ANZBP International Site Approval Application

ANZBP International Site Approval Application Form

Prior to completion, ensure you have read the requirements of the ANZBP International Site Approval Policy

The Australian and New Zealand Board of Perfusion (ANZBP) welcomes applications from international hospitals and perfusion services seeking approval for specified educational and pathway purposes. International Site Approval involves an assessment of the institution’s clinical services, supervision arrangements, equipment, safety systems and capacity to support perfusion education. Please review the ANZBP International Site Approval Policy before completing this application. Important: International Site Approval is granted for a specified purpose. Approval does not automatically constitute ANZBP-accredited clinical training, confer eligibility for CCP (ANZ) certification, or provide eligibility to practise in Australia or New Zealand.

The information collected in this application will be handled by the Australian and New Zealand Board of Perfusion in accordance with the ANZCP Privacy Statement. Information provided will be used for the purpose of assessing the training unit accreditation submission, including review of the unit’s capacity to provide appropriate supervision, clinical exposure, governance, and work-integrated learning support. Where required, the ANZBP will confirm with Monash University that the unit is an ANZBP accredited training site with approved ANZBP supervisors.

Application Type(Required)

New application

Renewal of existing approval

Variation to existing approval

Resubmission of documentation for approval

Purpose of Application(Required)

Support for enrolment in an ANZBP-Recognised University Program

International education and pathway governance

Other

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

Hospital Address(Required)

Main Contact for Application

Name(Required)

First Last

Email(Required)

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

Institution Requirements as per the Policy

For an application to be considered for approval, the institution much satisfy the requirements of the ANZBP International Site Approval Policy

Has the institution provided cardiac surgery services for at least 24 months? Yes/No(Required)

Describe the perfusion service and its maturity, including years, service and capacity.(Required)

Unit Type(Required)

Adults

Paediatrics

Mixed

Brief description of Case Mix

Total CPB Cases performed in the last 12 months.(Required)

Number of trainees being employed under this unit's application(Required)

Are any other trainees currently employed? If yes, describe how trainees are staged in progression and how the unit will ensure adequate access, evaluation and supervision for all trainees?(Required)

The policy requires sufficient staffing, resources, and rostering capacity to support training without compromising patient safety or service delivery

Will the unit have sufficient staffing resources and capacity to support training without compromising patient safety or service delivery. Yes/No?(Required)

The policy requires maintained equipment, current perfusion protocols, emergency procedures, and systems for maintenance, incident reporting, escalation, orientation, and equipment competency.

Are emergency procedures and incident reporting systems documented and available? Yes/No?(Required)

Does the unit use maintained and in-service perfusion equipment consistent with the ANZCP Standards and Guidelines? Yes/No?(Required)

Are current CPB protocols documented and available? Yes/No?(Required)

The policy requires evidence that the trainee has secured employment and access to a work-integrated learning environment for the duration of training, with a recommended minimum of 3 days/week. It also requires support for examinations, workshops, and academic participation.

Describe how the institution will support employment for the entire training program, acknowledging that if the trainee loses employment at any time, they will be placed on intermission or withdrawn from the academic program, as per the University requirements.(Required)

Will the unit provide financial support for education? If not, please ensure the student is aware at time of employment.(Required)

Clinical Supervision Requirements

The policy requires access to appropriate supervisors, a named Lead Supervisor, sufficient Clinical Supervisor capacity, and an uploaded supervision plan identifying supervision level, nominated supervisors, review points, escalation arrangements, and any conditions.

Proposed Lead Supervisor Name(Required)

First Last

Proposed Lead Supervisor Email(Required)

Proposed Lead Superiisor Qualifications and Experience(Required)

Lead Supervisor Supporting Documentation

Drop files here or

Max. file size: 32 MB.

Please upload the following documentation for the proposed Lead Supervisor. Documents are required to assist the ANZBP in assessing the qualifications, clinical experience and suitability of individuals nominated to supervise perfusion trainees. Required documentation: 1. Current Curriculum Vitae (CV): Detailing relevant perfusion qualifications, professional certifications, clinical experience and previous supervisory or educational responsibilities. 2. Letter of Support: An official letter from the Head/Chief of Perfusion (or equivalent) endorsing the nominated supervisor and confirming their suitability and capacity to undertake clinical supervision responsibilities.

Proposed Clinical Supervisor/s, Email Address/es(Required)

Clinical Supervisor Supporting Documentation

Drop files here or

Max. file size: 32 MB.

