01 Application for General Registration

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PO Box 248 T: 1300 721 732Collins Street West Vic 8007 T: +61 3 9286 1888E: [email protected] F: +61 3 9286 1880W: mrpb.vic.gov.au

Office Hours: Monday Friday, 9.00am to 5.00pm

INFORMATION & INSTRUCTIONS FOR APPLICANTS(GENERAL REGISTRATION)

Before completing the application form applicants should carefully read the following information and instructions.

Please use block letters when answering questions. Tick the applicable box to answer questions. If there is insufficient space on the form to answer a question please attach a separate sheet.

ADDRESS

If you are concerned about your private address appearing on that part of the register that is open to the public forinspection, you can provide an alternate address (work address).

PROOF OF IDENTITY

The following documentation must be provided with the application as proof of identity:

a certified copy of one of the following documents of identification: a current drivers licence, a currentpassport, or another official form of identity that has a photograph; and

if you have changed your name and any of the documents supporting your application are in your formername, you must supply an original or certified copy of an official document (e.g. marriage certificate, deed poll,change of name certificate) attesting to the name change.

QUALIFICATIONS FOR REGISTRATION

In accordance with section 6 of the Health Practitioners Registration Act2005, to be eligible for general registrationyou must be qualified for general registration in the health profession. The qualifications required for registration canbe located at www.mrpb.vic.gov.au.

Applicants must submit documentary evidence for each approved qualification required for registration with the Board.A certified copy of the qualification, or a certified copy of an academic transcript conferring successful completion ofthe qualification, must be provided.

Recent graduates must also provide certified evidence attesting to the successful completion of any period ofsupervised practice prior to gaining employment as an independent practitioner. Any one of the followingdocumentary evidence must be provided:

A Statement of Accreditation issued by the Australian Institute of Radiography;

A statement of successful completion of the intern model program from the Professional Accreditation andEducation Committee of the Professional Accreditation and Education Board, Australian Institute ofRadiography;

Certificate of Accreditation issued by the Accreditation Board of the Australian and New Zealand Society ofNuclear Medicine;

A statement of successful completion of an internship from the Nuclear Medicine Internship Committee of theVictorian Society of Nuclear Medicine Technologists; or

A statement from the university verifying successful completion of that period of supervised practiceundertaken within the program of study designed to facilitate the achievement of competent practice within thespecific medical radiation discipline.

If your qualification is not listed as an approved qualification on the Boards website then please contact the Board.


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WORK STATEMENT

You are required to supply the Board with a work statement from your current employer or, if not currently employed,from your most recent employer as evidence of your recent clinical practice.

The statement must be dated, be on the employers letterhead and must be signed by the responsible workplacemanager/director or human resources manager. The statement must confirm the dates of employment, the nature ofthe duties performed, and the mode of employment (i.e. full-time, part-time or casual). If your employment was part-time or casual, the total number of hours worked per week must be stated. If you are supplying a photocopy of the

work statement, it must be a certified copy.

PROFESSIONAL INDEMNITY INSURANCE

All registrants are required to have professional indemnity insurance not less than $5,000,000. If you do not have therequired level of insurance and do not provide an employer declaration, you will have a condition imposed on yourregistration that you cannot engage in medical radiation practice.

EVIDENCE OF REGISTRATION/LICENSE FROM ANOTHER JURISDICTION

If you currently hold a registration/license with another authority you must supply an original or certified (see below)copy of your Annual Practising Certificate or Use License from the jurisdiction you are currently entitled to practise in.

If the jurisdiction in which you are registered does not issue an annual practising certificate, a letter or certificate ofgood standing will suffice.

ENGLISH LANGUAGE COMPETENCY

The Board must be satisfied that an applicant can communicate effectively in the English language. A good commandof both written and spoken English is required. Please refer to the English Language Standard on the Boards websiteunder policies for further information.

APPLICATION FEE

You must pay the prescribed fee as set out by the Board. The schedule of fees may be obtained on the website underregistration. The fee payable will only grant you registration to 30 November 2012. Under the Act, it is theresponsibility of the medical radiation practitioner to ensure they are continually registered.

