Plastic Surgeon

9th July, 2008
Dear Applicant,
Thank you for your enquiry regarding the recently advertised position of Visiting Medical Officer -
Plastic Surgery, Permanent Part Time, Surgical Services, Murwillumbah District Hospital, (Vacancy
Reference: 0053/08).
Please note that the closing date for applications is the 8th August, 2008
To apply you will need to:

· Complete the application and other forms provided in the information package
· Read the attached Guidelines for Applicants
· Ensure that for each *selection criteria you make a separate heading then, for each one,
describe your experience, skills and knowledge and explain how they could be used in this job.
Please note that general resumes, curriculum vitae (CV) or portfolios, by themselves, will not
satisfy our requirements with regard to the selection criteria.
*We have used certain terms in the selection criteria. Please refer to the Guidelines for Applicants for
an explanation of these terms.
All NSW public sector employees require 'Appropriate understanding' of EEO, ethical
practice, cultural diversity and occupational health. Information is included in this package to
help you achieve that understanding.
Other useful information may be obtained by visiting the following Internet sites:
www.health.nsw.gov.au/jobs www1.health.nsw.gov.au/health/jobs/index.html
www.eeo.nsw.gov.au www.eeo.nsw.gov.au/whatseeo/whatseeo.htm
www.workcover.com.au www.workcover.com.au
www.dir.nsw.gov.au www.dir.nsw.gov.au/workplace/safety/index.html
www.health.nsw.gov.au/living/immunisation/index.html
There are various forms attached to this application kit including the Prohibited Employment
Declaration. Please complete these forms and submit with your application where possible. If you
are unable to submit these forms with your application please bring them with you to interview.
If you are the successful candidate, you may be asked to provide evidence of protection against
specified infectious diseases. Information relating to this requirement is included in your Application
Kit and in the Applicant Guidelines.
If you require further information regarding this position, the contact officer is:
Dr Dennis Pisk who can be contacted on (07) 55067454.
Late applications will only be accepted with the prior agreement of the above officer (please
see Late Applications section in the Applicant's Guidelines).
Applications can be lodged:

· On-line at www.ncahs.nsw.gov.au/apply/
· By mail to Recruitment Services, PO Box 126, Port Macquarie NSW 2444
· By email to RecruitmentServices@ncahs.health.nsw.gov.au
Applications or part applications are not accepted by fax.
Yours sincerely
Recruitment Services for
Mr Chris Crawford
NCAHS CHIEF EXECUTIVE
1800 196 991
GUIDELINES FOR APPLICANTS
Thank you for your interest in applying for a position with North Coast Area Health Service. The
purpose of this information kit is to assist you in preparing your application. A checklist has been
provided at the end of this document.
1. OCCUPATIONAL SCREENING & VACCINATION
NSW Health is committed to ensuring the health and safety of all clients in health care settings and
providing a safe and healthy working environment for all staff and other clinical personnel, including
students. This commitment includes adopting an assessment, screening and vaccination policy that
minimises the risk of acquiring infectious diseases.
Information will be included as part of your application kit if the position that you are applying for is
required to comply with the NSW Health policy for Occupational Assessment, Screening &
Vaccination Against Specified Infectious Diseases. Successful/preferred candidates must provide
documentation to demonstrate evidence of protection.
2. APPLYING FOR THE POSITION

You need to apply online or in writing for the position.
The NCAHS preferred method for submitting job applications is via our online application facility. By
applying for jobs online you ensure that your application is received promptly and you are notified of
its receipt. Applying for positions online allows you to track previous applications and to be notified
when certain types of jobs are advertised.
It is most important to prepare a good application as it will be used to decide whether you get an
interview. A good application shows why you are the best person for the job and how your skills,
knowledge and experience meet the selection / essential criteria.
Your application should contain the following:
· A completed application form (if you are unable to submit before closing date please bring
with you to interview).
· Your claim against the selection / essential criteria.
· Your resume (curriculum vitae).
· A completed Prohibited Employee Declaration (if you are unable to submit before closing date
please bring with you to interview).
Note: You do not need to submit copies of your qualifications or certificates as this
paperwork can be provided at interview (please see Section 11 Tertiary Qualification in this
document).
Before writing your application, you should:
· Read the advertisement and position description carefully. Make a note about anything you don't
understand and need to ask about.
· Telephone the enquiries person. More information about the position is available from the
enquiries person. Read through the position description first then ask them any questions
to clarify your understanding of the role.
· Get as much additional information as you need to write a good application. You may consider
meeting the enquiries person to have a look at the workplace, talk to people in similar
positions and read any relevant information.
3. LATE APPLICATIONS
Late applications will not be accepted without prior arrangements. If you wish to submit a late
application, please telephone the contact officer as noted on the front page of this package.
4. ORGANISATIONAL OVERVIEW
The North Coast Area Health Service (NCAHS) was established on 1 January 2005 by the merger of
the former Northern Rivers Area Health Service and the central and northern sectors of the former
Mid North Coast Area Health Service. The restructuring process is ongoing and is aimed at
improving the efficiency of the delivery of Health Services to the communities within the North Coast
Area.
The NCAHS provides a range of services under the following programs: Population Health, Primary
and Community Based Services, Aboriginal Health, Outpatient Services, Emergency Services,
Overnight Acute In-patient Services, Same Day Patient Services, Mental Health, Rehabilitation and
Extended Care and Teaching and Research.
5. THE RECRUITMENT AND SELECTION PROCESS
The recruitment and selection process commences with NCAHS identifying a vacancy, advertising it,
short listing applicants, calling suitable applicants to interview, checking referee reports, conducting
criminal record checks and offering appointment to the preferred candidate(s).
6. NOTIFICATION OF RECEIPT OF APPLICATION
It is not Health Service policy to acknowledge applications upon receipt, however, you may contact
the person that you sent the application to for confirmation of receipt of your application.
7. WRITING YOUR APPLICATION
You need to write your claims against the selection criteria to show the selection committee that you
have the right mix of skills, knowledge and experience to do the job. Make separate headings for
each selection criterion. For each one, describe your skills, knowledge and experience and show
how they could be used in the job. Emphasise your major achievements and use positive language,
for example "my success in my current position demonstrates my ability to do ......."
Key words used in Selection Criteria
Demonstrated knowledge
You need to give examples that prove you have this area of knowledge.
Ability to
You do not need to have done this kind of work before, but your skills, knowledge and experience
must show that you are capable of doing the work. Describe things that you have done which proves
you can do this kind of work.
Experience in
You have to show how you have done this work before, give examples.
Effective, Proven, Highly developed, Superior

These are all asking you to show your level of achievement. Give as much detail as you can using
examples of your achievements to show your skills, knowledge and experience.
NCAHS requires all employees to have an awareness of the principles and practices related to
EEO (Equal Employment Opportunity)

NCAHS believes that equality in employment is a fundamental right for all people. EEO principles
ensure that people are not discriminated against and have equal access to conditions of
employment, training and development, promotional opportunities and evaluation of performance.
The outcome of good EEO practice is a diverse and skilled workforce, improved employment access
and participation of EEO groups and a workplace culture displaying fair practices and behaviours.
Quality Management / Quality Improvement

NCAHS is committed to ensuring all its services are continually improving and meeting customer's
requirements and expectations, external standards and legislated requirements. This health service
utilizes best practice, benchmarking, internal audit, customer feedback mechanisms and external
accreditation programmes to review and improve service delivery and outcomes. Each employee is
expected and encouraged to participate in quality improvement activities and to review their own
work practices regularly.
Ethical Practices
Each employee of NCAHS is accountable for their performance. All employees must observe the
Code of Conduct and ensure that no fraudulent or unethical practices or conflict of interests exist.
Occupational Health & Safety

NCAHS is committed to safe work practices and environments and regularly reviews facilities and
practices to minimise risk. Each employee has legislative requirement to ensure their work is carried
out safely. NCAHS is also committed in assisting with the prompt return to work of injured workers.
Smoke Free Workplaces

As part of a state-wide Government strategy NCAHS is moving toward becoming a totally smoke free
workplace. Applicants need to be aware that the position they are applying for may be in a facility
that is already or may soon become a totally smoke free workplace. Apart from award based work
breaks (morning tea, lunch etc.) absences from the workplace for smoking breaks will not be
permitted.
Cultural Diversity
NCAHS believes that all people, regardless of race, religion, cultural origin or language have an
equitable right of access to health care services, NCAHS also recognises that the diversity of its staff
is one of our great assets.
8. APPLICATION FORM AND RESUME
Enclosed with this kit is a standard application form which you must complete and attach to the front
of your application.
You also need to complete a resume / curriculum vitae which includes
· Any qualifications
· Professional affiliations
· Details of professional registration
· Employment history
· Name, address and contact numbers of at least 2 employment related referees.
Personal information such as martial status, number of dependants etc are not relevant to the
requirements of the position and should not be included in your application.
If you are intending to apply for more than one position please submit a separate application
for each position.
9. THE ROLE OF THE SELECTION COMMITTEE
The selection process will be undertaken by a committee. Each selection committee is convened with
care to ensure that it has the necessary expertise to make a sound decision in a fair and impartial
way. Collectively, the committee will have an understanding of the vacancy and its role and will be
responsible for the integrity of the final selection decision. The panel will consist of at least 3
members, one will be independent to the direct line management of the vacancy. If you are called to
an interview you are entitled to ask who is on the panel.
10. INTERVIEW
The most suitable applicants (short listed from their written application) will be called for an interview
where each candidate's strengths and weaknesses in relation to the selection criteria are further
assessed. The purpose of the interview is to provide the applicant with the opportunity to expand on
information presented in their application and to enable the panel to gather further data for the
assessment process.
The body of the interview will be structured so that each candidate is asked the same series of
questions based upon the selection criteria. It is not an opportunity for the selection committee to ask
applicants 'tricky' or obscure questions, but rather to assist you in presenting your case in the best
manner possible. You may be given the questions prior to your interview, if this is to happen you will
be advised when notified of your interview arrangements.
At the interview you will be given the opportunity to ask questions about the position. The questions
offer candidates the chance to demonstrate their interest in, and understanding of the position and its
duties. At this stage you may also present information to the committee which you feel may assist
your application.
If you are offered an interview and you have any special needs (i.e. wheelchair access to the
building, interpreter for hearing impaired persons) you should inform the person who contacts you.
11. REFEREE REPORTS
Comments as to your demonstrated ability or potential to fulfill the selection criteria will be sought
from your nominated referees. Referees will be required to confine their comments to direct
knowledge of you. It is therefore important that you nominate referees who are able to discuss your
suitability in relation to the selection criteria. Consider providing them with a copy of the position
description so that they are prepared to provide relevant information to the selection committee,
Written referee reports are not required.
12. TERTIARY QUALIFICATIONS
Where a position with NCAHS requires an applicant to possess certain tertiary qualifications or
where an applicant claims to hold certain qualifications in support of their application for employment,
the following points should be noted:
· Candidates will be required to complete and sign a NCAHS Verification of Tertiary Qualifications
Form, included in this package. You do not need to forward copies of your qualifications with
your application.
· Candidates will be required to provide proof of such qualifications at interview (or as otherwise
agreed) by presenting original copies of awards and academic transcripts or other evidence
deemed to be acceptable by NCAHS as proof of qualifications.
· Qualification claims made by applicants may be verified by NCAHS with the issuing institution.
· Falsely claiming qualifications can lead to dismissal and/or prosecution for any relevant offence.
13. CRIMINAL RECORD CHECK
NCAHS requires that criminal record checks be undertaken for all positions. A criminal record does
not necessarily disqualify applicants recommended for selection. If rejection of your application is
considered purely because of a criminal record, you will be given an opportunity to discuss the matter
fully before a final decision is made.
14. WORKING WITH CHILDREN CHECK
Many positions within NCAHS are located in areas where services are provided to children or where
children are frequently present. Under the NSW Child Protection Act 1998 employers must ensure
that persons to be engaged in child related employment are screened (prior to employment) for their
suitability to work with children. If the position you are applying for is deemed to be "Child Related
Employment" the details you have provided for your Criminal Record Check will also be provided to
authorized child protection agencies for screening.
An authority to undertake Criminal Record and Working with Children checks will need to be signed
at interview (or as otherwise agreed).
15. PROOF OF IDENTITY
Proof of identity is required by all applicants and is similar to that required by banks. If you are called
to interview you will be advised of what proof you will be required to bring to interview.
16. REDUNDANCY / RETRENCHMENT / TERMINATION
Employees who have accepted a redundancy from a NSW Public Sector employer are required to
include information relating to the redundancy / retrenchment in their application.
The information will not disqualify an applicant from being selected for interview or offered the
position, however, it may mean that a proportion of the severance pay covering the period of re-
employment may have to be repaid.
17. POST SELECTION FEEDBACK

