N/AContinuing Professional DevelopmentHas the applicant demonstrated CPD over the past 12 months consistent with their registration requirements, professional association requirements, or as part of a self-managed CPD portfolio consistent with professional requirements?Comments:____________________________________________________________________________________________________________________________ FORMCHECKBOX FORMCHECKBOX Yes FORMCHECKBOX NoCredentialing Referee Reports (For those seeking extended scope of clinical practice only)A credentialing referee report has been received from the applicant’s referee. FORMCHECKBOX FORMCHECKBOX SECTION 9 – APPROVAL BY PROFESSION LEAD OR DELEGATEOn completion of all aspects of the Procedure for Credentialing and Defining the Scope of Clinical Practice for Allied Health Professionals, I am satisfied that the applicant has the appropriate credentials and registration, or professional membership eligibility to undertake the scope of clinical practice for the position for which they are currently employed within ACT Health. YES FORMCHECKBOX NO FORMCHECKBOX (If no, provide details) ________________________________________________________The scope of clinical practice requested is granted for: 1 YEAR FORMCHECKBOX LESS THAN 1 YEAR FORMCHECKBOX (Specify) ______ monthsApproved by the Profession Lead or delegate: YES FORMCHECKBOX NO FORMCHECKBOX Signed: ___________________________________________Date: / /Name: ____________________________________________Position: __________________________________________Note: The duration of the credentialing and scope of clinical practice approval is one year, subject to satisfactory renewal of registration or professional membership eligibility where appropriate, or a lesser time as determined by the Profession Leador delegate.DATE DUE FOR RE-CREDENTIALING: / /A copy of the application is to be provided to the applicant on request. The original application and associated documents are either to be kept on secure paper file or electronically scanned for monitoring and reporting.Appendix 3ACT HEALTH EXTERNAL ALLIED HEALTH PROFESSIONALSCredentialing and Scope of Clinical Practice – External Application FormPlease note that this form is a sample only. Please contact AHCredentialing@.au for the latest version of the allied health credentialing form that is relevant to your individual circumstances Application for external allied health professionals (not-employed by ACT Health) providing clinical services within ACT Health facilitiesThis form is used for initial credentialing and re-credentialing of external allied health professionals.External Allied Health Professionals working within ACT Health facilities are required to comply with the ACT Health Procedure for Credentialing and Defining the Scope of Clinical Practice for Allied Health Professionals. The procedure recognises two categories of Allied Health Professionals that are required to complete the application process for credentialing and scope of clinical practice:1. Registered Allied Health Professionals must satisfy the requirements of a National Board to practise clinically or provide clinical supervision. The relevant ACT Health Allied Health Professions include: Dental Prosthetics, Dental Therapy, Nuclear Medicine Technology, Occupational Therapy, Oral Health Therapy, Pharmacy, Physiotherapy, Podiatry, Psychology, Radiation Therapy and Radiography.2. Self-Regulated Allied Health Professionals hold a relevant allied health qualification providing eligibility for membership of a Professional Association. The relevant ACT Health Allied Health Professions include: Art Therapy, Audiology, Cardiac Science, Counselling, Dietetics, Exercise Physiology, Genetic Counselling, Neurophysiology Technology, Orthoptics, Prosthetics and Orthotics, Respiratory Science, Sleep Science, Social Work, Sonography and Speech Pathology.OFFICE USE ONLYApplication recorded: Yes FORMCHECKBOX No FORMCHECKBOX Date: / /Name: Position:Signature:SECTIONS 1 – 7: TO BE COMPLETED BY EXTERNAL ALLIED HEALTH PROFESSIONALSECTION 1 – APPLICANT’S DETAILSNote: Please ensure that your name(s) reflects that which is published on any national register for your profession.SurnameGiven name(s)Previous name(s)Date of birthPlace of birthPostal addressPhoneMobileEmailPURPOSE OF SEEKING ACCESS TO PROVIDE CLINICAL SERVICES WITHIN ACT HEALTH FACILTIES:Locum or agency allied health professional seeking to provide clinical services to patients within Canberra Hospital and Health Services facilities FORMCHECKBOX