STATUTORY DECLARATION

The information provided in the application must be verified by Declaration under section 107 of the Evidence Act1958. The application will not be processed unless it is properly witnessed and includes the full name, address andqualification of the witness and includes the required documentation. A list of persons who may witness a statutorydeclaration is provided on page 3 of these instructions.

Please note that Medical Radiation Practitioners cannot witness Statutory Declarations in Victoria.

CERTIFICATION OF DOCUMENTATION

All copies of documents (e.g. qualifications, proof of identity) that are required to be submitted with the applicationmust be certified copies. A certified copy is a photocopy that has been certified by one of the persons listed on page 3of the instructions as a true and accurate copy of the original document.

The person certifying documents must:

write or stamp that the original document has been sighted and that the photocopy is a true and accurate copy

sign and date the statement

print his/her full name and address and the capacity/occupation pursuant to which the certification is made.


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LIST OF PERSONS WHO MAY CERTIFY DOCUMENTS & WITNESS STATUTORY DECLARATIONS:

Victoria only: Justice of the Peace legal practitioner (barrister or solicitor) Public Notary registered medical practitioner (doctor) member of the police force registered dentist registered pharmacist accountant who is a member of:

- the Institute of Chartered Accountants inAustralia; or

- the CPA Australia; or- the National Institute of Accountants.

Outside Australia within the Commonwealth: Commissioner for oaths or declarations for the

place where the declaration is made Public Notary Justice of the Peace for the place where the

declaration is made judge or magistrate of a court in the place where

the declaration is made officer of an Australian embassy or consulate who

is legally designated to take declarations or oaths legal practitioner (barrister or solicitor).

Australian States and Territories: Justice of the Peace for the state or territory in

which the declaration is made legal practitioner (barrister or solicitor) Public Notary Commissioner for oaths or declarations in the state

or territory where the declaration is made

Outside Australia outside the Commonwealth: Public Notary judge or magistrate of a court in the place where

the declaration is made officer of an Australian embassy or consulate who

is legally designated to take declarations or oaths.

CERTIFICATES OF GOOD CHARACTER

Applicants for registration are required to supply two Certificates of Good Characters not more than three months old.

Each certificate should be completed by a registered medical radiation practitioner, a registered medical, dental orlegal practitioner, a minister of religion or a commissioned officer in the armed services - or any other person qualifiedto take a Statutory Declaration in Victoria.

Neither referee must be related to the applicant. Each referee must have known the applicant for at least 12 months.

SHARING OF INFORMATION

The Medical Radiation Practitioners Board of Victoria may make inquiries or exchange information and documentswith past and present employers, educational institutions, registration boards, licensing authorities, and accreditingbodies regarding any matters relevant to your application for registration with the Board.

ENQUIRIES & FURTHER INFORMATION

Under normal circumstances, once an application is in order and the appropriate fee has been paid, registration will begranted.

Further copies of the application form may be downloaded from the website.

The Boards website www.mrpb.vic.gov.auhas general information on registration requirements and policies.

The application form and fee are subject to periodical change and you should check the above website before lodgingyour application to make sure that you are using the current form and paying the correct fee.

If you have a query, please contact the Board on:

T. 1300 721 732T. (03) 9286 1888 orE. [email protected]


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Office Hours: Monday Friday, 9.00am to 5.00pm

APPLICATION FOR GENERAL REGISTRATION AS AMEDICAL RADIATION PRACTITIONER

Health Professions Registration Act2005

I apply to the Board for registration pursuant to the Health Professions Registration Act2005 to practise as a Medical RadiationPractitioner under one or more of the following divisions:

Radiographer Non-Practising

Radiation Therapist

Nuclear Medicine Technologist

(please tick applicable box or boxes)

PERSONAL DETAILS: (please use BLOCK letters throughout)

Title (please tick)

Mr Ms Mrs Miss Other (please specify)

First Name(s) (as stated on Birth Certificate)

Surname(legal name) Date of Birth:

/ /

Any other names by which you are/have been known eg Maiden Name (if applicable) Male / Female

POSTAL ADDRESS:This address will be recorded on the register and used for all mail

Suburb

State Postcode Country

Telephone Number(s) (AH:) Fax Number

Email

Is this your private address? (please tick applicable box) Yes No

If Yes, do you authorise the Board to include it on the section of the register that is open to the publicfor inspection? (please tick applicable box) Yes No

OFFICE USE ONLY

Fee Paid .................................... Date Banked ................................. Registration No........................... Date ........................................


