IUD Insertion Train the Trainer Program Application Form

Name*

First Last

Date of Birth*

Phone Number*

Email address*

Enter Email Confirm Email

Do you have unconditional AHPRA Registration?*

Yes
No

It is a pre-requisite of enrolment that you have unconditional AHPRA Registration.

What is the postcode of your primary place of practice?

Readiness: Participants in the IUD Train the Trainer Program should have extensive experience in contraceptive counselling and have well-developed bimanual pelvic examination skills. Generally, this would mean participants have undertaken a FPAA Certificate in Reproductive & Sexual Health or a RANZCOG certificate or diploma, or have considerable experience in sexual health and gynaecology.

Have you completed a FPAA National Certificate in Reproductive & Sexual Health or equivalent?*

If yes, please provide the state/territory and the year training was completed?

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 have at least 2 years’ experience with IUD insertion in your practice?*

Yes
No

Have you inserted at least 30 IUDs?*

Yes
No

Do you maintain your practice with inserting at least 10-12 IUDs each year?*

Yes
No

Are you able to manage trainees with clinical training logs and assessing competency in IUD insertions?*

Yes
No

Are you willing to be an ongoing provider for IUD insertion training?*

Yes
No

Do you have the support of your practice and practice nurse to assist with training?*

Yes
No

Do you consent for your name to be added to SHINE SA’s website as an IUD insertion trainer?*

Yes
No

Consider your level of experience with the following procedures and how often you perform them in your current practice.

Cervical Screening Test*

Bimanual examinations*

Removal of IUDs*

Management of IUD problems, including treatment of PID*

Consider your level of experience with the following procedures and how often you perform them in your current practice.

Insertion of IUDs in multiparous women*

Very confident
Somewhat confident
Not confident
N/A

Insertion of IUDs in nulliparous women*

Very confident
Somewhat confident
Not confident
N/A

Other information to support your application.

Please provide a brief description of where and when your IUD insertion training was completed:*

Work experience relevant to this course

Eligibility for this program is at the discretion of the Coordinator of Medical Education and/or LARC Coordinator.

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