Supervised practice plan and supervisor's agreement for international medical graduates sacar diSSS “AMPS Prose Medical This supervised practice plan and supervisor's agreement form is to be completed by the supervisors) snd applicant {or limited or provisional registration when: 4. applying for limited or provisional registration 2, seeking aperoval to change current supervised practice arrangements, Compicting this form + Read and complete all -equired questions Place Xin al apptcabie boxes {fend the Privacy Notice onthe Iasi page of te plan ~ Ensure that al pages and required attachments ar rekumed to ANPRA. ‘Type or print clearly in BLOCK LETTERS “Ensure all supporting documents aze.on Ad ection A: Details of applicant/intemational medical graduate What aro the detala of the apalicantintemational medical graduate? Family name anes. patient eee en oes Posiiontie General Practitioner Name of employing jon Alpha Medical Centre, Cobram Nama of employer contact Yinka Baiogun Location(s) st which the IMG wil be practising 24 Wiliam Street, Cobram Vie 9644 seas0 fecve rom: 25.une 2016 Page 1°Section B: Details of proposed principal supervisor What are the dots of the proposed principal supervisor? SPPAIO Rogistration number Me 0f0/0j0it[sisjay Registration type (eolect all that apply): General 5K Specialist rove details below) Speciaites ‘Geveral Pracice Number of years with general andlor spec General ‘Specialist 2s Quatiicaions a - MBBS, OCH{Sydnay) FRACGP _ i Postiontite (General Pracitioner _ Organisation Name ‘Alpha Medical Conte Crganisetonlesaton(s 24 Viliom Steet, Cooram Vie 3644 Daytime contact number(s) Business hours Mobile Alter hours STS reeset fh osisisi7iil2iajela} [olais|7|s\e|s\alelz| [ols temigii@gmailcom Note: The emt! adores wl be provided to the third party prover ofthe Boar's onine education and essesement ‘module for supervisors. ‘Are you a Director of Medical Services or Director of Clinical Training (or equivalent)? Yes x No Do you concurrently consult your own patients while providing supervision? Yes Have you completed the supervisor's online education and assessment module? a ves 2X No=Ioain eats wi be provided via oma ater the supervision arrangements have been approved. tecve fom: 25.Ame 2018 Poce 2SPPA-30 Requirements for supervisors Ittne proposed principal supervisor: + does not have specialist registration, andlor +s not qualified inthe sere fed of meccine as the proposed positon forthe IMG, andlor + does not have thee years FTE experience with gonoral andlor specialist registration in Australie, please provice a witten explanation forthe Board's consideration 23 to why the supervisor does rot meet the requirement, dtals Or the superviser’s training and experience, why they are suitable to 00 a auperiecr and how ti proposed that elieive suponvain wil be undertaken. ‘The Principal supervisor hes over 15yrs of general pracice experienced as assassed by the RACGP. He has been supevising ‘and mentering IMG in genersl practice for over 2yre He alae mentored medical student in general pracce and he in examiner ty the RACE, GQ ese atach 2 separate sieet i your proposal doesnot tin the space provided Directors of Medical Services cr Directors of Cincal Training (or equivalent) who are approved as principal supervisors ang who {ko responsi for appointing term co-supervisors for IMGS ara not required to provide ths procesal, bul must eneure tha each ‘erm op-auperviser completes the supsriso’'scnlina education and assesement mace, tects the requternanls for super sors in tie Guidelines and is quatried in the relevant Feld of medicine for each of the terms of the proposed positon for BING. For general practices oniy EBs the practice currently accreted to the RACGP Standards for General Practices (th ecition)? © Yes-AGRAL~ atachmont ie eaures Yes GPA Acaediaton - Atacimentivequred ‘No you must prove proposals the Bard eee blow) @85 You must etach a copy of your accreditation carats for each prectice location. ‘The copy does not need tobe carted - AHPRA vl ven tho information provided the general practice isnot curently accredited to the RACGP Standards for General Practices (4th edition) you must provide & \itten explanation to satsty the Board that you have structures in place 1 suppext sale practice by the IMG. @ Frease attach « separate sheet if your proposal does no tin the space provided sPPAO fective trom: 25 June 2018 Pave 9SPPA-20 Dotaile of ethor ragistrants currently cupervised by the principal euporvisor ‘The Board wil not normaly aporove any practioner to have direct supervisory responsibly for more then four IMGs. Pracivoners camo! be the cect superiso fr more than one IMG on level one supervision unless they de not consult wit (‘hor oun) patients wile supervising IMGs, Prospecive supervisors wi are proposing io supervise more than four IMGs must srovide @ proposal to the Board 2s to how they nl provide supension to each IMC. |A.DMS or DCT (or equivalent) whois approved 28 a pncil supervisor, and wh takes responsi for appointing tarm co-superviso's, must ensure that in delegating supersion, tnt lerm co-Syperisors wal nt supervise more than four IMGS at 2 time. Otherwise thay ae raquired ta provide & propose! o tha Board about haw the torm co-suparisor wil povida supervision to ach IMG. nee Pam aes Fernando Celuhennedige Sumudy Sennett MED MED Section C: Details of the first proposed co-supervisor “The Board expects principal cypervicere to be responsible fort adequate cupanvision of IMGs regeress of wheiher co-supervsors have been nominated to supondse the dayto-day pracee of Gs. The principal supervisor is sxpecied to signoff the supervision reports required by the Bosra, (One of more co-supervisors should also be appointed to ensura the IMG is sunervsed when the principal supervisors absont If ‘co-supenvser cannot be appointed in advance, the pricipal supervisor must inform the Board what rangement will be made for ‘he principal supervisors absence, for examplo, for sick leave oF snrual leave. ‘A Director of Medical Services of Director of Clinical Training (or exuivalen) who takes responsbilty for appointing term co- ‘scpericors may ba exam fom completing his section Oui musl ensure that any lar co-supenssors appointed meet the requierents defined in te Guidelines Whet are the details ofthe fist proposed co-supervisor? Fomly name ‘Sulla First given name ‘Abiodun Alade Registration type (solect all tht apply) General 7K Specialist (orovide tats besou) Number of years with general and/or specialist registration: Generet ‘Specialist Spectast $ a Quelicatons - ‘MBBS, DCH(Sychey) FRACG Posiontite (General Pracitionar Organisation Name ‘Alpha Mesical Genie, Wodonga SPPASO Etecve fom: 25,un0 2010 Page 4SPPA-30 Organisation locaton(s) ‘2 Mialoton Cresent, Wodonga Vio 3680 Daytime contact numbers): tenes hour oie Atorhours ‘oj2telojstefejejejs] [olajojaja|tjole loleTolajaltjelatiye Ema acrase (bsulull@yabao com — - Note: The email ederess wil be provided tothe tir! party provider of te Boar's onine education and assoxsmont ‘module for superiors. Have they completed the supervisor's online education and assessment module? x Yes No—lgin detais wil be provided via email ter he supervision arrangements have been approved. TEES bo they concurrently consult their own patients wile providing supervision? & Yes No Requiromonts for supervisors tthe proposed co-supervisor: + does not have specialist registration, andlor “1s not quattie in he same field of medicine as te proposed postion for he IMG, andor * does nct have lee years FTE experience wih general andlor specials registration in Australis, please provide a written explanation forthe Board's consideration a8 1 why the suparvisar does not meet the requirement, tes ‘ofthe supervisors taining and experience, why thoy ara suitable to be @ supervisor and how tis proposed that effective ‘supervision willbe undertaken, @ Please atcha separate shes your proposal doos na fin the space provided Details of other registrants currently supervised by the first co-superviser sPA0 fectve tom: 25.hune 2016 Page sWhat are the details ofthe second proposed co-supervisor? Fenty ame Registration type (select al that apply): = Genera TT) Specialist (provide deta: bolow) Species ‘Number of years with gonaral andlor specialist registration Spe Business hours Mobite ‘ter hours Note: The email address wil be provided tote thc paty provider ofthe Snares ontne education and assessment ‘medule for surervisors. Fave they completed the supervisors onine education and assessment module? Yes "No ~togin dete wal be provided va ema ater the superisionerrangements have been approved, EEE 00 chey concurrenty consult their own patints while providing supervision? SPAS techie rom 25.une 2018 ‘ Pose 6SPPA-30 Requirements for supervisors It he proposed co-superisor: + d98s not have specialist registration, andor isnot qualfied In he same feld of medicine as he proposed position forthe IMG, andlor + doss not have thee years FTE experionce with general andlor specialist reglataton in Australi, lease provide a writen explanation forthe Boar's consideration 2s lo why the supervisor does nat meet the requirement, cetals ofthe superiso’s taining and experience, why thoy are sulable fo be a suporveer and how itis proposed that sfecive supervision wil be undertaken, @ Pease atic separate sheet your proposs does not inthe epace proved Details of other registrante currently supervised by the second co-supervisor 2 a aerate 3 a lata a aR Section E: Details of the third proposed co-supervisor (if applicable) What are the details of the third proposed co-supervisor? Fomiy name Registration yp (select all that apply): Gonerat Specialist (rovide dotals belom) Specialties — Numbor of years with general andlor specialist registration: Ge Specialist Spaciaist Qualieations Postiontide. SPPASO roche em 28.4 2016,Organisation Name Organisation catin(s) Daytime contact numbers) Businoss hous Mobi aller hours Note: The email addrass wil be provided to te tied party provider ofthe Boards cnine education and ssseesment ‘adie for supervisors. Have they completed the supervisor's online education and aseeesmont modulo? Yee 'No—Iogin dots wil be provided via email afer the supercon arrangements have boon approved. Do they concurrently consult ther own patients while providing supervision? Yes 5 te Requirements for supervisors Ihe proposed coupe: “does not nave specie eistaon, andor “fo not quali nthe some eld of madcine ws te propose polo or the MG, anlor + dos note Ee years FTE experince nh general anc spect repstalion i Aue, ‘ease prove a wrten expansion forthe Boars consideration a o why the supenisor Goes not meet he requirement, tds Ste spss tainty ore wperanen why oy are sab a mipervin ee tow hs opened that elton Siperasbr ef bs Undaron @ Please stach a separ sheet i your proposal oes not fin the space provided Details of other registrants currently supervised by the third co-supervisor ecine fom 25.1 2016 Page 8Details of proposed tarm co-supervisors (for hospital positions only’ MSs and OTs (or equvelent can delegate day-to-day supervision to term co-supervisors, DDMISs and BCs (or equivalent) win take resporiity Tor appainting tem co-supervisors mus! ensure that any ttm ce-supenvsore appointed meet the cequrements defined in the Guldelnes. DMS or OCTs must provide the dela of orm ossubervs0rs below, so tat they can complete the onine education and assessment module for nupervisore Details of term co-supervisors appointed by & DMS or DET @ rier det blow o atach a separate sheet wih the folowing deta (only incude em co-supenisors append to. euporvice thi a). Detalls of first term co-supervisor amilyname a 7 Fist given name _ - _ : Regist Registration type (soleet al that apply): Generat Specialist Email address Note: The emai acess wil be provided tothe third party provider of the Boare's online education and assessment ‘module tor supervisors, Have they completed the supervisor's o Yes No login detais wil be provided via ema after the supervision arrangements have been approved. Don't know e education and assessment module? Details of second term co-supervisor Family name Fist ven name Registration type {select all that apply): General <> Speciatiet Email address ‘The email adoress wl be provided tothe third party orovder of te Boares onlin education and assesment ‘modu for eupericors, Have they completed the supervisor's online education and assessment module? Yes No login details wil be provides via email ator te supervision arangements have been approved. 1 Dont know sPPAgO Page 0SPPA-3¢ Details of third term co-supervisor Family name FReglctration number Registration type (select al that apply): ee oooo$§ = melo! | | LELITT TD General LI Specialist ‘Note: The email aides wl be provided tothe third party provider ofthe Boere's online educetion and assessment ‘modile for supervisors. Have they completed the supervisor's online education and assessmont modulo? Ty Yes ‘No login dois willbe proved vs email after he supenision arrangements have been spproves. Dorit know ecve ren: 25 tne 2016 Page 10SPPA-30 Section G: The proposed supervised practice plan ALL SECTIONS MUST BE COMPLETED Please ensure he deta ofthe supervised practice plan are completed by the principal supervisor together withthe IMG. @ sete space below or atach yous oun supervised practice pian which indices these elements Iti be ensured that ine IMG gots all the neccessary suppory for sae practice within the General practice Got ‘The supervision arrangement as sipuin! by the AHPRA wil be sty adhered fo. IMG willbe supported in all ways towards achlovingNer vocational regiswation Alendance at regula clinical meetings in-ncuse and tose cqganised by other sorvee provider, wil be encouraged. Patient demancs, time management and workioed wl iso be balanced, so thatthe IMIG wil have enough time fr professional development. IMG wil aso be encourage to partiipate in RACGP examination workshops, which could be of hep in ataining vosationnal registration sePA20 fectve ern: 25.une 2016 Page 14SPPA-30 Frequency of meetings with principal supervisor and type of meetings ‘There wil be regular weekly face to face meeting with he Phone consultation is available al te tine IMG is also encouraged to seek immediate advise on any case, that micy pose chlenges lo her. IMG wll not be lef without edequate supervson plan and suppertin place ‘Sm group fearing on waokty baal, wl be ancoureged Folowship education suppor ny the Murray PHN and Sogong training, wil alsa be supported with