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EMPLOYMENT ADDRESS:

Note: If you have already made arrangements for employment in Victoria in anticipation of being granted registration, pleaseprovide the information sought below regarding your prospective employment rather than your current employment.

Employer Name

Address

Suburb

State Postcode Country (Please specify if not Australia)

Telephone Number Fax Number

Email

QUALIFICATIONS:

Refer to the website www.mrpb.vic.gov.aufor a summary of the qualifications required for registration. Complete the details soughtbelow in relation to any relevant degrees, diplomas or other certificates that you hold or are entitled to receive.

Provide documentary evidence for each qualification listed by attaching a certified copy of the qualification, or an original or certifiedcopy of an academic transcript confirming satisfactory completion of the qualification.

Relevant Qualification(s)The name of the Institution/s

which awarded the qualification/s:Year Awarded

PREVIOUS REGISTRATION:

Have you previously been registered by the Board or the MRTB of Victoria? (please tick applicable box) Yes No

If you ticked Yes please complete the following:

(a) registration number

(b) date of registration / / date registration expired / /


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RECENT CLINICAL PRACTICE:

Have you provided Medical Radiation Practitioner services in the preceding two years? (please tick) Yes No

If you ticked No you must provide further information on the Boards Recency of Practice form Appendix A of the Recency ofPractice Guidelines. This form can be obtained from the Board or downloaded from our website www.mrpb.vic.gov.au.

If yes, please indicate the area(s) of practice that you have participated in (please tickapplicable boxes):

Radiography Radiation Therapy Nuclear Medicine Technology

R1 General RT1 Megavoltage Treatment N1 General

R2 CT RT2 Kilovoltage Treatment N2 Radiopharmacy

R3 DSA RT3 Computer Planning N3 Radionuclide therapy

R4 MRI RT4 Simulation including CTand hybrid imaging(MRI/PET/Ultrasound)

N4 PET /Molecular Imaging

R5 Mammography RT5 Stereotactic Services N5 CT diagnostic or nondiagnostic (hybrid systems)

R6 Dental RT6 Brachytherapy N6 Ultrasound

R7 DXA RT7 IMRT and IGRT N7 Clinical Education

R8 Radiation Safety Consultant/Officer

RT8 Radiation SafetyConsultant/ Officer

N8 Radiation SafetyConsultant/Officer

R9 Ultrasound RT9 Clinical Education N9 Management

R10 Clinical Education RT10 Management N10 Research

R11 Management RT11 Research N11 DXA

R12 Research RT12 PACS/SystemsAdministration

N12 MRI

R13 PACS/ SystemsAdministration

RT13 Academia N13 PACS/ SystemsAdministration

R14 Academia RT14 Applications specialist N14 Academia

R15 Applications specialist RT15 Megavoltage Imaging (2Dand 3D)

N15 Applications specialist

R16 Veterinary RT16 Advanced Practice egbreast localisation

N16 Radiopharmacy practice

N17 Veterinary

PRACTISING WHILST UNREGISTERED:

Have you practised as a Medical Radiation Practitioner in Victoria whilst unregistered? Yes No

If you ticked No, your application will be considered prior to Board approval. However, if you have been practising whilstunregistered, your application cannot be considered until the next meeting of the Board and you must cease practisingimmediately. If you have been practising whilst unregistered, you will need to provide a letter of explanation detailing why youwere practising unregistered and for how long.

The Board considers it an extremely serious matter to practise whilst unregistered.