Feedback will be available to applicants regarding their performance upon request.
_______________________________________________________________________________
APPLICANT CHECKLIST
Have you
· Read the position description and the selection criteria?

· Read the information in relation to Occupational Assessment, Screening & Vaccination?
· Researched the position thoroughly?
· Addressed the selection criteria?
· Presented you application in a neat, concise and clear manner?
· Completed the NCAHS Application for Employment Form (submit with application if possible
or bring to interview)?
· Completed the Prohibited Employment Declaration (submit with application if possible or bring
to interview)?
· Completed the Verification of Tertiary Qualifications Form (submit with application if possible or
list your qualifications in your resume/CV or statement addressing selection criteria - bring
copies of qualifications to interview)?
· Stapled your application in the left hand corner (NO PAPERCLIPS)?
Do not send plastic sleeves or folders

NORTH COAST AREA HEALTH SERVICE
POSITION DESCRIPTION
POSITION TITLE: Visiting Medical Officer - Plastic Surgery

POSITION NUMBER: 0053/08
LOCATION: Murwillumbah District Hospital
DEPARTMENT: Surgical Services
AWARD: Visiting Medical Officer
SALARY: As per contract
HOURS: 4 per week
ESSENTIAL CRITERIA: (these are the qualifications, knowledge, skills and experience required to
perform the duties, against which each applicant is judged)
• Eligible for full registration with the NSW Medical Board.

• Have Fellowship of Royal Australiasian College of Surgeons and may have relevant sub specialist
certification and training and/or other specialist recognition as provided for under the Health Insurance
Act 1973.
• Demonstrated relevant current clinical practice at a high standard in Plastic Surgery relevant to the
years of experience.
• Demonstrated commitment to teaching and continuing education.
• Demonstrated ability to work and communicate effectively as part of a team and provide leeadership of
a team.
• Evidence of commitment to providing high quality health services and continuity of care to the local
community.
• Knowledge and evidence of applying quality improvement in the clinical environment.
ROLE RESPONSIBILITIES
• * Provide specialist elective minor Plastic Surgery to patients at Murwillumbah District Hospital (service
delineation Level 3) and other sites as may be required within Tweed/Byron Network.
• * Maintain current professional development and certification as per the relevant college and NCAHS.
• * Ensure the safe clinical practice by junior staff and other relevant staff through supervision and
education within the clinical environment.
• * Ensure quality and standards of care are met within own clinical practice and patient care refleccts
current best practice guidelines and is evidence based.
• * Participate in risk managemetn and quality programs of the Tweed/Byron Network and NCAHS
including reporting of IIMS, Root Cause Analysis, M&M meetings and clinical audit department
meetings.
• * Ensure compliance with relevant legislation and regulations, NSW Department of Health policies,
NCAHS policies and procedures.
• * Utilise appropriate information systems to enable informed decision making and care planning
including results reporting, theatre management systems, etc.
• * Communicate with the staff and clinicians of the Tweed/Byron Network and NCAHS across all
disciplines in the carrying out of role.
• * Ensure completion of medical records for patients under own care.
• * Participate and support in relevant education programs as appropriate for medical students, junior
medical staff and Specialist trainees.
• * Be aware of and understand relevant OH & S principles and practices, and actively promote a culture
of safety in the workplace.
• * Participate in annual Performance Review.
PURPOSE OF ROLE
* To provide and support the development of minor Plastic Surgery services to patients of The
Tweed/Byron Network in support of the Clinical Services Plan for the Clinical Network.
* To support and facilitate a culture of learning and best practice consistent with the teaching role of
The Tweed/Byron Network.
KEY INTERNAL AND EXTERNAL RELATIONSHIPS
• * Provide advice and support to Clinicians, including other Visting Medical Officers (VMO), Staff
Specialists, Nursing staff, Allied Health staff and GPs to ensure quality and continuity of care.
• * Patients and carers with communication of clinical management and care planning.
• * Executive of Tweed/Byron Network to support clinical service provision and planning.
• * Medical Staff Council.
CHALLENGES
• * Manage and prioritise competing demands, and be a leader in the resolution of conflicts.
PERFORMANCE REVIEW: (eg. A review of performance will be conducted 3 months after
commencing and annually therafter, or (if applicable) the apointee will be required to enter into a 12
months Performance Agreement.
MANDATORY RESPONSIBILITIES FOR ALL EMPLOYEES
Safety : It is the employees responsibility to:
·Attend orientation and fire drill training on commencement
·Report accidents, incidents and potential hazards immediately to their supervisor
·Be familiar with emergency and evacuation procedures
·Comply with occupational health and safety requirements and exercise responsibilities
appropriate to the level of the position.
·Take reasonable care of the health and safety of yourself and others
In Service Education : All staff are to attend the following courses:

·CPR (all clinical staff)
·First Attack Fire Fighting and Fire Exiting
·Fire Awareness and Safety
·Evacuation Theory and Practical
·Manual Handling
·Mandatory Notification of Child Abuse
·Infection Control Lectures
·Quality Assurance - EQUIP - CHASP
Code of Conduct
Staff members are expected to observe the provisions of the NCAHS Code of Conduct as part of the conditions
of their employment and/or engagement. Staff are to familiarize themselves with the contents of the NCAHS
Code of Conduct and ensure they observe its provisions. Departure from this Code of Conduct and the Acts on
which it is based could be grounds for disciplinary action including termination of employment.
Continuous Quality Improvement

All staff must be aware of the contents of the Policy and Procedure Manuals for their Department and work
within the principles contained therein. Each staff member is expected to exhibit a commitment to quality
service and to participate in activities to enhance continuous quality improvement.
Child Protection
All staff have an obligation to ensure that the rights and wellbeing of children are protected. Staff must be
aware of their responsibilities toward children as contained in Policies and Procedures issued from time to time
by the NSW Department of Health and North Coast Area Health Service.
Smoke Free Workplaces

North Coast Area Health Service promotes a smoke free work environment. All employees are to ensure that
they abide by the Smoke Free workplace policies issued by NCAHS.
Staff Apparel and Uniforms

All staff must abide by the NCAHS corporate uniform policy.
The preceding information is an accurate statement of the duties, responsibilities and

requirements of this position.
EXECUTIVE OFFICER:_______________________________ Date:_________________
I have read and understand the requirements of the position as described in this Position
Description.
EMPLOYEE:______________________ ________________________ Date:______________

(Signature) (Name)
To be signed on commencement of employment.
DATE COMPILED: _____________________DATES REVIEWED:_______________________

PHYSICAL DEMANDS OF JOB TASKS
Demands Description Frequency
Kneeling / Squatting Tasks involve flexion/bending at he knees and ankles, possibly Not Applicable
at the wrist in order to work at low levels.
Leg / Foot Tasks involve use of the leg and or foot to operate machinery. Not Applicable
movement
Hand / Arm Tasks involve use of hands/arms - eg stacking, reaching, typing, Occasional
movement mopping, sweeping, sorting and inspecting
Bending / Twisting Tasks involve forward or backward bending or twisting at the Occasional
waist.
Standing Tasks involve standing in an upright position without moving Occasional
about.
Driving Tasks involve operating any motor powered vehicle. Occasional
Sitting Tasks involve remaining in a seated position during task Frequent
performance.
Reaching Tasks involve reaching overhead with arms raised above Not Applicable
shoulder height or forward reaching with arms extended.
Walking / Running Tasks involve walking / running on even surfaces Not Applicable
Tasks involve walking on uneven surfaces Not Applicable
Tasks involve walking up steep slopes Not Applicable
Tasks involve walking down steep slopes Not Applicable
Tasks involve walking whilst pushing / pulling Not Applicable
Climbing Tasks involve climbing up or down stairs, ladders, scaffolding, Not Applicable
platforms, trees
Working at heights Tasks involve making use of the ladders, foot stools, scaffolding Not Applicable
etc. anything where the person stands on an object other than
the ground
Lifting / carrying Tasks involve raising / lowering or moving objects from one level Not Applicable
/ position to another, usually holding an object within the hands /
arms
Light lifting / carrying (0-9kg) Not Applicable
Moderate lifting /carrying (10-15kg) Not Applicable
Heavy lifting/ carrying (16 kg and above) Not Applicable
Restraining Task involves restraining patients/clients/others Occasional
Pushing / pulling Tasks involve pushing/pulling objects away from or towards the Not Applicable
body. Also includes striking or jerking
Grasping Tasks involve gripping, holding, clasping with fingers or hands Frequent
Manual Dexterity Tasks involve fine finger movements - ie keyboard operations, Frequent
writing
SENSORY DEMANDS OF JOB TASKS

