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Contraceptive Implant Train the Trainer Program Application Form

Home > Contraceptive Implant Train the Trainer Program Application Form

Home > Contraceptive Implant Train the Trainer Program Application Form

Complete the following form to express interest in SHINE SA’s Contraceptive Implant (Implanon NXT) Train the Trainer Program.

Contraceptive Implant Insertion Train The Trainer Application

Name*
First Last
Phone Number*
Email address*
Enter Email Confirm Email
What is your AHPRA Registration Number?*
Preferred Course Date*
Do you have Professional Indemnity Insurance?*
- Yes
- No
It is a pre-requisite of enrolment that you have Professional Indemnity Insurance that covers you for this training.
Do you hold a current Implanon NXT theory and simulation training certificate/statement of attendance?*
- Yes
- No
Please attach evidence of your Implanon NXT training
Max. file size: 50 MB.
Are you registered with the manufacturer as an Implanon NXT inserter/remover to receive relevant clinical updates to PI?*
- Yes
- No
Do you have at least 12 months clinical experience with insertion and removal of Implanon NXT?*
- Yes
- No
Please provide information on your relevant professional development / qualification/s in Reproductive and Sexual Health or equivalent:
Please provide information on your relevant current or recent past experience in clinical education/teaching:
Do you agree to teach the standard Implanon NXT insertion and removal technique and comply with national training standards?*
- Yes
- No
Do you agree to provide evidence of training (e.g. Certificate/statement of attendance) to your trainees who attend/complete training?*
- Yes
- No
Do you agree to maintain clinical competency as a trainer via: (A) Provision of at least 1 Implanon NXT training session per year, (B) Maintenance of knowledge, clinical practice and professional development in contraceptive practice and implants?*
- Yes
- No
If you are successful in becoming a credentialed trainer, do you consent for your name to be added to Organon and SHINE SA’s website as an Implanon NXT Trainer?*
- Yes
- No
Note: Eligibility for this program is at the discretion of the Coordinator of Medical Education and/or LARC Coordinator.
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This resource is only available for free to organisations in SA Australia, due to funding requirements. If you are outside SA, this component of your order will not be dispatched. If you're still interested in this product please email shinesalibrary@shinesa.org.au

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Herpes
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