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CLINICAL EXPERIENCE:

Complete the details sought below in relation to your clinical experience in radiography, radiation therapy or nuclear medicinetechnology over the past two years, including any compulsory undergraduate/postgraduate clinical training (i.e. professionaldevelopment year / intern year).

Please note that if you are unable to complete the following table, you will need to provide written details of your previous training,together with your proposed training to ensure that you are competent to provide Medical Radiation Practitioner services.

Name of EmployerLocation of Employment & Telephone No

Range of Practice(Procedures/Modalities)

If not full-time, state

the number ofhours worked per

week

Period Employed(Starting date Finishing date)

WORK STATEMENT:

You are required to supply the Board with a work statement from your current employer or, if not currently employed, from yourmost recent employer as evidence of your recent clinical practice.

The statement must be dated and on the employers letterhead and must be signed by the responsible workplace manager/directoror human resources manager. The statement must confirm the dates of employment, the nature of the duties performed, and themode of employment (i.e. full-time, part-time or casual). If your employment was part-time or casual, the total number of hoursworked per week must be stated. I f you are supplying a photocopy of the work statement, it must be a certified copy.


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PROFESSIONAL INDEMNITY INSURANCE:(This is not applicable if you have indicated that you are non-practising).

The Board has determined that the approved level of cover (i.e. the minimum sum insured for professional indemnity insurancerequired by the Board) is:

no less than $5 million cover for any single claim (i.e. for each claim) that may be made against the Medical RadiationPractitioner

This insurance may be provided by an employer, professional association or industrial association. Without the insurance cover,

you must not practice. (please tick)

Do you have, and will you continue to have for the period of your registration, professional indemnityinsurance in connection with your practice as a Medical Radiation Practitioner?

Yes No

Name of Insurer:

Policy Number:

(please tick)

Is your insurance cover provided by your employer? Yes No

Employers Name:

Name of EmployersRepresentative:

Contact Telephone Number:

Employers Insurance Company:

Policy Number: Expiry Date / /

Please note that you can register prior to having your insurance in place.However, before you commence practising you must provide your insurance details to the Board.

REGISTRATION OR LICENSING IN ANOTHER JURISDICTION:

(please tick)

Do you currently hold or have you previously held registration or a licence to practise radiography,radiation therapy or nuclear medicine technology with a registration board in another State or Territoryof Australia or with a registration authority in another country?

Yes No

If you answered No, proceed to the next section.

If you ticked Yes please complete the following:

(a) date first registered / / date registration expires / /

(b) place of registration

Certificate of Good Standing:

If you answered Yes, you are required to arrange for a Certificate of Good Standing to be sent to the Board from each registrationboard / authority with which you are currently registered or (if not currently registered) from the registration board / authority withwhich you were most recently registered.

It is the applicants responsibility to ensure that Certificates of Good Standing are forwarded to the Board. Certificates must be sentdirectly from the relevant registration board/authority to the Board and will not be accepted if received from an applicant or agent.


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FITNESS TO PRACTISE:

English Language Competency

The Board must be satisfied that an applicant can communicate effectively in the English language. A good command of bothwritten and spoken English is required. If English is not your first language, you will be required to demonstrate English languagecompetency by providing evidence of either:

(1) the IELTS examination (academic module) with a minimum score of 7 in each of the four components (listening, reading,writing and speaking) all obtained at the one sitting; or

(2) completion and an overall pass in the OET with grades A or B only in each of the four components.

Please refer to the English Language Standard on the Boards website for further information.

1. Is English your first language? (please tickapplicable box) Yes No

If you answeredYes, proceed to the Application Fee

2. Have you passed either of the following: (please tickapplicable box)

International English Language Testing System (IELTS); or Australian Occupational English Test (OET)

If you answered YES, please provide a certified copy of your results

If you answered NO, please contact the Board.

