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South Eastern Sydney & Illawarra Area Health Service

Application Form for Appointment as a VMPEndocr

BACKGROUND INFORMATION: PAEDIATRIC CARDIOLOGY

Hospital Role Delineation within that discipline & Level of Service.

Site Hospital Role Delineation *St George Hospital Level 3/4 PaediatricsSydney Children's Hospital/NSWChildren’s Heart Service(SCH/NSWCHS) Level 6 PaediatricsRoyal Hospital for Women Consultative neonatal

* Detailed Hospital Role delineation documents are available on request: In general, Level 6 facilities have a multi-disciplinary highly specialised team and appropriate equipment to deal with the most complex surgical conditions in that specialty 24 hours a day, seven days a week. Level 4 services are focussed on local and generally less complex cases that have an unlikely need for high dependency care and sub-speciality services. Level 4 facilities will in general have limited after hours services and in that discipline will be networked with Level 6 services for complex patient care.

+ Individuals appointed to each type of appointment must be willing and able to meet the needs of the relevant facilities as outlined in the background information.

Types of Positions

Number to be appointed

Brief Position Overview

22AArea

Tertiary Paediatric Cardiology

2 Sydney Children’s & Royal Hospital for WomenComprehensive clinical and consultative service including diagnostic and interventional echocardiology (including trans-oesophageal echos); admitting, outpatient, on call and consultation privileges to SCH and consultant/echo services to RHW. Appointees to the category will automatically be appointed to NSW Children’s Heart Service but will not automatically be offered privileges at Children’s Hospital Westmead (CHW). Emergency catheter privileges only on the Randwick catheter site may be required but it is expected patients requiring catheters will be transferred to CHW

22BPaediatric Cardiology

1 St George HospitalThis St George position has diagnostic, non-interventional echocardiology and general cardiology consultation only, without on call or admitting privileges. The successful applicant will automatically be offered an appointment to NSW Children’s Heart Service but will not automatically be offered privileges at either SCH or CHW. This position may be significantly modified during the term of this appointment to be consistent with Area Health Service Clinical Service Planning.

22CPaediatric Cardiology Cross Accredited as part of NSW CHS

As RequiredSydney Children’s & Royal Hospital for WomenIndividuals who are currently appointed to CHW as cardiologists within the NSW Children’s Heart Service will be eligible for appointment to SCH with consultation privileges. Any other privileges would be negotiated only if required. This cross appointment will only be for the duration of the substantive CHW appointment. A letter of support from the Director of NSWCHS will be required to accompany this application form.

Name……………………………………… 1

APPLICATION FORM

POSITION DETAILSPosition applied for:

Surname: Other Names

Postal Address:

Email Address:Telephone Number: Business Mobile

Home Fax

Position Types Available Preferred Category of appointment

(please tick)

List other subspecialty interest you wish to apply for, if not specified in

(Column 1)

Tick here if applying for an appointment in:

□22A

Area Tertiary Paediatric Cardiology

Visiting Medical Officer

□

Honorary Medical Officer

□


□22B

Paediatric Cardiology


□


□


□22C

Paediatric Cardiology Cross Accredited as part of NSW

CHS


□


□

This application must be accompanied by the following documentation(please tick checklist below)

DOCUMENTATION REQUIRED: For VMP’s with current SESIHS triennium appointments:

□ Copy of current Medical Indemnity Insurance□ Updated Curriculum Vitae (Note: This is a recruitment process and as such it is competitive. An up-to-

date Curriculum Vitae is required for comparative consideration against other candidates)□ Evidence of Continuing Medical Education □ For current triennium VMPs, whose employment is under a working visa, Certified (*see below) copy of

current Passport and/or Visa covering the Quadrennium period.□ Completed and Signed consents for a Criminal Record and Working with Children Check (attached)□ Completed and Signed Health Declaration (attached)

Name……………………………………… 2

□ Fully completed application form with responses to the selection criteria

DOCUMENTATION REQUIRED: For New Applicants (eg: applicants not currently holding a full, triennium appointment with SESIHS)

□ Copy of current registration with NSW Medical Board/evidence registrable□ Copy of qualifications & evidence for special privileges if sought

(eg Medical Degree, MBBS or equivalent, certification from recognised Colleges supporting subspecialty qualifications and special privileges)

□ Up-to-date Curriculum Vitae□ Evidence of Continuing Medical Education □ Certified (*see below) copy of Certificate of Fellowship of the appropriate College or Professional