Sight Tasks involve use of eyes (sight) as an integral part of task Constant
performance - ie looking at screen/keyboard in computer
operation, working in dark environment, interpreting x-ray film etc
Hearing Tasks involve working in a noisy area - eg boiler room, workshop Not Applicable
and/or operation of noisy machinery/equipment
Smell Tasks involve the use of the smell senses as an integral part of Frequent
the task performance - eg working with chemicals
Taste Tasks involve use of taste as an integral part of task performance Not Applicable
Touch Tasks involve use of touch as an integral part of task Frequent
performance
PSYCHOSOCIAL DEMANDS
Tasks involve interacting with distressed people Constant
Tasks involve interacting with people with mental illness/disability Occasional
EXPOSURE TO CHEMICAL HAZARD

Dust Tasks involve working with dust - eg sawdust Not Applicable
Gases Tasks involve working with gases Occasional
Fumes Tasks involve working with fumes - ie which may cause Occasional
problems to health if inhaled
Liquids Tasks involve working with liquids which may cause skin Occasional
irritations if contact is made with skin eg dermatitis
Hazardous Tasks involve handling hazardous substances including storage Constant
Substances and transporting
WORKING ENVIRONMENT
Lighting Tasks involve working in lighting that is considered inadequate in Not Applicable
relation to task performance - eg Glare
Sunlight Exposure to sunlight Not Applicable
Temperature Tasks involve working in temperature extremes - eg working in a Not Applicable
cool room, working outdoors, boiler room
Confined Spaces Tasks involve working in confined spaces Occasional
ACCIDENT RISK
Surfaces Tasks involve working on slippery or uneven surfaces Not Applicable
Housekeeping Tasks involve working with obstacles within the area - bad Not Applicable
housekeeping
Heights Tasks involve working at heights below knee level and/or above Not Applicable
shoulder height
Manual Handling Tasks involve manual handling tasks Occasional
BIOLOGICAL HAZARDS
Biological Products Tasks involve working with blood/blood products/body fluids Constant
PROHIBITED EMPLOYMENT DECLARATION
CHILD PROTECTION (PROHIBITED EMPLOYMENT) ACT 1998
The Child Protection (Prohibited Employment) Act 1998 makes it an offence for a person convicted of a serious sex offence (a Prohibited
Person) or a Registrable Person under the Child Protection (Offenders Registration) Act 2000, to apply for, undertake or remain in, child-
related employment. It does not apply if an order, from the Industrial Relations or the Administrative Decisions Tribunal or the Commission
for Children and Young People declares that the Act does not apply to a person in respect of a specific offence.
Section 5 of the Child Protection (Prohibited Employment) Act 1998 defines a serious sex offence as:
·an offence involving sexual activity or acts of indecency that was committed in NSW and that was punishable by penal servitude
or imprisonment for 12 months or more, even if the sentence was not served; or
·an offence involving sexual activity or acts of indecency that was committed elsewhere and that would have been punishable by
penal servitude or imprisonment for 12 months or more if it had been committed in NSW; or
·an offence under Sections 91D-91G (other than if committed by a child prostitute) and 578B or 578C (2A) of the Crimes Act 1900
or a similar offence under a law other than a law of NSW; or
·an offence of attempting, or of conspiracy or incitement, to commit an offence referred to in the preceding paragraphs; or
·any other offence prescribed by the regulations.
Note: A conviction for carnal knowledge is classified as a serious sex offence under this legislation.
Child-related employment means any employment, where at least one of the essential duties of the position involves direct contact with
children where that contact is not directly supervised. Section 3 of the Child Protection (Prohibited Employment) Act 1998 specifies that
child-related employment is employment:
·involving the provision of child protection services;
·in pre-schools, kindergartens and child care centres (including residential child care centres);
·in schools or other educational institutions (not including universities);
·in detention centres (within the meaning of the Children (Detention Centres) Act 1987);
·in refuges used by children;
·in wards of public or private hospitals in which children are patients;
·in clubs, associations or movements (including of a cultural, recreational or sporting
·nature) having a significant child membership;
·in any religious organisation;
·in any entertainment venues where the clientele is primarily children;
·as a babysitter or childminder that is arranged by a commercial agency;
·involving fostering or other child care;
·involving regular provision of taxi services for the transport of children with a disability;
·involving the private tuition of children;
·involving the direct provision of health services;
·involving the provision of counselling or other support services for children;
·on school buses;
·at overnight camps for children;
·any other prescribed by regulation.
Under this Act:

·it is an offence for a Prohibited Person to apply for, undertake or remain in child related employment;
·employers must ask existing employees, both paid and unpaid, and preferred applicants for employment to
declare if they are a Prohibited Person or not;
·all child-related employees must inform their employers if they are a Prohibited Person or remove themselves from
child-related employment. A Prohibited Person is someone who has been convicted of a serious sex offence or, who
has had a finding for a charge of a serious sexual offence proven in court, even if a conviction was not recorded;
·penalties are imposed for non compliance.
I am aware that I am ineligible to apply for, undertake or remain in, child related employment if I have been convicted of a serious
sex offence as defined in the Child Protection (Prohibited Employment) Act 1998 or if I am a Registrable Person under the Child
Protection (Offenders Registration) Act 2000.
I have read and understood the above information in relation to the Child Protection (Prohibited Employment) Act 1998. I am
aware that it is an offence to make a false statement on this form.
I declare that I am / am not*a person prohibited by the Act from seeking, undertaking or remaining in child related employment.
*(delete whichever is not applicable)
I understand that this information may be referred to the Commission for Children and Young People and/or to NSW Police for law
enforcement purposes and for monitoring and auditing compliance with the procedures and standards for employment screening in
accordance with Section 36 (1)(f) of the Commission for Children and Young People Act 1998.
Position: _____________________________________ Location: ____________________________ Employee No: _______________
Name: _______________________________________ Signature: ___________________________ Date: _______________
Contact Number: _______________ ( Note: Please seek legal advice if you are unsure of your status as a Prohibited Person.)
____________________________________________________________________________________________________________
THIS FORM IS TO BE FULLY COMPLETED AND RETURNED TO NORTH COAST AREA HEALTH SERVICE
____________________________________________________________________________________________________________
CONFIDENTIAL
APPLICATION FOR EMPLOYMENT
A pre-employment check for relevant criminal convictions is Health Service policy.
The Health Service supports Equal Employment Opportunity and a smoke free work environment
Position Information Closing date: 8th August, 2008

Position Title:
Position Vacancy No: Position Location:
Personal Information
Family Name: Other Names:
Preferred Title: Mr. Mrs. Miss. Ms. Dr. Other.
(Please Tick)
Contact Address: Telephone:
Home
Postcode Work
Public Sector Redundancy Payments

Have you received any redundancy, retrenchment or termination payment from any New
South Wales public organisation?
Yes No If 'yes' please attach details
Eligibilty to work in Australia
Are you legally entitled to work in Australia? Yes No
(Note: to be eligible for employment you MUST be an Australian citizen, permanent resident or
posses a current work permit. Original documentation of your residence status MUST be produced
upon request.)
Health Status
Anti-discrimination legislation and Equal Employment Opportunity protect employees against
unlawful discrimination. If special arrangements would assist your application for the position or in
carrying out its duties, should you be successful in your application, please attach details. In some
circumstances a job fitness medical may be requested. If so, the matter will be discussed with you. It
is necessary for the Selection Committee to be aware of any disability or pre-existing medical
condition which could affect your capacity to carry out all the functions of the position. Do you know
of any disability or medical condition which could affect your ability to carry out the duties of
this position as you understand them?
Yes No If yes please provide a brief explanation.
Applicant's Statement
The information provided in this application and any attached papers is, to the best of my
knowledge, true and accurate in every respect. I understand that any statement I make (or
information I knowingly withhold) which is found to be false or misleading as to the
substance of my application, will constitute grounds for termination of any contract of
employment entered into.
SIGNED: __________________________________________________ DATE: ___/___/___

____________________________________________________________________________
Office use only: Application received (Date) _________________
Signed by selection Committee ________________ Date ___/___/____
VERIFICATION OF TERTIARY QUALIFICATIONS
(Please print clearly when completing this form)
Applicants Name:
Applicants Address:
Contact Phone No's:
Position Applied for Name:
Position Applied for Number:
Qualification Full Name Issuing Institution Date Issued Sighted Verified
Statement by Applicant:
I _____________________ declare that the above details are correct and that the above
qualifications are genuine. I also acknowledge that the North Coast Area Health Service may verify
the above information with the Institution concerned and any false declaration regarding my
qualifications could lead to dismissal from employment and/or prosecution for any relevant offences.
I agree to pride proof of the above qualifications at interview (or as otherwise agreed) by presenting
original copies of Degrees, Diplomas, Certificates, Awards, academic transcripts or other evidence
as deemed appropriate by the North Coast Area Health Service.
Signed: _____________________________ Date:______________________________

APPLICANT
Occupational Assessment, Screening & Vaccination Against Specified Infectious

Diseases
IMPORTANT REQUIREMENTS FOR

POTENTIAL EMPLOYMENT WITHIN NSW HEALTH FACILITIES
NSW Health is committed to ensuring the health and safety of all clients in health care
settings and providing a safe and healthy working environment for all staff and other clinical
personnel, including students. This commitment includes adopting an assessment, screening
and vaccination policy that minimises the risk of transmission of infectious diseases.
Each position within NCAHS has been categorised as either category A or category B
according to its potential for transmission of specified infectious diseases. Staff in Category A
positions have contact with clients, or contact with blood, body substances or infectious
material. Most NCAHS positions are category A. Applicants for Category A positions must
comply with NSW Health Policy Directive 2007_006 Occupational Assessment, Screening
and Vaccination Against Specified Infectious Diseases.
If you are the preferred candidate for a Category A position you must provide evidence
of protection for specified infectious diseases, as described in Table 1 for assessment
by a NCAHS Occupational Vaccination Assessor. It is recommended you prepare this
documentation prior to interview however you will only be required to produce it if you are the
preferred candidate.
As a full course of vaccinations may take several months to complete, you are advised to
consult your local doctor/vaccine provider immediately if you do not possess the appropriate
documentation (take the information on the following page with you to ensure you receive the
correct vaccines/tests). If you require clarification of requirements or documentation
standards contact details for NCAHS Occupational Vaccination Assessors are provided on
Page 5. Please note these staff work as Occupational Vaccination Assessors on a part time
basis and may not be immediately accessible.
If you are the preferred candidate for a Category A position you must also provide
evidence of your Tuberculosis (TB) status. This involves demonstrating you have had a
recent assessment to exclude active TB and establishing your baseline Tuberculin Skin Test
Status (TST) – previously referred to as a Mantoux Test.
TB Screening must be done by a TB Service or by a delegate nominated by the TB Service.

