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Placement Preference Form

Name:
Address:
Telephone (Home):
Mobile:
Email:
Fax

Please email a recent CV to [email protected] It will be sent to the GP Supervisor in the General Practice/Hospital

Do you have any disabilities or health issues which require special consideration to assist you while on your placement? If yes please specify below.

If your medical degree was obtained outside Australia, do you have any limitations on your provider number?

Do you intend to practice Obstetrics or Anaesthetics during your term?  Yes No
If yes, you must have completed DRANZCOG training or 12 months accredited Anaesthetics training.  Have you completed this required training? Yes No
Are you interested in working in an Aboriginal Medical Service Yes No

For General Pathway Registrars:
Have you completed your rural requirement?         Yes No
If Yes, where did you complete this placement?

 

Your Training Plans for 2008
First Term: 21 January, 2008 – 20 July, 2008


Placement Term
Basic Extended Skills Post
Advanced Advanced Rural Skills Post
Subsequent Leave
Hospital

Please indicate whether you will be training full time or part time.
Full Time Part Time
If part time please indicate the number of sessions per week
Please list your three preferred Training Placements

1
2
3

Please state why you have chosen your particular preference. This can include such things as educational requirements or family/personal circumstances which you feel may impact on your placement.

 

Second Term: 21 July, 2008 – 18 January, 2009


Placement Term
Basic Special Skills
Advanced Advanced Rural Skills Post
Subsequent Leave
Hospital

Please indicate whether you will be training full time or part time.
Full Time Part Time
If part time please indicate the number of sessions per week
Please list your three preferred Training Placements

1
2
3

Please state why you have chosen your particular preference. This can include such things as educational requirements or family/personal circumstances which you feel may impact on your placement.

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