APPLICATION FEE:

The fee for initial registration in Victoria is currently AUD $220 for 17 months or $140 for 11 months (applicable from January2012 to November 2012 only). The fee must be paid with the application. The fee provides registration until 30 November 2012.Please note that as from 1 July 2012, medical radiation practitioners will be nationally regulated by the Medical RadiationPractitioners Board of Australia.

Payment Options

I authorise the Board to charge: (please tickapplicable box)

$220.00 - Practising $140.00 - Practising January 2012 to November 2012 only $70.00 - Non-practising

Visa Mastercard Please tick type of card (Note: only these credit cards accepted)

For processing purposes, please print numbers clearly.

Card No:ExpiryDate:

/

Name ofCardholder:

Signature ofCardholder: Date:

/ /

CHEQUE/MONEY ORDER payable to: Medical Radiation Practitioners Board of Victoria

Cheque Account Name

Cheque No.

Bank Branch

Money Order Number AustraliaPost Branch


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STATUTORY DECLARATION:

The information provided in the application must be verified by Declaration under section 107 of the Evidence Act 1958. The list ofpersons who may witness a Statutory Declaration are set out in s107A of that Act and include a Justice of the Peace, barristerand solicitor of the Supreme Court, member of the police force, registered medical practitioner, dentist, pharmacist andbank manager.

The application will not be processed unless it is properly witnessed and includes the full name, address and qualification of thewitness and includes the required documentation.

Please note that Medical Radiation Practitioners cannot witness Statutory Declarations in Victoria.

I declare, knowing that a person making a false declaration is liable to the penalties of perjury, that:

(i) I am the person named in this application;

(ii) the details contained on this application form are true and correct;

(iii) I am not the subject of any disciplinary proceedings (including any preliminary investigations or actions that may lead todisciplinary proceedings) in relation to my occupation as a Medical Radiation Practitioner and my right to practise as aMedical Radiation Practitioner in another State or Territory or another Country has not been cancelled or suspended and notrestored;

(iv) I am not personally prohibited from practising as a Medical Radiation Practitioner, or subject to any special conditions incarrying on that practice as a result of any criminal, civil or disciplinary proceedings;

(v) I have not been found guilty of an indictable offence in Victoria or an equivalent offence in another jurisdiction;

(vi) I am not an alcoholic or drug-dependent person;

(vii) I do not have a physical or mental impairment which significantly impairs my ability to practise as a registered MedicalRadiation Practitioner;

(viii) I will, at all times during practice, abide by the Boards Guidelines for Professional Indemnity Insurance;

(ix) I will not commence practice as a Medical Radiation Practitioner until I have professional indemnity insurance;

(x) at all times during practice, I will be covered by an approved level of professional indemnity insurance; and

(xi) that the statements made above and in the attached documents are true and correct.

Signature of applicant: ...................................................... ...............................................................................................................

Declared at ....................................................................... this ............................................... day of .......... ................................ 20 ...........

Full name of authorised witness: ........................................................

Address of witness: ..

..

Signature of authorised witness: ........................................................ Qualification: ....................................................................................

List Of Persons Who May Witness Statutory Declarations:

Victoria only: Justice of the Peace legal practitioner (barrister or solicitor) Public Notary registered medical practitioner (doctor)

member of the police force registered dentist

registered pharmacist

accountant who is a member of: the Institute of Chartered Accountants in Australia; or

the CPA Australia; or the National Institute of Accountants.

Outside Australia within the Commonwealth: Commissioner for oaths or declarations for the place

where the declaration is made Public Notary Justice of the Peace for the place where the declaration

is made judge or magistrate of a court in the place where the

declaration is made officer of an Australian embassy or consulate who is

legally designated to take declarations or oaths

legal practitioner (barrister or solicitor).

Australian States and Territories: Justice of the Peace for the state or territory in which the

declaration is made legal practitioner (barrister or solicitor) Public Notary Commissioner for oaths or declarations in the state or

territory where the declaration is made

Outside Australia outside the Commonwealth: Public Notary judge or magistrate of a court in the place where the

declaration is made officer of an Australian embassy or consulate who is

legally designated to take declarations or oaths.


