VRGP Registration and Consent Form

Completion of this form is required to register with the Victorian Rural Generalist Program.

The final section of this form includes a request for your consent for the VRGP to collect, use, disclose and store your information for the purposes of supporting your training.

Please contact Kate Carlile, VRGP Program Coordinator, via coordinator@vicruralgeneralist.com.au if you have any questions or need any assistance.

This form takes approx. 10 minutes to complete.

Thank you.

Your details

Title *

First Name *

Middle Name

Last Name *

Date of Birth *

Gender *

Aboriginal and Torres Strait Islander identification *

Country of birth *

Citizenship *

Email *

Mobile *

Residential Address *

Street address *Street address line 2

City *

State *

Postcode *

Your background

Suburb, State and Postcode where you completed Primary School education *

Suburb *

State *

Postcode *

Suburb, State and Postcode where you completed Secondary School education *

Suburb *

State *

Postcode *

Suburb, State and Postcode where you lived prior to commencing University education *

Suburb *

State *

Postcode *

Have you ever lived in rural Victoria? *

NoYesUnknown

Your eduction

Your current level of training *

Medical StudentPrevocational trainee (not yet enrolled in college training)RG Advanced Skills traineeRG Consolidation of Skills traineeGeneral Practice Vocational trainee

University (incl Rural Clinical School) name for your primary medical qualification *

Country your university is located in *

Date of Medical Graduation *

Are you in receipt of a scholarship? *

YesNo

Name of scholarship *

Your GP Training status

What college have you / do you intend to apply for? *

What is your current application status? *

What date did you apply to enrol with the college? *

What intake year have you / do you intend to apply for? *

What training program did you apply for? *

If known, what was the outcome of your application

Your registration and medical care provider details

Do you have an AHPRA registration number? *

YesNo

Your AHPRA medical registration number *

Do you have a Medicare Provider Number Stem? *

YesNo

Medicare Provider Number Stem *

Your career interests

What geographical locations are of career interest to you? *

Your consent

I am registering for the Victorian Rural Generalist Program (VRGP). I understand that the Victorian Rural Generalist Program and Department of Health, Victoria, may collect, use, disclose and store my information:

to match doctors to available VRGP training positions at Victorian health services;
to communicate with doctors, including to provide confirmation of applications, notification of additional information required, confirmation of the information provided, reminders and to make allocation offers;
to maintain, correct or update our participant records;
to liaise with supervisors, medical training organisations or colleges where needed;
to improve our services, in particular our data-base, the VRGP-CRM, through monitoring, quality improvement activities, audits, surveys and program evaluations;
to undertake training, education and research for the VRGP;
to provide support services to you and your family, partner or children during the placement such as schooling assistance or community integration;
to track your geographical location and progress through-out the placement and at the end of your placement;
to assess an application for special consideration based on a health condition;
to report, monitor, evaluate, model or forecast for the VRGP to other agencies within the Department, such as to the State-wide Reference Committee, Department of Health, or the Commonwealth Department of Health, and to any external contractors engaged by the Department of Health Victoria to assist it in fulfilling its reporting obligations;
and as detailed in the VRGP CRM Privacy Statement.

I understand that the information which the Victorian Rural Generalist Program and Department of Health collects, uses, discloses and stores about me for the above purposes may include:

my first name and last name (which will be made publicly available on the VRGP website);
my email address and mobile number;
my date of birth and age;
my gender;
whether I live in rural or regional Victoria;
whether I identify as Aboriginal or Torres Strait Islander;
whether I or my parents were born in Australia;
whether I speak a language other than English at home;
whether I have a culturally diverse background;
whether I identify as a person with a disability;
my residency status;
VRGP enrolment details, Medical Board of Australia Registration Number, Medical Intern Placement Number;
current and past education;
qualifications and employment history (along with other information included in their curriculum vitae);
VRGP Clinical lead feedback in relation to my VRGP training participation;
my geographical location (tracked over the course of my placement)
end of training practice location and the rurality of practice location as identified under the Monash Modified Model zones.
health information (in the event I am applying for special consideration on medical grounds.)

I understand that my information may be transferred and/or stored safely outside of Victoria.

I understand that I may refuse to provide the above personal (including sensitive) and health information but that in such a case I may become ineligible to participate in the VRGP.

I agree that, in the event my application for a VRGP funded position is unsuccessful at first instance, my name and email may be retained on the VRGP-CRM database for a period of up to 2 years from the date of this consent for the purpose of being contacted by VRGP if a placement subsequently becomes available to me, and otherwise as required by law. (If you do not check this box, we will not be able to contact you for susbequent placement opportunities.)

I consent to receiving direct marketing from the Department of Health and the VRGP about:

- improvements or changes to the VRGP-CRM on SIMS

- opportunities being offered through the VRGP-CRM on SIMS, and

- its other projects, activities, services and health system developments.

Consent regarding dependent's personal information (if applicable) *

I consent to my dependent's personal information being collected by the Department of Health for the purpose of receiving non-financial education support throughout the placement or a directly related secondary purpose; orI understand that if I do not provide my dependent's personal information, they will be ineligible to receive that support; orNot applicable (no dependents, no support required or prefer not to provide this information)

Signature *

Draw signature|Type signatureClear

Date signed *