ANZBP Supervisor Application Forms

ANZBP Supervisor Application Form

Prior to completion, ensure you have read the requirements of the ANZBP Clinical Supervision Policy .

Use this form to apply for approval as an ANZBP Approved Lead Supervisor or ANZBP Approved Clinical Supervisor under the ANZBP local training pathway. Only ANZBP-approved supervisors may provide recognised clinical supervision under an ANZBP-approved training arrangement. This form may also be used for renewal of supervisor approval where required by the ANZBP

Is this application linked to a current ANZBP Training Unit Application(Required)

Application is in progress

Application is being renewed

Application has been approved

Uncertain of status

Name of training unit / hospital / service provider(Required)

Applicant Information

Application Type(Required)

Lead Supervisor

Clinical Supervisor

Name(Required)

First Last

Email(Required)

Site(s) of Employment(Required)

Primary Clinical Site where supervision will occur;(Required)

Head of the Perfusion Department (add own name if head of department)(Required)

Credentialling and Eligibility for Supervision

I am a CCP (ANZ) or OTP (ANZ) with current ANZBP registration:(Required)

Yes

If no, you will need to upload the following supplementary documents for consideration at the end of this application. 1. A letter of support from the lead supervisor at your unit, detailing your experience and value as a clinical supervisor 2. Overseas CCP (current).

Eligibility as a supervisor(Required)

I fulfill eligibility for clinical supervisor or lead supervisor.

I am a CCP (ANZ) or OTP (ANZ) with less than 2 years post certification

I am neither a CCP (ANZ) or OTP (ANZ)

The policy threshold is different for each role: Lead Supervisors must hold current CCP (ANZ) or OTP (ANZ) and have at least five years’ experience at the required threshold, while Clinical Supervisors must hold current CCP (ANZ) or OTP (ANZ) and have at least two years’ post-qualification experience

Date of CCP Certification or OTP Recognition:(Required)

Total years' experience post certifcation.(Required)

Upload evidence of current CCP (ANZ) certification or OTP (ANZ) recognition(Required)

Max. file size: 32 MB.

Supervision Experience and Suitability

Describe your previous supervision, teaching, mentoring, or trainee support experience.(Required)

Describe how you provide feedback and support clinical development.(Required)

Are you able to assume full responsibility for the case and take over from the trainee where required?(Required)

Describe any experience, formal education or professional development relevant to clinical supervision, feedback, reflective practice, or workplace-based learning(Required)

Applicant Supporting Letter(Required)

Max. file size: 32 MB.

Please upload a supporting letter addressing the requirements of the Policy, detailing your experience in supervision, education and training support, and why you are suitable to undertake the role. The letter must be endorsed by the Head of the Perfusion Department, or by a Senior Cardiothoracic Surgeon where the applicant is the Head of the Perfusion Department.

Referee Letter of Support(Required)

Max. file size: 32 MB.

A letter of support detailing your experience and value as a clinical supervisor

Core Acknowledgements for all Supervisor Applicants

Please read each statement carefully and tick each box to confirm that the applicant meets, acknowledges, accepts, or accepts responsibility for the relevant requirement. These declarations form part of the ANZBP Supervisor Approval Application, and ANZBP may rely on them when assessing the applicant’s suitability for approval. The applicant:

Acknowledges that they have read and understand the inherent requirements of the ANZBP Clinical Supervision Policy, and all other relevant policies regarding training.(Required)

Yes

Acknowledges that only ANZBP-approved supervisors may provide recognised clinical supervision under the ANZBP local training pathway.(Required)

Yes

Acknowledges that clinical supervision must support patient safety, trainee progression, work-integrated learning, and certification integrity.(Required)

Yes

Acknowledges that supervision must be clearly planned, documented, and matched to the trainee’s stage of progression, case complexity, and risk to patient safety(Required)

Yes

Acknowledges that supervision must include orientation, feedback, review, documented evaluation, and escalation of concerns where required.(Required)

Yes

Acknowledges that I must be available, appropriately skilled, and able to assume responsibility for the case and take over where required.(Required)

Yes

Acknowledges that Local Trainee Perfusionists must have direct supervision for the first 125 cases.(Required)

Yes

Acknowledges that indirect supervision may occur only where appropriate under ANZBP policy after 125 cases, and that under indirect supervision the supervisor must remain on-site, immediately available, and not simultaneously responsible for another procedure.(Required)

Yes

Acknowledges that a trainee must not be on call on their own and must not respond to a call in without their supervisor.(Required)

Yes

Acknowledges that supervisor approval is not automatic, is not indefinite, and must be renewed every three years(Required)

Yes

Agrees to notify the ANZBP as soon as practicable of any material change relevant to supervision, including changes in employment, supervisor availability, supervision level, institutional support, patient safety concerns, or trainee progression.(Required)

Yes

Acknowledges that if my certification currency lapses, the trainee will not be able to use my supervised cases towards their certification, and recognise the need to ensure currency,(Required)

Yes

Acknowledges that the ANZBP may require completion of an ANZBP-endorsed supervision course or other formal supervisor development activity as a condition of approval, renewal, or continued approval.(Required)

Yes

Agrees that I have sufficient time, patience, availability and clinical capacity to undertake the supervision role safely and effectively.(Required)

Yes

Lead Supervisor Declarations

The applicant:

Acknowledges that the Approved Lead Supervisor has overarching responsibility for the trainee’s supervision plan, evaluations, progression, and liaison with the ANZBP.

Yes

Acknowledges that, if approved, I will be responsible for overseeing the trainee’s supervision plan and progression.

Yes

Agrees that, if approved, I will be responsible for providing or coordinating clinical feedback.

Yes

Acknowledges that, if approved, I will be responsible for supporting problem-solving, setting clinical goals, and supporting education and professional development.

Yes

Acknowledges that, if approved, I will be responsible for liaising with the ANZBP regarding trainee progression, documentation, and any concerns.

Yes

Acknowledges that, if approved, I will be responsible for ensuring records and evaluations are completed as required.

Yes

Acknowledges that, if approved, I will be responsible for ensuring supervision arrangements remain appropriate to the trainee’s stage of development

Yes

Acknowledges that, if approved, I must advise the ANZBP if the trainee’s employment ceases during the traineeship, or if another material change arises.

Yes

Clinical Supervisor Declarations

The applicant:

Acknowledges that, if approved, I will inform the Approved Lead Supervisor of concerns relevant to trainee progression, conduct, or supervision

Yes

Final Declaration

Final Declaration – (enter your full name)(Required)

By entering my full name, I confirm that: the information provided in this application is true and correct to the best of my knowledge; I understand the responsibilities of the role for which I am applying; I understand that ANZBP may request further information, clarification, updated documentation, or institutional endorsement; I understand that approval may be not granted, reviewed, not renewed, suspended, or withdrawn where ANZBP is no longer satisfied that the requirements of the Policy are being met.

Additional Supporting Documentation (where relevant)

Any additional supporting documentation.

Max. file size: 32 MB.

eg. overseas CCP (current).

ANZBP Supervisor Application Forms