<p>Continuing Professional Development Accreditation Application Form </p><p>Under the auspices of the Australian Pharmacy Council (APC) The Pharmacy Guild of Australia, Queensland (Guild) may accredit Continuing Professional Development (CPD) for pharmacists that is eligible to be used as supporting evidence of continuing competence. </p><p>To complete this application, CPD providers will need to have reviewed, and referred to, the following documents:  CPD Accreditation Applicant Guide  Australian Pharmacy Council Accreditation Standards for CPD Activities, 1 July 2013.  Australian Pharmacy Council Accreditation Marketing Policy, 21 May 2015 Version 2.2.  PSA National Competency Standards Framework for Pharmacists (2010 and 2016).  Australian Privacy Principles </p><p>Section 1 General Details</p><p>Activity title</p><p>Contact Phone Person Name of applicant (primary contact) Organisatio Email n Name New Approval status sought Re-approval  existing approval reference number: Proposed commencement date of Click here to enter a date. activity </p><p>Requested duration of approval once off e.g. conference 2 years 1 year 3 years Duration of activity (i.e. total time days or hours engaged in learning)</p><p>Estimated number of CPD credits Group 1 ______applying for Group 2 ______Group 3 ______Activity format Lecture Online module Journal article Conference Other</p><p>Section 2 Mandatory Requirements What is the justification for conducting the activity?</p><p>(APC CPD Standard 2.1)</p><p>Q.CPD.F8.V6: CPD Accreditation Application Form – 14/11/2017 Print Date: 14/11/2017 Page 1 of 8 Evidence examples: explanation, needs analysis documentation, collated feedback, survey data, proposals etc. What are the learning objective/s for the activity? Learning Objective/s</p><p>(APC CPD Standard 1.1, 3.1) 1. [insert learning objective]</p><p>2. [insert learning objective]</p><p>3. [insert learning objective]</p><p>4. [insert learning objective]</p><p>5. [insert learning objective] </p><p>Please list the Competency Standards that are addressed by the learning objectives and proposed content. Applicants can choose to use either the National Competency Standards 2010 and/or the National Competency Standards 2016. It is It is mandatory that learning objectives (in their entirety or individually) be at least mapped to the standard level. </p><p>National Competency Standards 2010 (tick the competency standard/s the activity and learning objectives addresses) (APC CPD Standard 1.1, 3.1 Domain 1 Professional and ethical practice Tick Standard 1.1 Practise legally Standard 1.2 Practise to accepted standards Standard 1.3 Deliver ‘patient-centred’ care Standard 1.4 Manage quality and safety Standard 1.5 Maintain and extend professional competence Domain 2 Communication, collaboration and self-management Standard 2.1 Communicate effectively Standard 2.2 Work to resolve problems Standard 2.3 Collaborate with members of the health care team Standard 2.4 Manage conflict Standard 2.5 Commitment to work and the workplace Standard 2.6 Plan and manage professional contribution Standard 2.7 Supervise personnel Domain 3 Leadership and management Standard 3.1 Provide leadership and organisational planning Standard 3.2 Manage and develop personnel Standard 3.3 Manage pharmacy infrastructure and resources Standard 3.4 Manage quality service delivery Standard 3.5 Provide a safe and secure working environment Domain 4 Review and supply prescribed medicines Standard 4.1 Undertake initial prescription assessment Standard 4.2 Consider the appropriateness of prescribed medicines Standard 4.3 Dispense prescribed medicines Domain 5 Prepare pharmaceutical products Standard 5.1 Consider product requirements Standard 5.2 Prepare non-sterile drug products Standard 5.3 Aseptically prepare sterile drug products Standard 5.4 Prepare cytotoxic drug products Domain 6 Deliver primary and preventive health care Standard 6.1 Assess primary health care needs Standard 6.2 Deliver primary health care Standard 6.3 Contribute to public and preventive health Domain 7 Promote and contribute to optimal use of medicines Standard 7.1 Contribute to therapeutic decision-making Standard 7.2 Provide ongoing medication management Standard 7.3 Influence patterns of medicine use Domain 8 Critical analysis, research and education Standard 8.1 Retrieve, analyse and synthesise information Standard 8.2 Engage in health, medicines or pharmacy practice research Standard 8.3 Formally educate and train students and healthcare colleagues</p><p>National Competency Standards 2016 (tick the competency standard/s the activity and learning objectives addresses) (APC CPD Standard 1.1, 3.1)</p><p>Q.CPD.F8.V6: CPD Accreditation Application Form – 14/11/2017 Print Date: 14/11/2017 Page 3 of 8 * Universally applicable to all pharmacists</p><p>Domain 1 Professionalism and