diferent cases review end appraisal Availablity of co-suiporvisors for asistanco. How wilf the IAG cack assistance? For example, fave to face, lleptione ot ‘The Coupsnisar val be avalabe on phone contac all the tie and trough telesanference How wi the IMG’s performance be assessed? For example, direct observation of practice, mecical record reviews, case reviews els. |UG pertoramnace wil be assessed by direci observation, regular medical record review and plann ‘Smal grcup leaming activites, wil also be used to assass the ING SPPA0 fecive rom 25 June 2016 Page 12SPPA-30 Section H: Signatures ‘By egnng i frm, you cot: ‘+ tha the nfommatien abeut you on thi form fs comolote, accurate ar up ode, and st you wl promt not AMPRA {rat information cages, end 4 nat you neve reac the Privacy Nobis on ths fal page ofthe tom. APRA'S privacy policy expats how yo may 200068 ae sk correction of yor personal mocnaton hel by AHPRA and he Soars, outa comple APRA ‘Beta broach of your privacy end how your coral ul be deat ih “This policy can be aocoeaud 2 ue shors gov loinc Nome cfapntcansQ . ([ABiSSUN ONERSBE ATI ESTE J] Signsture of aaplcarsntc Lf Ss] Ba Name ot employer ontact lor [Mews Breage ‘ios forsee" 7 | s “| PENSE) BSE) L_ Beow iano ot (ha losuN ARCADE Sutures A ena ame otseeand ensuperisa” f 1 ‘Slenatue of second eo eparviaar ate i ) moo Name ftird eoapenrsor ‘Signatrs ct cam powieee 1 VOT a ‘sPP5.20 Ets am: 25.9 2018 eae 18Principal supervisor's agreement | agree to be the principal supervisor of (name of IMG) OF Abiocun Oyebade Alboye: ‘anc to provide supervision in accordance with the Board's Guidelines, | confirm that | can provide the folowing levels of supervision. | understand that the level of supervision will be termined by the Board. Note: Refor tothe Guiotines: Supervised practice fr interational medical gracuates ora full description for each lovel of Supervision. Please mark the relevant noxes below. Level 1~ the supervisor takes direct and principal responsibilty foreach inclvigual patent Levet 2 the supsnvsor shares withthe INS responsibilty for each invoual atin’ {Level 3 tho IMG takes primary responsibilty for cach inivcust patient Level 4~ the IMG takos ful responstiliy foreach individual patent I the atove levels do not correspond to the proposed lava of supervision for hospitel based postion, describe ths lavel of supervision and supervision structures, Please sttacin a separate shoo your propel dss not tin the epeee provided urther agree to 1. ensure as far a5 possible, that tne ING is practsing safely end is not placing th publ aris 2. observe the IMG's work (ar where applicable, delegate the observation of dayto-iay work o appropriately qualified co- supervisors), conduct case reviews, periodically candct performance reviews and address any probleme that are identified 2. ensure thal any tem co-supervisors that! appoint that are delegated the day-to-day cuperviion meat the requirements set in the Board's guidelines (hs is only applicable to DMS or DCT (or equivalent) a hospital seting) 4. ensure before | dalegate supervision fo a temporery co-supervisr, that hashe has ganaralanilor specialist regetration and is approoraely experienced t provide the supervision 5. not the Board immediately i | have concems about the IMG's cnicel peremance, health or conduct orifthe RUG fs to comply with condition, undertakings ar requirements of registration 6. ensure thatthe IMCS practises in accordance with wark amangernonts approved by the Boars 7. ensure that Boars approval has beer cbisined for any proposed changes to supervision or work atrengements before they are implements 8. inform the Board if am no longer able or wiling 1 undertake the role ofthe I's supervisor 9. provide reports to the Boar ina form approved by tho Board including an orientation report end @ work performance report ‘afer roe months inal registration and work performance reports at renewal or new application cra subsequent inorvals 138 determined by the Board 10. complete the online education anc assessment maduie (gin deala wil he provided after the supervision arrangements have boon approved). Signature pa supervisor Dae ras - — So ) oO Bri (isi {| tous} /j2teltj? ‘sPpm20 foc fm: 25 June 2018 Page 14This AGPAL Confirmation Certificate acknowledges that the following practice is ACCREDITED with Australian General Practice Accreditation Limited (AGPAL) Accredited General Practice Alpha Medical Centre Cobram 24 William Street COBRAM VIC 3644 Practice Id: GP10370 Date of Accreditation Survey: 31 August 2016 Standards: GPEd4 Date Accreditation Awarded: 14 November 2016 Accreditation Expiry Date: 23 September 2019 Authorised By Dr Richard Choong Chair ‘The paviog of acorectation once granted i tree yeas THSAGPAL Contimaton Conia nsec to enty the grates curon aus wh AgPAL CConttmation Print Date -15 November, 2016