Confirmation by nominee (to be completed by the nominee)

I, (insert title and full name of nominee here), consent to being nominated to act as an education provider for (insert title and full name of practitioner here).

In doing so, I confirm that:

  1. I am (complete the applicable option/s)

☐a registered health practitioner who holds registration with the (select relevant board)Board of Australia—AHPRA registration number (insert number here)

☐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).

  1. I have been provided with and read a copy of the practitioner’s schedule of conditions and/or schedule of restrictions and I am aware of the specific education conditions/restrictions imposed.
  2. I am eligible to act as an education provider as I
  3. do not have a close collegiate, family, social, contractual or financial or treating relationship with the practitioner
  4. have attached a copy of my curriculum vitae to demonstrate I have suitable training, experience and/or qualifications in order to provide the education required
  5. do not have anycurrent conditions, undertakings or restrictions on myregistration and/or my right to practise as a result of disciplinary action
  6. have not have been the subject of any adverse findings in previous disciplinary proceedings
  7. satisfy any additional criteria outlined in the practitioner’s schedule of conditions and/or schedule of restrictions.
  8. If I am approved as an education provider, I agree to provide a written education plan to the Office of the Health Ombudsman (OHO), outlining the nature, content, proposed assessment and outcomes of the education program.
  9. On completion of the education, I am willing to provide a report to the OHO specifically addressing the practitioner’s participation in the education program, assessment results and their learning outcomes.

Contact details for education provider

(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)

Acknowledgement by education provider

Signature: Date: Click here to enter a date.

Please return this form to the Office of the Health Ombudsman.