Institution□ Certified (*see below) copy of current Passport. The original must also be brought to interview to be

sighted. □ Certified (*see below) evidence of your eligibility to work in Australia (eg Certified copy of Australian

Passport (current), International Passport (current) and Work Visa (current), Australian Birth Certificate, or Certificate of Australian Citizenship)

□ Copy of Marriage Certificate or Deed Poll advice if your name now differs from that appearing on the documentation listed above

□ Copy of current Medical Indemnity Insurance Cover □ Completed and Signed consents for a Criminal Record and Working with Children Check (attached)□ Completed and Signed Health Declaration (attached)□ Fully completed Application Form with responses to the selection criteria

*CERTIFIED BY JUSTICE OF THE PEACE or NOTARY PUBLIC

I, Dr _________________________certify that the information supplied with this application is correct and hereby authorise South Eastern Sydney and Illawarra Area Health Service to obtain information as to my past performance as a medical practitioner.

Signed: ____________________________________________________Date: _____/___/__

To Submit Applications

Applications must be accompanied by the listed supporting documentation above and can be submitted in the following ways:

By post to: Senior Medical Officer ServicesSESIHSLocked Bag 8808South Coast Mail Centre NSW 2521

In person to: Senior Medical Officer ServicesLevel 2, West WingLawson House, Wollongong Hospital

As certified documents are required, emailed or faxed applications cannot be accepted.

Current Triennium Visiting Medical Practitioners appointed to the Northern Network of the Area Health Service have been advised in writing of their eligibility to apply for the above positions.

Criminal Record Checks and where appropriate Working with Children Checks will be conducted on all recommended applicants.

Name……………………………………… 3

All applicants are required to complete ALL the following pages. Additional A4 pages may be attached if necessary.

ESSENTIAL CRITERIA1 Demonstrated relevant current clinical practice at a high standard relevant to the years of experience:

2 Demonstrated commitment to quality improvement, patient safety and risk management:

3 Preparedness to participate in any on call roster and other clinical roles as advertised, if requested and credentialed: (Please tick) Yes No If no please Comment:

4 Demonstrated commitment to continuing self education and development (eg MOPS, CME certificates, peer review, QA):

5 Demonstrated ability, fitness and wellbeing to fulfil the full scope of clinical privileges advertised in the position:

6 Evidence of commitment to the goals of an organisation in which you have worked beyond direct patient care (eg committee representation):

7 Demonstrated participation in teaching and training of medical officers both undergraduate and post-graduate:

HIGHLY DESIRABLE CRITERIA8 Evidence of commitment to providing high quality health services and continuity of care to the local population

Name……………………………………… 4

of that facility network as determined by SESIAHS:

DESIRABLE CRITERIA9 Demonstrated good communication, organisational and interpersonal skills:

10 Demonstrated ability to work in a multidisciplinary team:

11 Demonstrated ability to adapt clinical practice in accordance with emerging trends:

12 Preparedness to participate in provision of services at an Area level established during the appointment period following an appropriate consultative process: (Please tick) Yes No If no please Comment:

13 Evidence of contribution to research

Demonstrated evidence of sub-specialty interest & training relevant to the position14 Outline Post fellowship training in subspecialty areas and any expertise in management:

15 Could you also include any other specific procedures you are endorsed as competent to perform unsupervised

Name……………………………………… 5

that are above and beyond the usual training within that discipline. This is arbitrarily defined as procedural skills that less than 10% of graduates within that specialty are trained to perform routinely. Please identify whether logs are available or not:

Demonstrated experience in the care and management of children

16 If yes, please present evidence of (i) formal training and (ii) experiential learning in the management of children less than 12 years old:

(i) Evidence of formal training:

(ii) Evidence of experiential learning within the last five (5) years:

Possible Impediments

All applicants are to complete this section fully. Whilst it is understood you may summarise the details of any individual matter, failure to declare a matter may result in immediate termination or suspension of any employment

offered as a result of this application. If more space is required add an appendix.

17 If appointed to the advertised position, is there any issue that may impede you fulfilling the full scope of activities and privileges required of the position?

18 Have you had any limitations placed on your clinical privileges or appointment in any previous medical position? If yes, please specify the nature, cause and duration of those changes?

19 Has there ever been any conditions placed on your medical registration in any state or country in which you have practiced? If yes, please specify the nature, cause and duration of these conditions?

20 Have you been involved in any medico-legal claim (settled/unsettled / claimed) since graduating from medicine? If yes, please briefly specify nature of event and outcome of these actions if known. (eg action related to inadequate consent: claim successful)?