Contact details for TB services are included in this package. Guidelines on the TB Screening
requirements are on Page 2 of this package.
YOUR APPLICATION FOR EMPLOYMENT WILL NOT BE SUCCESSFUL UNLESS YOU

COMPLY WITH THE NSW POLICY.
Information is available at www.health.nsw.gov.au/ohs_vaccination/
Occupational Screening & Vaccination Applicant Package(V2) 3 August 2007 Page 1

TABLE 1: EVIDENCE OF PROTECTION FOR SPECIFIED INFECTIOUS DISEASES
Infectious
Disease Acceptable Evidence to Demonstrate Protection
Diphtheria, One documented dose of adult dTpa vaccine (Boostrix or Adacel vaccine).
tetanus,
pertussis Serological testing for diphtheria, tetanus and pertussis is not recommended,
and will not be considered as evidence of protection.
Hepatitis B Evidence of a completed, age appropriate, course of hepatitis B vaccine and

documented evidence of post vaccination blood test for anti-HBs ≥ 10mIU/mL;
or evidence of past hepatitis B infection (blood test anti-HBc positive).
Vaccinated applicants without documented evidence of their vaccine doses

must provide a positive antiHBs result and detailed description of the
vaccination history.
Vaccine non-responders must provide documented evidence of vaccine doses.
Measles, Birth date before 1966; or documented evidence of two doses of MMR vaccine
mumps, rubella at least one month apart; or documented evidence of positive IgG for measles,
mumps and rubella.
Pre- and post- vaccination serological testing for measles, mumps and rubella
is not recommended and should not routinely be undertaken.
Tuberculin skin testing must be delayed for a month after this

vaccination.
Varicella Statement of a history of chickenpox; or documentation of physician-diagnosed

(Chickenpox) shingles; or documented evidence of a positive varicella IgG; or documented
evidence of age appropriate varicella vaccination.
Persons with a negative or uncertain history of varicella should have

serological testing to identify if vaccination is required.
Tuberculin skin testing must be delayed for a month after this

vaccination.
EVIDENCE OF COMPLIANCE WITH TUBERCULOSIS (TB) SCREENING
1. Active tuberculosis disease must be excluded.

• You must submit a completed Health Care Worker TB Assessment questionnaire
(found on page 3 of this package) or provide documentation from TB Screening
Service that you have been assessed and active tuberculosis has been excluded
in the last 12 months.
• A chest xray is not routinely required
AND
2. Baseline tuberculin skin test (TST) status must be established.

• Applicants with documentation of a TST ≥ 10mm do not require another TST.
• Applicants with documentation of a previous TST <10mm which was done more
than 12 months ago must undergo individual assessment to determine if TST is
required for recruitment Contact a North Coast TB Service or Vaccination
Assessor to arrange assessment.
• Applicants who do not have documentation of a previous TST will require TB
screening by a Tuberculosis Service or a delegate nominated by the TB Service.

HEALTH CARE WORKER Name:
TUBERCULOSIS (TB) ASSESSMENT
Completed form to be submitted to Vaccination Assessor (via Convenor) with
documented evidence of previous TB screening, including Tuberculin Skin Test
(TST) results (if available).
DOB:
Documented evidence of previous TB screening including Tuberculin Skin Test (TST) results should be submitted
with this assessment (if available).
You can elect to have this assessment undertaken in a private consultation with a clinician.
This information will be used to decide if clinical review and/or testing is required.
Clinical History Assessment of risk of TB infection

Do you have any of the following TB symptoms:
Cough Yes No List the places you have been overseas in the
Haemoptysis (coughing blood) Yes No last 5 years and the length of time at each place:
Fevers / Chills / Temperatures Yes No ………………………………………………………..
Night Sweats Yes No ................................................……………………..
Fatigue / Weakness Yes No .................................................................…………
Anorexia (loss of appetite) Yes No …………………………………………………………
Unexplained Weight Loss Yes No  …………………………………………………………
Have you ever had: List where you have worked in health-related
Treatment for TB Yes No positions in the last 5 years:…………………………
A vaccination for TB (BCG) Yes No ……………………………………………………………
If yes, when?...................... …………………………………………………………..
Contact with a person with TB? Yes No …………………………………………………………..
Current health status:
Do you have a chronic illness? Yes No
Do you take any medications? Yes No
Do you have a disease or condition
which affects your immune system? Yes No
If you answered yes to any of the questions above, please provide details. (Indicate if you would prefer to provide
this information in private consultation with a clinician):
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
I declare that the information I have provided is correct, to the best of my knowledge.
Print name: …………………………………………………………
Signature: …………………………………………………………… Date: ………………………………….

NSW Tuberculosis Services
Metropolitan C lin ics Telephone
Central Sydney & Canterbury Hospital 9787 0946

South Western Sydney Concord Hospital 9767 5675
Royal Prince Alfred Hospital 9515 8846
Liverpool Hospital 9829 4888
Northern Sydney & Hornsby Hospital 9477 9317

Central Coast Manly Hospital 9976 9542
Royal North Shore Hospital 9926 7905
Gosford Hospital 4320 3388
South Eastern Sydney & Prince of Wales Hospital 9382 4636

Illawarra St George Hospital 9350 2503
St Vincent's Hospital 8382 3876
Sydney Hospital 9382 7535
Wollongong Hospital 4253 4138
Western Sydney Parramatta Health Services 9843 3110

Nepean Hospital 4734 2536
Children's Hospital Westmead 9845 2578
Rural Clinics:
Hunter & John Hunter Hospital 4921 3372

New England Taree Health Centre 6592 931 S
Tamworth Base Hospital 6767 7787
North Coast Lismore Base Hospital (also services Tweed Heads) 6620 2280
Coffs Harbour Health Campus 6656 7855
Port Macquarie Health Centre 6588 2755
Greater Southern Wagga Wagga Centre of Public Health 6933 9125

Bega Community Health Centre 6492 9620
Cooma Community Health Centre 6455 3201
Goulburn Community Health Centre 4827 3913
Narooma Community Health Centre 4476 2344
Queanbeyan Community Health Centre 6298 9233
Young Mercy Care Centre 6382 1111
Greater Western Orange Base Hospital 6393 3480

Dubbo Centre of Population Health 6841 5576
Broken Hill Hospital (08) 8080 1317
Queensland TB Control Centre: (07) 3896 3963
General numbers for other States and Territories Health Departments

Australian Capital Territory: (02) 62442066 Western Australia: (08) 93253922
South Australia: (08) 82225483 Victoria: (03) 96374115
Northern Territory: (08) 89228804 Tasmania: (03) 62227293

NCAHS Occupational Vaccination Assessors for clarification on Vaccination and
Screening requirements
Please note these staff work as Occupational Vaccination Assessors on a part time basis and
may not be immediately accessible.
Primary Employment site Telephone Contact Number

Tweed Byron Network
Jenny Penn (RN) Mullumbimby Hospital 02 6684 2266
Kerry Morrow (ICC)
Denise Stewart (ICC) Byron District Hospital 02 6685 6200
Janette van der Hoek (ICC) Murwillumbah Hospital 02 6672 0232
Gayle Barton (SH) The Tweed Hospital 07 5506 7475
Richmond Network
Bronwyn Browne (CN) Lismore Community Health 02 6620 2967
Anne McDonald (CN) Ballina Community Health 02 6620 6244
Karen Bullen (ICC) Ballina Hospital 02 6686 2111
Cheryl Ducat (EO/DON) Bonalbo Health Service 02 6665 1203
Lee Cameron (NUM) Casino & District Hospital 02 6662 2111
Leanne Schipanski (CN) Kyogle MPS 02 6632 1522
Alyson Jarrett (NM)
Lyndia Rennie (NM) Coraki Hospital 02 6683 2019
Delma Makejev (SH) Lismore Base Hospital 02 6620 2516
Kerrie Hardy (relief SH)
Anne Owen (ICC) Nimbin MPS 02 6689 1400
Sandra Reid (ICC) Urbenville MPS 02 66341600
Coffs Clarence Network
Amy Lowe (NUM) Grafton Base Hospital 02 6640 2232
Jane Nichols (ICC) 02 6640 2484
Margaret Flannagan (RN) 02 6640 2350
Robyn Armstrong (SH) Coffs Harbour Health Campus 02 6656 7664
Kirsty Browne (relief ICC)
Rebecca Moore (RN) Bellingen / Dorrigo 02 6659 5839
Roslyn Cook (ICC) Macksville Hospital 02 6568 0626
Laurel Moore (CN) Maclean Community Health 02 6640 0123
Jude Lillington (ICC) Maclean District Hospital 02 6640 0111 Pager: 13
Jennifer Foster (RN)
Macleay Hastings Network
Jo Cooper (RN) Kempsey Hospital 02 6562 6155
(Pager 0002)
Marjorie Bolton (ICC) Port Macquarie Hospital 02 6580 1061 or
02 6581 2000 pager 44
Vicki Whitehead (CN) Port Macquarie Community Health 02 6588 2755
Pam Olive (RN) Wauchope Hospital 02 6585 1300
CN: Community Nurse EO/DON: Executive Officer/Director of Nursing

ICC: Infection Control Coordinator NUM: Nurse Unit Manager, NM: Nurse Manager,
RN: Registered Nurse SH: Staff Health

APPLICANT OCCUPATIONAL VACCINATION AND SCREENING CHECKLIST
You must submit:
Evidence of having had adult diphtheria, tetanus, pertussis vaccine (Documentation of

ADT, Tet-tox or childhood diphtheria, tetanus, pertussis vaccination is NOT
acceptable).
Hepatitis B vaccination documentation OR detailed information regarding your hepatitis

B vaccination.
Documentation of Hepatitis B blood test result.
If your date of birth is in 1996 or later: evidence of receiving 2 doses of measles,

mumps, rubella (MMR) vaccine at least one month apart OR documentation of a
positive blood test result for all three diseases.
If you date of birth is prior to 1966: an indication that your date of birth is prior to
1966 in your vaccination and screening record.
A statement that you have had chickenpox OR documentation from a Doctor confirming
a diagnosis of shingles OR documentation of a positive varicella blood test result OR
evidence of having of receiving 2 doses of varicella vaccine at least one month apart.
A completed Health Care Worker TB Assessment form OR documentation supporting

exclusion of active TB disease (within 12 months).
Evidence that your baseline TST status has been appropriately established.
The NCAHS expects a high standard of documentation so there is no doubt regarding

your level of protection.
• For vaccination and TST documentation it is essential to be able to identify what was
administered (ideally with a batch number), when the vaccine/TST was given, the identity
of the clinician who administered the vaccine/TST or provided the information.
• Transcriptions of blood test results must indicate the test undertaken and interpretation of
the result.