Yes FORMCHECKBOX NoORPrivate allied health professional providing clinical services to patients within Canberra Hospital and Health Services facilities FORMCHECKBOX Yes FORMCHECKBOX NoORProviding clinical supervision involving direct patient care to staff or students within Canberra Hospital and Health Services FORMCHECKBOX Yes FORMCHECKBOX NoORAcademic seeking honorary appointment within Canberra Hospital and Health Services FORMCHECKBOX Yes FORMCHECKBOX NoOROther ACT Government Directorate employee, non-government organisation, or organisation not otherwise stated seeking to provide clinical services within Canberra Hospital and Health Services FORMCHECKBOX Yes FORMCHECKBOX NoOR Other FORMCHECKBOX Yes FORMCHECKBOX No (Please specify): __________________________________________________________________PREVIOUSLY CREDENTIALED WITH ACT HEALTH: FORMCHECKBOX YES FORMCHECKBOX NODate of previous approval: / / SECTION 2 – CRIMINAL HISTORY AND QUALIFICATIONSConfirmProvidedNational Police Check:Application has been made/pending: FORMCHECKBOX Application not yet made: FORMCHECKBOX Working with Vulnerable People Check: (Where required for self-regulated professions)Application has been made/pending: FORMCHECKBOX Application not yet made: FORMCHECKBOX Evidence of qualifications Certified copy of primary allied health qualification or equivalent (if not previously provided) and postgraduate qualifications (where relevant). FORMCHECKBOX N/A FORMCHECKBOX N/A FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX SCOPE OF CLINICAL PRACTICEPlease list the profession(s) in which you are seeking the core scope of clinical practice:____________________________________________________________________________________________________________________________________________________________________________________________________ REGISTRATION AND PROFESSIONAL ASSOCIATION MEMBERSHIP ELIGIBILITY: FORMCHECKBOX Registered Profession(s): _________________________________________________________________Registration Number: ___________________ Registration Type:________________________ Expiry Date: / / Endorsements: __________________________FOR MEDICAL RADIATION/DENTAL/SONOGRAPHY PROFESSIONS: Location Specific Practice Number recorded: __________________Current radiation licence number: __________________________Australian Sonographer Accreditation Registry (ASAR) registration number: ________________ FORMCHECKBOX Self-RegulatedProfession(s): _______________________________________________________________Professional Association: ______________________________________________________Eligible for Membership: Yes FORMCHECKBOX No: FORMCHECKBOX Membership Number (if a member): ____________________________________________Expiry Date: / / Are you accredited with a professional association: FORMCHECKBOX Yes FORMCHECKBOX No (Please specify): ______________________________________________________________________________________________________________________________________Expiry Date: / / SECTION 3 – ADDITIONAL INFORMATIONConfirmProvidedCurrent Practising Status:Does your position or the position for which you have applied include any clinical responsibility (e.g. direct patient care or clinical supervision)? FORMCHECKBOX Yes FORMCHECKBOX NoCurriculum Vitae FORMCHECKBOX Evidence of appropriate Professional Indemnity Insurance (certificate of currency required)Insurance Company ___________________________________________________Policy Type __________________________________________________________Policy Number _______________________________________________________Amount ____________________________________________________________Expiry: / / FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Continuing Professional Development:Please provide evidence of completed CPD over the past 12 months as part of registration requirements, professional association requirements, or as part of a self-managed CPD portfolio consistent with professional requirements. FORMCHECKBOX Credentialing Referee ReportPlease attach a credentialing referee report from a discipline peer as part of your application.Attached: Yes FORMCHECKBOX No FORMCHECKBOX Comments: _____________________________________________ FORMCHECKBOX FORMCHECKBOX NON-AUSTRALIAN RESIDENTS ONLY: Do you require a Work Visa to practise in Australia? FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX Yes SECTION 4 – EXTENDED SCOPE OF CLINICAL PRACTICEOnly include details of clinical practice specific to extended scope of clinical practice that you are qualified to perform (provide copies qualifications where relevant). FORMCHECKBOX N/AAreas of clinical practiceQualification completedDatecompletedCopy provided FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX SECTION 5 – LIMITED SCOPE OF CLINICAL PRACTICEHas your scope of clinical practice been limited, or do you wish to limit your scope of clinical practice for any reason? If yes, please specify why: FORMCHECKBOX Yes FORMCHECKBOX NoSECTION 6 – CONFIDENTIAL PROFESSIONAL INFORMATIONHave you ever been denied registration or professional association membership? Are there any restrictions or special conditions placed on your registration or professional association membership? Have any claims, investigation or lawsuits for malpractice been made against you? Has your scope of clinical practice or appointment at any health service been reduced, suspended or revoked, or have you had any conditions attached to your previous appointments for any reason? Is there any other information regarding your ability to practise that should be declared? If yes to any of the above, please attach details. FORMCHECKBOX FORMCHECKBOX Yes FORMCHECKBOX Yes FORMCHECKBOX Yes FORMCHECKBOX Yes FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX No FORMCHECKBOX NoSECTION 7 – DECLARATION BY APPLICANTTo the best of my knowledge, the information provided in this application is true and correct. I understand that any incorrect statement may result in refusal in granting or the withdrawal of existing credentials. I authorise the Profession Lead or delegate of my discipline to seek information relating to my credentials and experience as relevant to my application.I agree to inform ACT Health of any complaint made about my professional conduct or of any change in my registration or professional membership eligibility status.I understand that the information referred to in this application will be securely stored, and can be accessed as required by the Profession Lead and Chief Allied Health Officer or nominated delegates.Signature: ________________________________________Date: / /Name: ___________________________________________Position: _________________________________________SECTIONS 8 – 9: TO BE COMPLETED BY PROFESSION LEAD OR DELEGATESECTION 8 – CONFIRMATION OF CREDENTIALSConfirmReceivedRegistered Professions Copy of relevant qualifications received:National Board registration confirmed on AHPRA website:Date of sighting: / / Has the National Board placed any restrictions on the applicant’s practice or registration?If yes, provide details:________________________________________________________________________________________________________________FOR MEDICAL RADIATION/DENTAL/SONOGRAPHY PROFESSIONS: Location Specific Practice Number recordedCurrent radiation licence sighted and number recordedAustralian Sonographer Accreditation Registry (ASAR) registration number recorded FORMCHECKBOX FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Self-regulating professionsCopy of relevant qualifications received:Eligible for Professional Membership:Professional Membership details received: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX N/AContinuing Professional DevelopmentHas the applicant demonstrated CPD as part of their registration requirements, professional association requirements, or as part of a self-managed CPD portfolio consistent with professional ments:___________________________________________________________________________________________________________________________ FORMCHECKBOX FORMCHECKBOX Yes FORMCHECKBOX NoCredentialing Referee ReportA credentialing referee report has been received from the applicant’s referee. FORMCHECKBOX FORMCHECKBOX PART 9 – APPROVAL BY PROFESSION LEAD OR DELEGATEOn completion of all aspects of the Procedure for Credentialing and Defining the Scope of Clinical Practice for Allied Health Professionals, I am satisfied that the applicant has the appropriate credentials and registration, or professional membership eligibility to undertake the scope of clinical practice for the position for which they are seeking access to within ACT Health. YES FORMCHECKBOX NO FORMCHECKBOX (If no, provide details) ________________________________________________________The scope of clinical practice requested is granted for: 1 YEAR FORMCHECKBOX LESS THAN 1 YEAR FORMCHECKBOX (Specify) ______ monthsApproved by the Profession Lead or delegate: YES FORMCHECKBOX NO FORMCHECKBOX Signed: ___________________________________________Date: / /Name: ____________________________________________Position: __________________________________________Note: The duration of the credentialing and scope of clinical practice approval is one year, subject to satisfactory renewal of registration or professional membership eligibility where appropriate, or a lesser time as determined by the Profession Leador delegate.DATE DUE FOR RE-CREDENTIALING: / /A copy of the application is to be provided to the applicant on request. The original application and associated documents are either to be kept on secure paper file or electronically scanned for monitoring and reporting.Appendix 4Please note that this form is a sample only. Please contact AHCredentialing@.au for the latest version of the allied health credentialing form that is relevant to your individual circumstances CREDENTIALING REFEREE REPORT(This report is for new and external allied health professionals only; or those seeking to extend their scope of clinical practice)Referee’s DetailsReferee’s Name:Referee’s Position:Applicant’s DetailsApplicant’s Name:Allied Health Profession:Position applied for:1. Professional RelationshipHow long have you known the applicant?In what professional capacity have you known the applicant?When was your last professional contact with the applicant?Can you comment on the nature of the practice and patient population encountered in the professional practice of the applicant?2. Clinical Skills and KnowledgeHistory-taking, clinical examination and presentation of findings FORMCHECKBOX Poor FORMCHECKBOX Adequate FORMCHECKBOX Good FORMCHECKBOX Excellent FORMCHECKBOX Not Observed FORMCHECKBOX N/AClinical judgement and decision-making skills FORMCHECKBOX Poor FORMCHECKBOX Adequate FORMCHECKBOX Good FORMCHECKBOX Excellent FORMCHECKBOX Not Observed FORMCHECKBOX N/AClinical record keeping skills FORMCHECKBOX Poor FORMCHECKBOX Adequate FORMCHECKBOX Good FORMCHECKBOX Excellent FORMCHECKBOX Not Observed FORMCHECKBOX N/AClinical skills FORMCHECKBOX Poor FORMCHECKBOX Adequate FORMCHECKBOX Good FORMCHECKBOX Excellent FORMCHECKBOX Not Observed FORMCHECKBOX N/AAdditional comments on clinical skills and knowledge base in the applicant’s requested scope of clinical practice.Please comment on the applicant’s participation in Continuing Professional Development activities related to their requested scope of clinical practice.3. Work EthicPunctuality and reliability (completion of set tasks on time) FORMCHECKBOX Poor FORMCHECKBOX Adequate FORMCHECKBOX Good FORMCHECKBOX Excellent FORMCHECKBOX Not Observed FORMCHECKBOX N/AOrganisational skills FORMCHECKBOX Poor FORMCHECKBOX Adequate FORMCHECKBOX Good FORMCHECKBOX Excellent FORMCHECKBOX Not Observed FORMCHECKBOX N/AInitiative FORMCHECKBOX Poor FORMCHECKBOX Adequate FORMCHECKBOX Good FORMCHECKBOX Excellent FORMCHECKBOX Not Observed FORMCHECKBOX N/AAdditional comments on work ethic, reliability and punctuality:4. Communication and Interpersonal SkillsClarity of written communication FORMCHECKBOX Poor FORMCHECKBOX Adequate FORMCHECKBOX Good FORMCHECKBOX Excellent FORMCHECKBOX Not Observed FORMCHECKBOX N/ACommunication and rapport with patients and consumers FORMCHECKBOX Poor FORMCHECKBOX Adequate FORMCHECKBOX Good FORMCHECKBOX Excellent FORMCHECKBOX Not Observed FORMCHECKBOX N/ARelationships with other health professionals FORMCHECKBOX Poor FORMCHECKBOX Adequate FORMCHECKBOX Good FORMCHECKBOX Excellent FORMCHECKBOX Not Observed FORMCHECKBOX N/AAdditional comments on the applicant’s interpersonal skills:5. Employability Are you aware of any medical condition, mental or physical, (including substance abuse or dependence) and which might adversely affect the applicant’s ability to competently and safely practise within their requested scope of clinical practice? FORMCHECKBOX Yes (if yes, please specify) FORMCHECKBOX NoAre you aware of any formal complaints, or disciplinary or legal action against the applicant? FORMCHECKBOX Yes (please describe) FORMCHECKBOX NoWould you offer the applicant a clinical position in your workplace/clinical area? FORMCHECKBOX Yes FORMCHECKBOX No (please specify)Would you entrust the applicant with the clinical care of a family member? FORMCHECKBOX Yes FORMCHECKBOX No (please specify)6. Conflict of Interest and other commentsDo you have a personal relationship with the applicant or any conflict of interest in providing this referee report? FORMCHECKBOX Yes (please specify) FORMCHECKBOX NoOther comments you may wish to make (optional):7. SignatureName:Position:Signature:Date: / /Contact Number:Contact Email: ................
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