21 Have you been the subject of a formal internal workplace complaint in the last 3 years? If yes, please specify

Name……………………………………… 6

the nature of that complaint, when that complaint occurred, and if known, the outcome. (eg written complaint about handwriting – dismissed)?

22 Have you been the subject of a complaint to the HCCC or other statutory Body in the last 3 years? If yes, please specify the nature of the complaint and if known, the outcome (eg HCCC complaint about an account – resolved)?

23 Is there any relevant criminal history or pending criminal allegations that had, or may have, any impact on your possible employment or registration as a medical officer? eg, assault, fraud, unethical behaviour, theft, child abuse allegations?

RefereesAll applicants must nominate at least four referees meeting the following criteria:

Referee – criteria A;o At least one non-medical clinical colleague with whom you have worked in the last three years.

Referee – criteria B;o At least one medical clinician outside of your clinical discipline to whom you have referred or been

referred patients in the last three years on a regular basis. Referee – criteria C;

o At least one manager (clinical or non-clinical) within your current place of work to whom you have some accountability. If you hold a current public hospital clinical appointment in NSW and are active in that position, it is preferable that this be the site from which you select that manager.

Referee – criteria D;o At least one clinical peer from your discipline who can comment on your clinical practice in the last

three years.

NOTE: Referees can fulfil more than one criteria but at least four referees are to be supplied. Please specify on your application whether your referees should only be contacted consequent to you being short-listed.

The South Eastern Sydney and Illawarra Area Health Service reserves its right to require applicants to nominate additional referees if required and to contact the current supervisor of applicants prior to any offer being made, unless there are acceptable reasons for this not to occur. Applicants will be advised prior to this contact being

made.

Referee 1Referee Name Referee Criteria (A,B, C and/or D) Postal Address

Email AddressTelephone Business Mobile


Email Address

Name……………………………………… 7

Telephone Business Mobile





Please note: Referees contact details will only be available to the appointment panel and SMO Services.

Have you included the following documentation?

DOCUMENTATION REQUIRED: For VMP’s with current SESIHS triennium appointments:

□ Copy of current Medical Indemnity Insurance□ Updated Curriculum Vitae (Note: This is a recruitment process and as such it is competitive. An up-to-

date Curriculum Vitae is required for comparative consideration against other candidates)□ Evidence of Continuing Medical Education □ For current triennium VMPs, whose employment is under a working visa, Certified (*see below) copy of

current Passport and/or Visa covering the Quadrennium period.□ Completed and Signed consents for a Criminal Record and Working with Children Check (attached)□ Completed and Signed Health Declaration (attached)□ Fully completed application form with responses to the selection criteria

DOCUMENTATION REQUIRED: For New Applicants (eg: applicants not currently holding a full, triennium appointment with SESIHS)

□ Copy of current registration with NSW Medical Board/evidence registrable□ Copy of qualifications & evidence for special privileges if sought

(eg Medical Degree, MBBS or equivalent, certification from recognised Colleges supporting subspecialty qualifications and special privileges)

□ Up-to-date Curriculum Vitae□ Evidence of Continuing Medical Education □ Certified (*see below) copy of Certificate of Fellowship of the appropriate College or Professional

Institution□ Certified (*see below) copy of current Passport. The original must also be brought to interview to be

sighted. □ Certified (*see below) evidence of your eligibility to work in Australia (eg Certified copy of Australian

Passport (current), International Passport (current) and Work Visa (current), Australian Birth Certificate, or Certificate of Australian Citizenship)

□ Copy of Marriage Certificate or Deed Poll advice if your name now differs from that appearing on the documentation listed above

□ Copy of current Medical Indemnity Insurance Cover □ Completed and Signed consents for a Criminal Record and Working with Children Check (attached)□ Completed and Signed Health Declaration (attached)□ Fully completed Application Form with responses to the selection criteria

Name……………………………………… 8

To Submit Applications

Applications must be accompanied by the listed supporting documentation above and can be submitted in the following ways:

By post to: Senior Medical Officer ServicesSESIAHSLocked Bag 8808South Coast Mail Centre NSW 2521

In person to: Senior Medical Officer ServicesLevel 2, West WingLawson House, Wollongong Hospital

As certified documents are required, emailed or faxed applications cannot be accepted.

Name……………………………………… 9

Name……………………………………… 10

Name……………………………………… 11

Name……………………………………… 12

Name……………………………………… 13

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