INFORMATION FOR VISITING PRACTITIONERS (MEDICAL/DENTAL)
APPOINTED TO NORTH COAST AREA HEALTH SERVICE
1 JULY 2008 - 30 JUNE 2013 QUINQUENNIUM
A INTERPRETATION
"Area" means the North Coast Area Health Service (NCAHS)
"Clinical Service" means a health service and includes a hospital, unit, community service or other
service at which the visiting practitioner has clinical privileges.
"Clinical Service Manager" means the person to whom the practitioner is immediately responsible for
the performance of duties and clinical care of patients.
“Major Hospitals” for the purpose of these quinquennium appointments means The Tweed Hospital,
Murwillumbah District Hospital, Lismore Base Hospital, Grafton Base Hospital, Coffs Harbour Base
Hospital, Kempsey District Hospital and Port Macquarie Base Hospital being hospitals (excepting Nimbin
Hospital) included in List 3 of the 1996 Settlement Agreement between NSW Department of Health and
Australian Medical Association following the Joint Review under the March 1995 Fee for Service
Agreement. List 3 is a listing of hospitals where VMOs may elect by specialty group between Sessional
or Fee-for-Service payments.
“Networked Services” means a coordinated clinical service conducted at two or more hospitals or
health services by NCAHS
“Peripheral Hospitals” for the purpose of these quinquennium appointments means public hospitals at
Ballina, Byron Bay, Bonalbo, Maclean, Casino, Kyogle, Mullumbimby, Nimbin, Coraki, Urbenville,
Bellingen, Dorrigo, Macksville and Wauchope.
“Specialist” means a medical practitioner recognised as a Specialist for the purpose of the Health
Insurance Act 1973 (Commonwealth)
“Visiting Practitioner” means a member of the Visiting Medical or Dental Staff of North Coast Area
Health Service
B APPOINTMENT AND CLINICAL PRIVILEGES

1 Each Visiting Practitioner is appointed by the Chief Executive, with such clinical privileges as are
determined by the Chief Executive on the recommendation of the Medical and Dental Appointments
Advisory Committee. Appointments are to the North Coast Area Health Service with clinical privileges
being granted to specific clinical services within the Area. Appointment is conditional on the visiting
practitioner entering into a service contract with the Area.
2 A Visiting Practitioner wishing to vary their clinical privileges, or the locations at which any of these
privileges are exercised, should make application through their clinical service manager to the Medical
and Dental Advisory Appointments Advisory Committee (MDAAC) and the Chief Executive to have any
such variation approved. No changes to the clinical privileges or the locations at which those privileges
are exercised are to be made until the approval of the Chief Executive has been obtained, following
advice from the MDAAC.
3 Appointments are subject to the Chief Executive being satisfied, on the advice of the Medical and
Dental Appointments Advisory Committee as to the ongoing personal and professional conduct,
performance and services of each Visiting Practitioner. The relevant standards of professional conduct
for Visiting Practitioners are the NSW Health Code of Conduct (all Visiting Practitioners), the NSW
Medical Board's Code of Professional Conduct (medical practitioners), and the code of conduct issued
by a relevant professional college.
4 An appointment to NCAHS shall be regarded as a single appointment. Clinical privileges may extend to
more than one hospital or service. This will be reflected in the contractual arrangements between the
appointee and NCAHS. Resignation by a VMO specialist from a Major Hospital shall relate to the entire
appointment. It cannot be subsequently divided into multiple appointments despite the fact that there
may be multiple contracts relating to the services provided at different hospitals which may be
necessitated by the different remuneration arrangements required to be put in place at such hospitals.
5 Resignation in accordance with the Health Services Regulation 2003 from a VMO appointment in which
privileges have been provided to a Major Hospital shall automatically trigger the termination of the
contingent clinical privileges at any other NCAHS hospital or service. Specialist VMOs may resign their
secondary appointment at Peripheral Hospitals subject to the period of notice provided in their service
contract and the Health Service Regulation 2003, without affecting their Major Hospital appointment.
6 Where VMO Specialists are appointed to Networked Services such appointment is indivisible and
conditional upon continuation of the provision of services. VMOs cannot resign from any part of the
Networked Services arrangement without resigning from all their appointments with NCAHS.
C TERMS AND CONDITIONS

1 Terms and conditions for Visiting Medical Officers and Honorary Medical Officers (except Radiologists
and Pathologists) are prescribed in standard Sessional and Fee-for-Service contracts (including form of
Fee-for-Service Contract for Rural Doctor Package Hospitals) and related determinations/settlement
package including:
- Public Hospitals (Visiting Medical Officers – Fee-for-Service Contracts) Determination 2007
- Public Hospitals (Visiting Medical Officers – Sessional Contracts) Determination 2007
- Rural Doctors Settlement Package
D UNPAID LEAVE OF ABSENCE

1. All unpaid leave of absence must receive the prior approval of the clinical service manager. Other
than in unforseen circumstances beyond the control of the practitioner, at least three months prior
notice of unpaid leave of absence is to be given to the clinical service manager. Applications for
unpaid leave of absence should be made in consultation with relevant clinical colleagues and should
be made in writing to the relevant clinical service manager.
2. To provide the Area Health Service with assurance of the continuity of medical care to patients, the
visiting practitioner should hand over patients to another medical practitioner prior to commencing
unpaid leave of absence.
3. The Area Health Service is responsible for appropriate arrangements for cover whilst the visiting
practitioner is on unpaid leave of absence. However, the Area Health Service would appreciate
advice on cover arrangements when applying for unpaid leave of absence, particularly in
circumstances where the visiting practitioner is also making arrangements for cover of their private
practice.
4. The Area Health Service shall be responsible for the appointment of locum Visiting Practitioners to
the Area Health Service.
E ADHERENCE TO POLICIES
1. The Visiting Practitioner must comply with NSW Health policies prescribed as mandatory for health
service staff and Visiting Practitioners including (but not limited to) those relating to the provision of
clinical services, code of conduct, occupational health and safety, immunisation, workplace harassment,
equal employment opportunity and reporting of criminal convictions or disciplinary findings. Visiting
Practitioners are to also to comply with NCAHS Policies and By-Laws.
2. Visiting Practitioners may also be required to take part in training that may, from time to time, be
deemed mandatory by the Department of Health or the Area. This will include relevant training
relating to child protection.
3. A Visiting Practitioner should also take reasonable steps to comply with requests for information and
other reports required under Department of Health policies and guidelines for supplying information
relating to child protection.
F REGISTRATION, CERTIFICATION and MEDICAL INDEMNITY

1. Each Visiting Practitioner will maintain all certification and registration necessary to enable them to
provide the clinical services covered by their appointment. Evidence of this must be provided to the
Area promptly after being obtained. Any cancellation or suspension of such certification or
registration must be notified to the Area immediately.
2. Adequate professional indemnity cover with a recognised medical defence organisation or insurer
must be maintained by each Visiting Practitioner at all times during the term of their appointment.
Any change in status must be immediately notified to the Area Director Clinical Services.
3. The Area shall offer each medical practitioner proposed for appointment as a visiting medical officer,
who is eligible for professional indemnity cover from the New South Wales Treasury Managed Fund
under the applicable policies of the NSW Department of Health as issued from time to time, an
approved contract of liability coverage covering the term of the practitioner’s proposed appointment as
a visiting medical officer at the same time it provides a written service contract.
4. A visiting medical officer must have approved professional indemnity insurance in respect of civil
liability arising from the officer’s practice of medicine at a public health organisation, including in
respect of persons who elect to be private patients, to the extent that such liability is not covered by
an approved contract of liability coverage.
G DISCIPLINE, RESIGNATION, OR TERMINATION OF APPOINTMENT

1. Should the need arise to counsel or discipline a Visiting Practitioner for minor breaches of their
obligations under the terms and conditions of appointment, this will be done in the first instance by
the clinical service manager or local Area management.
2. Subject to the terms of appointment a Visiting Practitioner may, following an investigation

commissioned by the Chief Executive of North Coast Area Service for that purpose, be suspended or
terminated at any time by the Chief Executive where there has been a serious failure by the Visiting
Practitioner to observe the terms and conditions of their appointment. Any Visiting Practitioner dealt
with under this clause will be afforded due process and procedural fairness.
3. A Visiting Practitioner seeking to resign from their appointment must give at least three months’ (or
such lesser period as is agreed by the Chief Executive) notice in writing to the Chief Executive.
H PERFORMANCE REVIEW OF VISITING PRACTITIONERS

1. Visiting Medical Practitioners will be required, under NSW Department of Health (DOH) requirements
to participate in an annual performance review arrangement with their supervisor. This is in the
interest of enhancing professional development and Area Health Service objectives by providing
regular feedback about performance and identifying appropriate development opportunities, providing
an opportunity for two-way feedback, and to identify opportunities for the Area to support the
practitioner in maintaining and improving performance and managing issues.
2. These general principles are the result of extensive consultation between the NSW DOH, AMA,
ASMOF, The Rural Doctor’s Association and Area Health Services.
Application for Appointment, Credentialing and Clinical Privileges of
Specialists
1. Applicant and contact details