ethics *Standard 1.1 Uphold professionalism in practice *Standard 1.2 Observe and promote ethical standards *Standard 1.3 Practise within applicable legal framework *Standard 1.4 Maintain and extend professional competence *Standard 1.5 Apply expertise in professional practice *Standard 1.6 Contribute to continuous improvement in quality and safety Domain 2 Communication and collaboration *Standard 2.1 Collaborate and work in partnership for the delivery of patient-centred, culturally responsive care *Standard 2.2 Collaborate with professional colleagues *Standard 2.3 Communicate effectively *Standard 2.4 Apply interpersonal communication skills to address problems Domain 3 Medicines management and patient care Standard 3.1 Develop a patient-centred, culturally responsive approach to medication management Standard 3.2 Implement the medication management strategy or plan Standard 3.3 Monitor and evaluate medication management Standard 3.4 Compound medicines Standard 3.5 Support Quality Use of Medicines Standard 3.6 Promote health and well-being Domain 4 Leadership and management *Standard 4.1 Show leadership of self *Standard 4.2 Manage professional contribution Standard 4.3 Show leadership in practice Standard 4.4 Participate in organisational planning and review Standard 4.5 Plan and manage physical and financial resources Standard 4.6 Plan, manage and build human resource capability Standard 4.7 Participate in organisational management Domain 5 Education and research Standard 5.1 Retrieve, analyse and synthesise information Standard 5.2 Engage in health, medicines or pharmacy practice research Standard 5.3 Formally educate and train students and healthcare colleagues</p><p>How will participants be able to access the learning objectives?</p><p>(APC CPD Standard 1.1) Evidence examples: explanation, promotional material, presentation materials etc. Please give details of authors, content developers Pharmacist or Contribution to Activity and presenters and their involvement in the Subject Matter Name activity development. Expert (SME)</p><p>Pharmacist (APC CPD Standard 2.1) SME </p><p>Pharmacist SME </p><p>Pharmacist SME Pharmacist SME </p><p>Pharmacist SME </p><p>Declarations of conflicts of interests and activity sponsorship  Please attach a completed Conflict of Interest Declaration for each author, content developer and presenter.</p><p> Explanation of any activity sponsorship (if applicable)</p><p>(APC CPD Standard 2.4, 3.2) </p><p>How will conflicts of interests be made available to participants?</p><p>(APC CPD Standard 3.2) Evidence examples: explanation, presentation, handouts, website etc. Is the activity free of commercial bias and Yes No promotional language?</p><p>(APC CPD Standard 2.5) </p><p>Do limitations on information or referencing Yes No exist? . Content should be based on critical evaluation If yes, please give details: of relevant literature and/or practice-based professional evidence (and referenced Evidence examples: accordingly). - Activity content in which ideally references are < 5 years old. (APC CPD Standard 2.3) - Explanation of lack of evidence available or lack of change in evidence available and how this will be addressed must be explained. </p><p>What has been done to ensure the content relates to contemporary pharmacy practice? </p><p>(APC CPD Standard 2.1)</p><p>Methods of delivery must promote effective adult learning</p><p>(APC CPD Standard 4.1, 4.2) </p><p>Evidence examples: details of learning activities, details of assessments used, instructional material, presenters brief defining the role of the facilitator in monitoring discussions etc.</p><p>Where consideration of Group 2 CPD is Multiple choice questions (MCQs) requested and there is an assessment component, please nominate (and attach) what . Minimum of 5 MCQs per 1 hour of learning assessment is required. Sufficient technical difficulty . Must evaluate a participant’s achievement of . all of the learning outcome objectives Short answer questions Interactive workshop (APC CPD Standard 4.3, 4.4) . Minimum of two thirds of workshop must be interactive Q.CPD.F8.V6: CPD Accreditation Application Form – 14/11/2017 Print Date: 14/11/2017 Page 5 of 8 . Ratio of facilitator to participants should be no more than 1:20 Other – please specify </p><p>For the assessment above, please indicate how it will be marked and any other relevant information. . A maximum of two attempts per assessment is allowed . Participants can only be provided with answers to the questions of each attempt if the two attempts does not repeat any of the same questions . Pass mark for all assessments must be equal to or greater than 75%</p><p>(APC CPD Standard 4.3)</p><p>Is consideration of Group 3 CPD requested? Yes No (APC CPD Standard 4.4) If YES please attach an outline of how each participant will complete the pre and post activity reflective learning activity – the CPD Panel may also seek additional information to support a Group 3 application. Does the promotional material for the activity comply with the APC Accreditation Marketing Policy? </p><p>(APC CPD Standard 5.1) Evidence examples: promotional/advertising material </p><p>Describe how participants will be given the opportunity to evaluate the activity including: . Achievement of learning outcome objectives . Relevance of activity and content to practice . Overall satisfaction . Suitability of delivery? </p><p>How will the participants be notified of when and how they can complete the evaluations and provide feedback?