Local WBA Coordinator Application

Local WBA Coordinator Application

Please fill out this form to apply
Before completing this application, please familiarise yourself with the Local WBA Coordinator Position Description.

If you do not meet or need clarity around the below eligibility criteria, please contact the WBA team on 61+3 9320 0406 or via wba@acem.org.au for assistance.
Do you meet each of the criteria below? *

Currently undertaking clinical work (0.5 or greater) with the relevant Emergency Department. I am in Good Standing with my College (i.e financial and CPD compliant with ACEM or RACP). I am not the sole DEM, DEMT or Mentoring Coordinator at the relevant site. I have completed the 3 ACEM Assessing Cultural Competency Modules. I am a currently certified FACEM or, if applying for the role in a Paediatric Emergency Department, a current certified FRACP or Fellow as defined by the FACEM Training Program Site Accreditation Requirements.
Name *

First Name Last Name
Your Email *
Hospital where Local WBA Coordinator Role to be undertaken *

Street Address

Street Address Line 2
Are you replacing an existing Local WBA Coordinator? *

Yes No
Name of Exiting Local WBA Coordinator *

First Name Last Name
If you will be working in a Co-Coordinator model, please list the name/s of other Local WBA Coordinators at the site.
Qualification *

FACEM FRACP PEM Specialist
Date appointment effective *

Day Month Year
Date

The following questions relate to the Selection Criteria and the data will be used to tailor educational resources and orientation documents to your needs.
A requirement of being a Local WBA Coordinator is having an active engagement in workplace-based assessments within the emergency department in which they work. Please give a brief explanation of the how the WBA system works at your site e.g roster, trainee responsibility, scheduled days etc. How effective are these processes? *
Please detail any prior experience you have in the delivery of medical education activities, particularly in relation to mentoring, supervision and/or assessing junior doctors; including the provision of honest, appropriate and timely feedback. *
Please enter the following contact details for your Director of Emergency Medicine (DEM) and one of (if multiple) the Directors of Emergency Medical Training (DEMT) at your site. An email will be shortly sent to them asking them about your suitability for the role and to confirm your nomination.
DEM Name *

First Name Last Name
DEM Contact Email *
example@example.com
DEMT Name *

First Name Last Name
DEMT Contact Email *
example@example.com
Memorandum of Understanding

The Local WBA Coordinator Position Description sets out the rights, responsibilities and obligations of Local WBA Coordinators and the College, and all Local WBA Coordinators are required to indicate their understanding and acceptance of the conditions detailed in this document. Accordingly, you are asked to review and consider the duties outlined in the Position Description and complete the acknowledgement below:
*

I confirm that I understand my rights and responsibilities as set out in the Local WBA Coordinator Position Description.
Should you not be able to complete the acknowledgment, please contact the ACEM WBA team wba@acem.org.au
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Local WBA Coordinator Application

The following questions relate to the Selection Criteria and the data will be used to tailor educational resources and orientation documents to your needs.

Memorandum of Understanding