Primary Facility
Title & Surname
Given Name/s
Previous Name
Please include your previous name if it
appears on certificates
Date of Birth
Country of Birth
Residency status:
Australian Citizen Yes No
Permanent Resident of Australia Yes No
If No - List details of your current valid visa approval (include a copy with your
application)
Professional Address
Postcode
Phone (BH)
Phone (AH)
Fax
Mobile
Pager
e-mail address
Postal Address
(if different to Professional
Address above)
Postcode
Private Address
Postcode
This form sets a minimum information standard , however, information can also be provided
by the provision of a current curriculum vitae where indicated.
Please note: If you need to correct any error in your application, please initial the correction.
Please attach to this form:

• Current curriculum vitae
• Applicants who have not held previous appointments with NCAHS must provide certified copies of all
original qualifications
• Copy (copies) of current medical registration
• Copy of current medical indemnity insurance certificate (if applicable)
• Copies of relevant Visa documents (if applicable)
2. Application for Clinical Privileges
a. Speciality
PRIMARY
Honorary Yes No
SPECIALITY
Sub-Speciality
or
Area of Special Interest
(if applicable)
SECONDARY
SPECIALITY
(if applicable)
b. Please list the Facility or Facilities for which you are applying:
Facility Name Provider Number
Primary Facility
Facility 2
Facility 3
Facility 4
Facility 5
c. Application for scope of clinical practice

I wish to apply to define my scope of clinical practice to undertake the following:
Position/classification sought: (e.g. Consistent with Specialist General Surgeon or Specialist Consultant Cardiologist)
Scope of clinical practice sought: (e.g. General Surgery, Laparoscopy, Endoscopy, Breast Surgery)
(Please use additional pages, if required)

3. Qualifications * Can be detailed in CV
Qualifications University/Organisation Year obtained
For applicants who have not held appointments in NCAHS, please provide certified copies of qualifications or
evidence of qualifications obtained
4. Other training and clinical experience * Can be detailed in CV
With respect to your response to Section 2, please provide details of clinical experience and post-qualification training.
Include the title of course/s undertaken, the organisation offering the course, and the qualification obtained.
5. Clinical appointments * Can be detailed in CV
(a) Provide details on all current and previous public and private clinical appointments during the past five years
(including names of organisations and dates of appointment), or other places of practice (for example, general practice).
Organisation Term of
appointment
Main appointment: to
Other appointments: to
to
to
to
to
to
to
to
(b) Have you ever been denied a defined scope of clinical practice? Yes No
(c) Has your right to practise ever been withdrawn, suspended, terminated or reduced? Yes No
If you answered YES to either of the above questions, please provide full details.
6. Academic appointments/teaching experience * Can be detailed in CV

Provide details of current and previous teaching appointments (including names of organisations and dates of
appointment).
Organisation Status/Level Term of Appointment

to
to
to
to
to
to
to
7. Continuing medical education/continuing professional development
(a) Provide details of your involvement in continuing medical education/continuing professional development. Include
name of the college/organisation program in which you are enrolled.
(b) Please attach current re-certification statement or certificate from the relevant college or
advise of CPD activities, college based and other, undertaken in the last three years.
(c) Have you satisfied the continuing medical education/continuing professional

Yes No
development requirements of your college membership/ fellowship?
8. Clinical review/peer review

Do you regularly participate in formal quality and peer review activities? Yes No
Provide details of such quality/peer review activities.
9. Grand rounds/health service educational activities
(a) What educational training activities for junior staff have you participated in over the past
three years?
(b) Are you prepared to conduct a grand round or other educational activities, for example, on a Yes No
once a year basis?
10. Have you any other information to support this application
11. Regulatory and indemnity information
(a) New South Wales Medical Board Registration Registration number:
Is this registration temporary? Yes No
If yes, provide details.
(Attach a copy of current Registration Certificate)
(b) Does your registration pertain to an area of need. If so, Yes No

please detail the type of assessment process undertaken prior
to registration.
(c) Are you registered as a medical practitioner in any other Yes No

state or territory of Australia, or in another country? If so,
please specify.
(d) Do you have any conditions or restrictions placed on your Yes No

registration (either in New South Wales or elsewhere)? If so,
please provide full details
(e) Do you have a medical board appointed supervisor? If Yes No

so, please provide details (including name and location of
supervisor and frequency of supervision)
(f) In the past, have you ever had any conditions or Yes No
restrictions placed on your registration (either in New South
Wales or elsewhere)? If so, please provide full details
(g) Current medical indemnity cover (if applicable) Expiry date of current policy:
Attach a copy of current policy renewal certificate.
(h) Are your proposed clinical privileges reflected in or Yes No N/A (only if covered by
covered by your current medical indemnity insurance? TMF)
(i) Over the past 10 years, have there been or are there Yes No
currently pending any claims, settlements or judgments
against you?
(j) Has your current or any previous medical defence Yes No

organisation/insurer ever excluded or reduced any specific
area of practice, or terminated or denied coverage?
(k) If the answer to either of the above two questions is YES,

please provide a detailed explanation and specify the name of
the relevant medical defence organisation/insurer.
(l) Is your Provider Number subject to any restrictions?

Provider Number to be recorded in section 2 (b) Yes No
If YES, please provide full details.
(m) Do you have a Prescriber Number? Yes No
Prescriber Number:
If YES, is it subject to any restrictions? Yes No
If restrictions apply, please provide full details.
12. Health status

Do you have a disability/health issue that:
• may impact on your ability to perform any of the cognitive and physical
functions which would fall within the scope of practice that you are
seeking in this application?
• may require special equipment, facilities or work practices to enable you to Yes No
perform any aspect of the scope of practice you are seeking in this
application?, or
• might be relevant to determining your scope of practice?
(In answering this question, please have regard to the New South Wales Medical Board’s
Impaired Registrants (Health) Program, details of which are available at
www.nswmb.org.au under ‘Doctors’ Health’.)
If yes, please provide details of the disability/health issue, its impact on your ability to carry out the scope of practice
sought, and details of any special equipment facilities or work practices required.
This information can be provided on this form or, if you prefer, you can provide the information in a sealed envelope
marked ‘CONFIDENTIAL for Director of Medical Services ONLY’ appended to this application, and indicate here that
additional information is provided separately in this manner.
This information is sought to enable an assessment to be made as to whether you can safely perform the
inherent/reasonable requirements of the work which you seek to perform at the facility/facilities by submitting this
application, or whether any reasonable adjustments might be required to ensure that you can work in a way that ensures
patient safety.
13. Disclosure about disciplinary actions/criminal activity
(a) In the past 10 years, have you been the subject of disciplinary action in
Yes No
the course of your work as a medical practitioner?
If YES, please describe.
(b) In the past 10 years, have you been the subject of disciplinary action or
professional sanctions imposed by any registration board whether in New Yes No
South Wales or elsewhere?
(c) In the past 10 years, have you been the subject of any investigation,
inquiry or findings by any registration board (whether in New South
Wales or elsewhere) in relation to your ability to practise or have direct Yes No
patient contact, or regarding your professional performance or your
professional conduct?
(d) Have you ever been convicted or found guilty of any criminal offence,
including a drug or alcohol related offence? Yes
Yes No
Are you the subject of pending criminal charges?
If YES to any of the above, please provide full details or, if you prefer, provide the information in a sealed envelope
marked ‘CONFIDENTIAL for Director of Medical Services ONLY’ appended to this application, and indicate
here that additional information is provided separately in this manner.
(e) In the past 10 years, have you had any adverse findings made against
you that may be relevant to your appointment (in addition to anything you Yes No
may have noted above)?
If you require further space to answer any questions, please attach separate pages, identified with the relevant
section number.
14. Referees
Please provide details of three independent professional referees, preferably at least two in your specialty, who have
been in a position to judge your qualifications and experience during the past five years and who have no conflict of
interest in providing a reference.
Referee 1
Name
Position held currently
Professional address
Postcode
Phone (BH)
Phone (Mobile)
Fax
e-mail address
Referee 2
Name
Postcode
Phone (BH)
Phone (Mobile)
Fax
e-mail address
Referee 3
Name
Postcode
Phone (BH)
Phone (Mobile)
Fax
e-mail address
15. Agreement/Undertakings
I understand that in assessing my application for appointment as a visiting medical practitioner, the health service will
make additional enquiries as to my suitability for the position.
(a) I authorise the health service to conduct a criminal record check in relation to my history. Yes
No
(b) I authorise the health service to obtain information relevant to my application from the New Yes
South Wales Medical Board and any other board regulating health practitioners, whether in New
South Wales or elsewhere. No
(c) I authorise the health service to obtain information relevant to my application from my current Yes
and any previous medical indemnity organisation/insurer.
No
(d) I authorise the health service to obtain information relevant to my supervision requirements Yes
(where applicable).
No
(e) I authorise the health service to seek information as to my past experience, performance and Yes
current fitness from my referees and from other persons as the health service considers appropriate,
including any relevant health service, college or other professional organisation. No
(f) I authorise access to the above information by representatives of the health service’s Yes
credentialing committees.
No
(g) If appointed, I agree to familiarise myself with relevant Area Health Service by-laws, policies Yes
and procedures and the NSW Health Code of Conduct and to abide by them.
No
(h) If appointed, I agree to abide by confidentiality and privacy obligations and understand that Yes
breaches may result in disciplinary actions which could lead to the cessation of my appointment.
No
(i) I agree to notify the Director of Medical Services/medical leader of any event/situation which
may impact on my ability to exercise my scope of clinical practice, whether it be due to medical
Yes
registration matters, or otherwise. This includes matters about which I consider that the
Director/medical leader would wish to be informed and, as a minimum, includes the kinds of
information covered in this application (such as any criminal charges or convictions, reductions in No
registration or insurance).
(j) If appointed, I agree to comply with relevant ongoing educational/certification programs of my Yes
college/association/joint consultative committee and to furnish details to the health service on an
annual basis as requested by the Director of Medical Services/medical leader. No
(k) If appointed, I agree to participate in annual service review. Yes
No
(l) I agree to promptly notify the Director of Medical Services/medical leader through the Incident Yes
Information Management System (IIMS) of any adverse clinical event I am involved in or become
aware of. No
(m) If appointed, I agree to work within my defined clinical privileges and to make a further Yes
application should I seek to extend the clinical privileges granted to me.
No
(n) If appointed, should any question as to my credentialing or clinical practice arise, I agree that Yes
the health service may make such inquiries as it considers necessary to assess whether that
credentialing or my clinical privileges are appropriate. No
Declaration
As recommended under the Standard for Credentialing and Defining the Scope of Clinical Practice of the Australian
Commission for Safety and Quality in Health Care with respect to the information required for initial credentialing of a
medical practitioner, the health service requires that the following declaration is completed by applicants.
I hereby declare that I have not been subject to any prior change to the defined clinical privileges or denial, suspension,
termination or withdrawal of the right to practise (other than for organisational need and/or capability reasons) in any
other organisations and that I have not been subject to any prior disciplinary action or professional sanctions imposed
by any registration board.
I hereby declare that the information contained in this application is true and correct.
Signature of Applicant ………………………………………………………… Date