</p><p>(APC CPD Standard 6.1) Evidence examples: explanation, copy of the evaluation form (i.e. survey) etc.</p><p>If the activity has been designed for repeated delivery, explain how will the activity will be reviewed and modified over time? Evidence examples: explanation, content and assessment review (APC CPD Standard 6.3) policy and procedures etc.</p><p>Section 3 Attachments to be lodged with application form (if applicable) Attachments Session plan included with the application form Justification for activity - supporting documentation Completed Conflict of Interest Declaration for each author, content developer and presenter (including Bio or CV) Copy of content/instructional materials Group 2 applications – assessment tool Group 3 applications – reflective tool Promotional materials Copy of participant evaluation form Other: ______</p><p>Section 4 Declaration I declare as a provider of the educational activity that we will ensure that:</p><p> The activity will be delivered in accordance with the application as approved.  The Guild CPD Accreditation Review Panel will be notified of and provided with all amendments/ alterations prior to delivery of the activity.  The APC Accreditation Marketing Policy is complied with in all relevant material.  National Privacy Principles – Principle 2 will be complied with for all relevant material and storage of participant information.  We will provide the Guild with a summary of the participant evaluations annually.  We understand the Guild may (at any time) request appropriate information on the conduct of their activities, the number of participants attending, assessment results and any other information as required. This information will be used only for the purposes of monitoring the quality of Guild accredited CPD activities.  We understand that the Guild will monitor the ongoing performance of providers of accredited activities, which may include observation of accredited activities by a delegate(s) of the CPD Accreditation Review Panel. Declaration (APC CPD  We understand that the Guild reserves the right to revoke the accreditation of any Standards - 3.4, activity, should it fail to comply with the application as approved or the ongoing conditions 5.1, 6.2) for approval.  This activity is free of commercial bias and acknowledge the use of any promotional language is strictly prohibited  Contribution to the content for this activity is based on critical evaluation of relevant literature and/or practice based professional evidence. When using SME / author’s experiences to discuss a topic, they will disclose potential limitations of the evidence to the audience. </p><p>Signature: ______</p><p>Print Name: </p><p>Date: Click here to enter a date.</p><p>I have completed this document with the full understanding of my responsibilities in relation to delivering a CPD accredited activity and my typed name acts as my signature. Application Please forward your application and all supporting documentation to Lodgement [email protected]</p><p>Q.CPD.F8.V6: CPD Accreditation Application Form – 14/11/2017 Print Date: 14/11/2017 Page 7 of 8 Section 5 Billing Details These details will be used to generate an invoice for payment of the application fee Invoice / AB Receipt to N</p><p>Contact Person</p><p>Address Postal Address Postcod Suburb State e Telephon Email e Payment Please circle : Visa / MasterCard / Amex / Cheque Method Card No. Expiry Name on Signature card Bank - National Australia Bank EFT Account Name - The Pharmacy Guild of Australia Transfer BSB - 084 004 Account Number - 608 350 148 </p><p>Please make cheque/money order payable to: The Pharmacy Guild of Australia, Queensland Branch Note: Please ensure that you include your invoice number in the reference field so we can identify your payment. </p><p>Payment Terms and Agreement Accreditation fees are not transferable. Prices are subject to change. The final accreditation application outcome will not be finalised until full payment is received. </p><p>Contact Us</p><p>The Pharmacy Guild of Australia, Queensland Branch CPD Accreditation Phone: 07 3831 3788 Fax: 07 3832 0871 E-mail: [email protected] Web: www.guild.org.au/QLD </p>