Nomination
of education
Nomination for approval (to be completed by the practitioner)
I, (insert title and full name of practitioner here), am currently subject to conditions on my registration
and/or restrictions on my right to practise imposed by the Health Ombudsman, as outlined in my (tick
and complete applicable option/s):
☐ schedule of conditions, effective from (insert date conditions came into effect here)
☐ schedule of restrictions, effective from (insert date restrictions came into effect here)
By signing this form I confirm (tick and complete applicable option/s):
☐ Course of education:
1.
I have attached a copy of the curriculum of the nominated education (insert full education name
and provider details here).
2.
The education I have nominated covers the topic/s for the education as outlined in my schedule
of conditions and/or schedule of restrictions
3.
a.
(insert topics here)
b.
(insert topics here)
c.
(insert topics here).
The education I have nominated satisfies any additional criteria outlined in my schedule of
conditions and/or schedule of restrictions.
☐ Tailored education program:
1.
The education program provider is (tick and complete applicable option/s)
☐ a registered health practitioner who holds registration with the (select relevant board) Board of
Australia; AHPRA registration number (insert number here)
and/or
☐ an unregistered health practitioner who holds accreditation with, and/or is a member of, (insert
full name of the relevant professional institute/association/accrediting body/other (please
specify).
2.
The provider’s contact details are
(Insert auditor’s title, full name and position title)
(Insert auditor’s place of employment/where audit is to be conducted)
(Insert auditor’s postal address)
(Insert auditor’s phone number)
(Insert auditor’s email address).
3.
I have attached a copy of the provider’s curriculum vitae to demonstrate the nominated provider
has the training, experience and/or qualifications in order to provide the education required.
4.
The provider is not in a close collegiate, social or financial relationship with me.
5.
The provider does not have any current conditions, undertakings or restrictions on their
registration and/or right to practise as a result of disciplinary action.
6.
The provider has not been the subject of any adverse findings in previous disciplinary.
7.
I have provided the provider with a copy of my schedule of conditions and/or schedule of
restrictions.
8.
I have attached a copy of the written education plan outlining the nature, content, proposed
assessment and outcomes of the education program.
9.
I am aware that, at the conclusion of the education, I must provide evidence of successful
completion of the education together with a reflective practice report.
10.
I am aware that, at the conclusion of the education, the Office of the Health Ombudsman will
receive a report from the provider regarding my participation in the education, assessment
results and my learning outcomes.
Signature:
Date: Click here to enter a date.
Please return this form with required attachments to the Office of the Health Ombudsman.
Office of the Health Ombudsman
v
Email: [email protected]
Call:
07 3158 1329
Fax:
07 3319 6350
Post:
PO Box 13281 George Street
Brisbane Qld 4003