………………………………
Please note: If for any reason you are unable to sign the declaration above, please explain the circumstances.
Application for Appointment, Credentialing and Clinical Privileges of Visiting
General Practitioners
1. Applicant and contact details

Primary Facility Honorary Yes No
Title & Surname
Given Name/s
Previous Name
Please include your previous name if it
appears on certificates
Date of Birth
Country of Birth
Residency status:
Australian Citizen Yes No
Permanent Resident of Australia Yes No
If No - List details of your current valid visa approval (include a copy with your
application)
Professional Address
Postcode
Phone (BH)
Phone (AH)
Fax
Mobile
Pager
e-mail address
Postal Address
(if different to Professional
Address above)
Postcode
Private Address
Postcode
This form sets a minimum information standard , however, information can also be provided
by the provision of a current curriculum vitae where indicated.
Please note: If you need to correct any error in your application, please initial the correction.
Please attach to this form:

• Current curriculum vitae
• Applicants who have not held previous appointments with NCAHS must provide certified copies of all
original qualifications
• Copy (copies) of current medical registration
• Copy of current medical indemnity insurance certificate (if applicable)
• Copies of relevant Visa documents (if applicable)
2. Application for Clinical Privileges
Introduction
The purpose of delineating the privileges of medical staff is to ensure a high standard of patient care by
matching the work that a practitioner wishes to perform with demonstrated skill and competence in a hospital
with the delineated role of the hospital.
Below are suggested privileges considered appropriate for general practice.
It is understood that training and experience can vary considerably and any general practitioner who feels
that relevant experience equips him or her to undertake procedures not listed should enter these in the space
provided and describe briefly their special training in these areas.
The Credentials Committee will consider all of the clinical privileges requested in your application. The
clinical privileges granted will take into consideration the delineated role of the hospital or service and its
support capabilities.
Please attach any supporting documentation or data that will assist the Credentials Committee to
consider your application.
Outline nature of clinical privileges sought (may be more than one):
GP anaesthesia GP obstetrics
GP emergency medicine GP orthopaedics
GP general surgery GP paediatrics
GP medical Other
GP mental health
Details are to be specified on following pages where relevant. Please note that the Position Description
specifies the clinical and other duties expected of all General Practitioner Visiting Medical Officers. For
example, this could be:
1. Participate in the one in ten 24-hour ‘Doctor of the Day’ general practitioner
roster to provide:
• Medical services to patients of the Emergency Department;
• After-hours on-call to all admitted patients of the hospital; and
• Admission and ongoing care of patients.
2. Provide medical services to patients who are admitted under the GP Visiting
Medical Officer.
3. Participate in multi-disciplinary case conferences.
Please list the Facility or Facilities for which you are applying:
Facility Name Provider Number
Primary Facility
Facility 2
Facility 3
Facility 4
Facility 5
Anaesthesia
Other than for local anaesthesia, specific clinical privileges in this area must be requested. If requested,
clinical duties will involve the administration of anaesthetics to low risk patients.
Subject to the role delineation of the hospital and experience, new applicants should be able to demonstrate
completion of a training program for anaesthesia consistent with the Australian and New Zealand College of
Anaesthetist guidelines for general practice anaesthesia. Applicants for reappointment will be required to demonstrate
their compliance with the guidelines regarding caseloads and continuing medical education activities.
If privileges are requested in this area, please indicate below and support the application with evidence of
your experience and training.
Clinical Privileges Sought
Emergency Medicine
Subject to the role delineation of the hospital and experience, a general practitioner may:
• Manage patients with minor injuries and ailments; and

• Provide resuscitation and stabilisation of patients prior to their transfer to
higher levels of care.
If further privileges are sought in emergency medicine, please indicate below the clinical privileges requested and
support the application with evidence of your experience and training.
Additional Clinical Privileges Sought
General Surgery
Subject to the role delineation of the hospital and experience, a general practitioner may perform minor surgical
procedures.
• Removal of cutaneous and subcutaneous lesions, e.g. BCCs, sebaceous cysts

and lipomata.
• Drainage of simple abscesses.
• Surgical treatment of ingrown toenail.
If further privileges are sought in general surgery, please indicate below the clinical privileges requested and support
the application with evidence of your experience and training.

General Medicine
Subject to the role delineation of the hospital, a general practitioner may admit and manage medical inpatients. Patients with a range of acute and
chronic health presentations may be admitted to rural hospitals. Patients with serious acute or complex internal medicine problems may be admitted
under networked arrangements or in consultation with an appropriate specialist physician.
If further privileges are sought in general medicine, please indicate below the clinical privileges requested and support the application with evidence
of your training (e.g. Fellowship in Advanced Rural General Practice/Graduate Diploma in Rural General Practice) and experience (e.g. Advanced
Rural Skills Post in adult internal medicine).
Mental Health
Subject to the role delineation of the hospital and experience, a general practitioner may manage inpatients with
mental health conditions that do not need to be in designated or gazetted mental health beds.
If further privileges are sought in mental health, please indicate below the clinical privileges requested and support the
application with evidence of your experience and training.
Obstetrics
Specific clinical privileges in this area must be requested. Subject to the role delineation of the hospital and
experience, a general practitioner may:
• Manage obstetric patients only if they possess a Diploma of Obstetrics or

equivalent and agree to conform to guidelines developed jointly by the Royal
Australian & New Zealand College of Obstetricians and Gynaecologists
(RANZCOG); or
• Manage obstetric patients as part of shared-care arrangements with specialist
obstetricians.
Applicants for reappointment will be required to demonstrate their compliance with these guidelines and continuing
medical education activities. If privileges are requested in this area, please indicate below and support the application
with evidence of your experience and training.

Orthopaedics
Subject to the role delineation of the hospital and experience, a general practitioner may manage uncomplicated and
simple fractures.
If further privileges are sought in orthopaedics, please indicate below the clinical privileges requested and support the
Paediatrics
Subject to the role delineation of the hospital and experience, a general practitioner may attend paediatric inpatients in
accordance with the relevant NCAHS Management of Paediatric Emergency Department Presentations and Admissions
within Paediatric Medical Role Delineation Levels 1 – 3 Policies. Refer NC-Area-Pol-2945-07, 2946-07, and 2947-07.
If further privileges are sought in paediatrics, please indicate below the clinical privileges requested and support the
Other
Other clinical privileges may be requested e.g. sexual assault services, drug & alcohol services, etc.
If other clinical privileges are requested, please indicate below and support the application with evidence of
your experience and training.

3. Qualifications * Can be detailed in CV
Qualifications University/Organisation Year obtained
For applicants who have not held appointments in NCAHS, please provide certified copies of qualifications or
evidence of qualifications obtained
Page 22 of 36
4. Other training and clinical experience * Can be detailed in CV
With respect to your response to Section 2, please provide details of clinical experience and post-qualification training.
Include the title of course/s undertaken, the organisation offering the course, and the qualification obtained.
Clinical Privileges
Privilege Sought Training and Experience Requested
Yes/No
Anaesthesia Yes No
Emergency Medicine Yes No
General Surgery, other

than minor surgery Yes No
listed above
General Medicine Yes No
Mental Health Yes No
Obstetrics Yes No
Orthopaedics Yes No
Paediatrics Yes No
Other – please list below:
Yes No
Yes No
Page 23 of 36
5. Clinical appointments * Can be detailed in CV
(a) Provide details on all current and previous public and private clinical appointments during the past five years
(including names of organisations and dates of appointment), or other places of practice (for example, general practice).
Organisation Term of appointment

Main appointment:
to
Other appointments: to
to
to
to
to
to
to
to
(b) Have you ever been denied a defined scope of clinical practice? Yes No
(c) Has your right to practise ever been withdrawn, suspended, terminated or reduced? Yes No
If you answered YES to either of the above questions, please provide full details.
Page 24 of 36
6. Academic appointments/teaching experience * Can be detailed in CV
Provide details of current and previous teaching appointments (including names of organisations and dates of
appointment).
Organisation Status/Level Term of Appointment

to
to
to
to
to
to
to
Page 25 of 36
7. Continuing medical education/continuing professional development
(a) Provide details of your involvement in continuing medical education/continuing professional development. Include
the name of the college/organisation program in which you are enrolled.
(b) Please attach current re-certification statement or certificate from the relevant college or
advise of CPD activities, college based and other, undertaken in the last three years.
(c) Have you satisfied the continuing medical education/continuing professional

Yes No
development requirements of your college membership/ fellowship?
Page 26 of 36
8. Clinical review/peer review
Do you regularly participate in formal quality and peer review activities? Yes No
Provide details of such quality/peer review activities.
Page 27 of 36
9. Grand rounds/health service educational activities
(a) What educational training activities for junior staff have you participated in over the past
three years?
(b) Are you prepared to conduct a grand round or other educational activities, for example, on a Yes No
once a year basis?
10. Have you any other information to support this application
11. Regulatory and indemnity information
(a) New South Wales Medical Board Registration Registration number:
Is this registration temporary? Yes No
If yes, provide details.
(Attach a copy of current Registration Certificate)
(b) Does your registration pertain to an area of need? If so, Yes No

please detail the type of assessment process undertaken prior
to registration.
(c) Are you registered as a medical practitioner in any other Yes No

state or territory of Australia, or in another country? If so,
please specify.
(d) Do you have any conditions or restrictions placed on your Yes No

registration (either in New South Wales or elsewhere)? If so,
please provide full details
(e) Do you have a medical board appointed supervisor? If Yes No

so, please provide details (including name and location of
supervisor and frequency of supervision)
(f) In the past, have you ever had any conditions or Yes No
restrictions placed on your registration (either in New South
Wales or elsewhere)? If so, please provide full details
(g) Current medical indemnity cover (if applicable) Expiry date of current policy:
Page 28 of 36
Attach a copy of current policy renewal certificate.
(h) Is your proposed clinical privileges reflected in or Yes No N/A (only if covered by
covered by your current medical indemnity insurance? TMF)
(i) Over the past 10 years, has there been or are there Yes No
currently pending any claims, settlements or judgments
against you?
(j) Has your current or any previous medical defence Yes No

organisation/insurer ever excluded or reduced any specific
area of practice, or terminated or denied coverage?
(k) If the answer to either of the above two questions is YES,

please provide a detailed explanation and specify the name
of the relevant medical defence organisation/insurer.
(l) Is your Provider Number subject to any restrictions?