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CERTIFICATE OF GOOD CHARACTER

Applicants for registration are required to supply a certificate of good character from each of two referees.

Each certificate should be completed by a Medical Radiation Practitioner, a medical, dental or legalpractitioner, a minister of religion or a commissioned officer in the armed services - or any other personqualified to take a Statutory Declaration in Victoria.

Neither referee must be related to the applicant. Each referee must have known the applicant for at least12 months.

Full name of the applicant:

Details of the Referee:

Name:

Relationship to the applicant:

Occupation:

Address:

Telephone numbers: (W) (H)

Facsimile numbers: (W) (H)

The Referee is asked to complete the following: (please tick applicable box)

I have known the applicant for ____________ years.

Does the applicant have any criminal convictions that you know of? Yes No

Do you consider the applicant to be of good character? Yes No

Do you consider the applicant to be suitable for registration? Yes No

Please comment on any other matters that you consider to be pertinent:

I agree to supply additional information if required by the Board.

Signature: Date:


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CERTIFICATE OF GOOD CHARACTER

Applicants for registration are required to supply a certificate of good character from each of two referees.

Each certificate should be completed by a Medical Radiation Practitioner, a medical, dental or legalpractitioner, a minister of religion or a commissioned officer in the armed services - or any other personqualified to take a Statutory Declaration in Victoria.

Neither referee must be related to the applicant. Each referee must have known the applicant for at least12 months.

Full name of the applicant:

Details of the Referee:

Name:

Relationship to the applicant:

Occupation:

Address:

Telephone numbers: (W) (H)

Facsimile numbers: (W) (H)

The Referee is asked to complete the following: (please tick applicable box)

I have known the applicant for ____________ years.

Does the applicant have any criminal convictions that you know of? Yes No

Do you consider the applicant to be of good character? Yes No

Do you consider the applicant to be suitable for registration? Yes No

Please comment on any other matters that you consider to be pertinent:

I agree to supply additional information if required by the Board.

Signature: Date:


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CHECKLIST OF REQUIREMENTS:

IMPORTANT: Incomplete applications cannot be processed.

THE BOARD DOES NOT ACCEPT FAXED, PHOTOCOPIED OR EMAILED APPLICATIONS.

Please tick the boxes once you have included the documentation required.

Application Form completedI have completed all sections of the application form

Proof of IdentityI have supplied the original or certified copy of my current Drivers Licence or current Passport or Photographic identification

Evidence of change of name (if applicable)I have supplied the original or certified copy of all documents supporting the different name to that on my birth certificate, suchas Marriage Certificate, Deed poll/Change of name certificate

Evidence of QualificationsI have supplied the original or certified copy of my degree or diploma

Work Statement from employerI have supplied a statement from my current employer or, if not currently employed, from my most recent employer asevidence of my recent clinical practice

Evidence of registration/license from another jurisdiction (if applicable)I have supplied an original or certified copy of my Annual Practising Certificate or arranged to supply a Letter or Certificate ofGood Standing of my registration/license from another jurisdiction

Evidence of English language competency (if applicable)I have supplied an original or certified copy of my IELTS or OET results

Payment DetailsI have included payment

Statutory Declaration SignedI have signed and dated the declaration. The Statutory Declaration has been signed by a witness (who is authorised to signStatutory Declarations please refer to instructions page 2).

Certificates of Good CharacterI have supplied two Certificates of Good Character

Please note the following points regarding documentation and the processing of applications:

Applications will not be processed if required information or documentation is missing or if the prescribed application fee hasnot been paid. Incomplete applications may be returned to the applicant.

All photocopies of required documentation must be certified copies (refer to instructions - page 2).

Faxed copies of certified documents will not be accepted.

The mailing address for applications is:

The RegistrarMedical Radiation Practitioners Board of VictoriaPO Box 248COLLINS STREET WEST VIC 8007

PLEASE CHECK THAT ALL DETAILS HAVE BEEN COMPLETEDAS AN INCOMPLETE FORM WILL BE RETURNED TO YOU

Documents

01 Application for General Registration