Provider Number to be recorded in section 2 (b) Yes No
(m) Do you have a Prescriber Number? Yes No
Prescriber Number:
If YES, is it subject to any restrictions? Yes No
If restrictions apply, please provide full details.
12. Health status

Do you have a disability/health issue that:
• may impact on your ability to perform any of the cognitive and physical
functions which would fall within the scope of practice that you are seeking
in this application?
• may require special equipment, facilities or work practices to enable you to Yes No
perform any aspect of the scope of practice you are seeking in this
application? or
• might be relevant to determining your scope of practice?
(In answering this question, please have regard to the New South Wales Medical Board’s
Impaired Registrants (Health) Program, details of which are available at
www.nswmb.org.au under ‘Doctors’ Health’.)
If yes, please provide details of the disability/health issue, its impact on your ability to carry out the scope of practice
sought, and details of any special equipment facilities or work practices required.
This information can be provided on this form or, if you prefer, you can provide the information in a sealed envelope
Page 29 of 36
marked ‘CONFIDENTIAL for Director of Medical Services ONLY’ appended to this application, and indicate here
that additional information is provided separately in this manner.
This information is sought to enable an assessment to be made as to whether you can safely perform the
inherent/reasonable requirements of the work which you seek to perform at the facility/facilities by submitting this
application, or whether any reasonable adjustments might be required to ensure that you can work in a way that ensures
patient safety.
Page 30 of 36
13. Disclosure about disciplinary actions/criminal activity
(a) In the last 10 years, have you been the subject of disciplinary action in the course of your Yes No
work as a medical practitioner?
(b) In the last 10 years, have you been the subject of disciplinary action or professional Yes No
sanctions imposed by any registration board whether in New South Wales or elsewhere?
(c) In the last 10 years, have you been the subject of any investigation, inquiry or findings by Yes No
any registration board (whether in New South Wales or elsewhere) in relation to your ability to
practise or have direct patient contact, or regarding your professional performance or your
professional conduct?
(d) Have you ever been convicted or found guilty of any criminal offence, including a drug or
Yes No
alcohol related offence?
Are you the subject of pending criminal charges? Yes No
If YES to any of the above, please provide full details or, if you prefer, provide the information in a sealed envelope
marked ‘CONFIDENTIAL for Director of Medical Services ONLY’ appended to this application, and indicate
here that additional information is provided separately in this manner.
Yes No
(e) In the last 10 years, have you ever had any adverse findings made against you that may be
relevant to your appointment (in addition to anything you may have noted above)?
Page 31 of 36
If you require further space to answer any questions, please attach separate pages, identified with the relevant
section number.
Page 32 of 36
14. Referees
Please provide details of three independent professional referees, preferably at least two in your specialty, who have
been in a position to judge your qualifications and experience during the past five years and who have no conflict of
interest in providing a reference.
Referee 1
Name
Postcode
Phone (BH)
Phone (Mobile)
Fax
e-mail address
Referee 2
Name
Postcode
Phone (BH)
Phone (Mobile)
Fax
e-mail address
Referee 3
Name
Postcode
Phone (BH)
Phone (Mobile)
Fax
e-mail address
Page 33 of 36
15. Agreement/Undertakings
I understand that in assessing my application for appointment as a visiting medical practitioner, the health service will
make additional enquiries as to my suitability for the position.
(a) I authorise the health service to conduct a criminal record check in relation to my history. Yes
No
(b) I authorise the health service to obtain information relevant to my application from the New Yes
South Wales Medical Board and any other board regulating health practitioners, whether in New
South Wales or elsewhere. No
(c) I authorise the health service to obtain information relevant to my application from my current Yes
and any previous medical indemnity organisation/insurer.
No
(d) I authorise the health service to obtain information relevant to my supervision requirements Yes
(where applicable).
No
(e) I authorise the health service to seek information as to my past experience, performance and Yes
current fitness from my referees and from other persons as the health service considers appropriate,
including any relevant health service, college or other professional organisation. No
(f) I authorise access to the above information by representatives of the health service’s Yes
credentialing committees.
No
(g) If appointed, I agree to familiarise myself with relevant Area Health Service by-laws, policies Yes
and procedures and the NSW Health Code of Conduct and to abide by them.
No
(h) If appointed, I agree to abide by confidentiality and privacy obligations and understand that Yes
breaches may result in disciplinary actions which could lead to the cessation of my appointment.
No
(i) I agree to notify the Director of Medical Services/medical leader of any event/situation which Yes
may impact on my ability to exercise my scope of clinical practice, whether it be due to medical
registration matters, or otherwise. This includes matters about which I consider that the No
Director/medical leader would wish to be informed and, as a minimum, includes the kinds of
information covered in this application (such as any criminal charges or convictions, reductions in
registration or insurance).
(j) If appointed, I agree to comply with relevant ongoing educational/certification programs of my Yes
college/association/joint consultative committee and to furnish details to the health service on an
annual basis as requested by the Director of Medical Services/medical leader. No
(k) If appointed, I agree to participate in annual service review. Yes
No
Page 34 of 36
(l) I agree to promptly notify the Director of Medical Services/medical leader through the Incident Yes
Information Management System (IIMS) of any adverse clinical event I am involved in or become
aware of. No
Page 35 of 36
(m) If appointed, I agree to work within my defined clinical privileges and to make a further Yes
application should I seek to extend the clinical privileges granted to me.
No
(n) If appointed, should any question as to my credentialing or clinical practice arise, I agree that Yes
the health service may make such inquiries as it considers necessary to assess whether that
credentialing or my clinical privileges are appropriate. No
Declaration
As recommended under the Standard for Credentialing and Defining the Scope of Clinical Practice of the Australian
Commission for Safety and Quality in Health Care with respect to the information required for initial credentialing of a
medical practitioner, the health service requires that the following declaration is completed by applicants.
I hereby declare that I have not been subject to any prior change to the defined clinical privileges or denial, suspension,
termination or withdrawal of the right to practise (other than for organisational need and/or capability reasons) in any
other organisations and that I have not been subject to any prior disciplinary action or professional sanctions imposed
by any registration board.
I hereby declare that the information contained in this application is true and correct.
Signature of Applicant ………………………………………………………… Date

………………………………
Please note: If for any reason you are unable to sign the declaration above, please explain the circumstances.
Page 36 of 36

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9th July, 2008

To apply you will need to:

Applications can be lodged:

1. OCCUPATIONAL SCREENING & VACCINATION

2. APPLYING FOR THE POSITION

Your application should contain the following:

Before writing your application, you should:

5. THE RECRUITMENT AND SELECTION PROCESS

6. NOTIFICATION OF RECEIPT OF APPLICATION

7. WRITING YOUR APPLICATION

Key words used in Selection Criteria

Effective, Proven, Highly developed, Superior

EEO (Equal Employment Opportunity)

Quality Management / Quality Improvement

Occupational Health & Safety

Smoke Free Workplaces

8. APPLICATION FORM AND RESUME

You also need to complete a resume / curriculum vitae which includes

9. THE ROLE OF THE SELECTION COMMITTEE

11. REFEREE REPORTS

12. TERTIARY QUALIFICATIONS

13. CRIMINAL RECORD CHECK

14. WORKING WITH CHILDREN CHECK

15. PROOF OF IDENTITY

16. REDUNDANCY / RETRENCHMENT / TERMINATION

17. POST SELECTION FEEDBACK

· Read the position description and the selection criteria?

Do not send plastic sleeves or folders

POSITION TITLE: Visiting Medical Officer - Plastic Surgery

• Eligible for full registration with the NSW Medical Board.

KEY INTERNAL AND EXTERNAL RELATIONSHIPS

In Service Education : All staff are to attend the following courses:

Continuous Quality Improvement

Smoke Free Workplaces

Staff Apparel and Uniforms

The preceding information is an accurate statement of the duties, responsibilities and

EXECUTIVE OFFICER:_______________________________ Date:_________________

EMPLOYEE:______________________ ________________________ Date:______________

To be signed on commencement of employment.

DATE COMPILED: _____________________DATES REVIEWED:_______________________

SENSORY DEMANDS OF JOB TASKS

EXPOSURE TO CHEMICAL HAZARD

Under this Act:

Position: _____________________________________ Location: ____________________________ Employee No: _______________

Name: _______________________________________ Signature: ___________________________ Date: _______________

Position Information Closing date: 8th August, 2008

Position Vacancy No: Position Location:

Public Sector Redundancy Payments

SIGNED: __________________________________________________ DATE: ___/___/___

Contact Phone No's:

Position Applied for Name:

Position Applied for Number:

Qualification Full Name Issuing Institution Date Issued Sighted Verified

Signed: _____________________________ Date:______________________________

Occupational Assessment, Screening & Vaccination Against Specified Infectious

IMPORTANT REQUIREMENTS FOR

TB Screening must be done by a TB Service or by a delegate nominated by the TB Service.

YOUR APPLICATION FOR EMPLOYMENT WILL NOT BE SUCCESSFUL UNLESS YOU

Information is available at www.health.nsw.gov.au/ohs_vaccination/

Occupational Screening & Vaccination Applicant Package(V2) 3 August 2007 Page 1

Hepatitis B Evidence of a completed, age appropriate, course of hepatitis B vaccine and

Vaccinated applicants without documented evidence of their vaccine doses

Tuberculin skin testing must be delayed for a month after this

EXECUTIVE OFFICER:_______________ Date:_

EMPLOYEE:________ Date:

DATE COMPILED: _DATES REVIEWED:___

Position: _______________________ Location: Employee No: _

Name: _________________________ Signature: _ Date: ___

SIGNED: ________________________________________________ DATE: _/_/_

Signed: _ Date:__

Evidence of having had adult diphtheria, tetanus, pertussis vaccine (Documentation of

Hepatitis B vaccination documentation OR detailed information regarding your hepatitis

Documentation of Hepatitis B blood test result.

If your date of birth is in 1996 or later: evidence of receiving 2 doses of measles,

A completed Health Care Worker TB Assessment form OR documentation supporting