Please upload the following documentation for each proposed Clinical Supervisor. Documents are required to assist the ANZBP in assessing the qualifications, clinical experience and suitability of individuals nominated to supervise perfusion trainees. Required documentation: 1. Current Curriculum Vitae (CV): Detailing relevant perfusion qualifications, professional certifications, clinical experience and previous supervisory or educational responsibilities. 2. Letter of Support: An official letter from the Head/Chief of Perfusion (or equivalent) endorsing the nominated supervisor and confirming their suitability and capacity to undertake clinical supervision responsibilities.

Describe how direct and indirect supervision will be managed safely.(Required)

Supervision Plan

Please upload the documented supervision plan for each Local Trainee Perfusionist covered by this application. The supervision plan must be approved by the Lead Supervisor and supported by the employing unit. It must identify: the plan for training exposure, complexity progression, supervision plan, review points, escalation arrangements or any conditions or limitations relevant to practice.

File(Required)

Max. file size: 32 MB.

Local Professional and Regulatory Requirements

Is clinical perfusion a regulated profession in your country or jurisdiction? Yes/No?(Required)

If yes, identify the relevant regulatory or professional authority and applicable registration requirements.

Are perfusionists required to hold specific qualifications, licences or professional certification to practise at your institution? Yes/No(Required)

Describe any relevant national or institutional standards governing perfusion practice and patient safety.

Required Documentation

The ANZBP International Site Approval Policy requires a number of letters of support to fulfill the course work integrated learning component.

Head of Perfusion Name(Required)

First Last

Head of Perfusion Email(Required)

Head of Perfusion Supporting Letter(Required)

Max. file size: 32 MB.

Please upload a supporting letter from the Head of Perfusion addressing the requirements of the Policy.

Authorised Representative of Hospital Executive Name(Required)

First Last

Authorised Representative of Hospital Executive Email

Authorised Representative of Hospital Executive Supporting Letter(Required)

Max. file size: 32 MB.

Upload a letter from an authorised representative or hospital executive that confirms and acknowledges the requirements in the Policy.

Head of Cardiothoracic Surgery Name(Required)

First Last

Head of Cardiothoracic Surgery Email

Head of Cardiothoracic Surgery Supporting Letter(Required)

Max. file size: 32 MB.

Upload a letter from the Surgical Head of Department (or senior surgeon at contracted site, if a company). This letter is to offer support to the perfusion department and willingness to nuture the development of the trainee during this period, and also that confirms and acknowledges the requirements in the Policy

International Training Site Declarations

Please read each statement carefully and tick each box to confirm that the Hospital or Service Provider meets, accepts, acknowledges, or accepts responsibility for the relevant requirement. These declarations form part of the application, and ANZBP may rely on them when assessing suitability for accreditation. The applicant;

Declares that the hospital training unit fulfils the requirements of the ANZBP International Site Approval Policy in relation to case volume, case mix, departmental capacity, staffing, supervision capacity, equipment, protocols, governance, training support, and patient safety, as applicable to the accreditation sought.(Required)

Yes

Acknowledges and understands that admission to the Monash University Master of Cardiovascular Perfusion is determined by Monash University in accordance with its published admission requirements, as amended from time to time.(Required)

Yes

Acknowledges that accreditation of a training unit by the ANZBP does not, of itself, guarantee admission of any individual applicant to Monash University, and that individual applicants must independently satisfy all Monash University admission and enrolment requirements.(Required)

Yes

Agrees that supervision of trainees will occur in accordance with the ANZBP Clinical Supervision Policy and acknowledges that Lead Supervisor and Clinical Supervisor applications must be submitted concurrently with this application.(Required)

Yes

Confirms that a documented supervision plan has been prepared for each trainee included in this application, approved by the Lead Supervisor, supported by the employing unit, and uploaded as part of this application(Required)

Yes

Has sufficient staffing, rostering, resources and organisational capacity to maintain safe clinical service delivery and support education and supervision without compromising patient safety.(Required)

Yes

Will provide a suitable environment and appropriately allocate time for course examinations and associated academic requirements(Required)

Yes

Will provide reasonable support for the trainee’s participation in study and learning activities associated with the ANZBP-recognised training pathway(Required)

Yes

Confirms that the trainee has secured, or will secure, employment and access to an appropriate work-integrated learning environment for the duration required to support the academic and clinical components of the pathway(Required)

Yes

Acknowledge that if the trainee loses employment, they will be required to take intermission or forced to withdraw from the academic program and training program, and will notify the ANZBP as soon as possible if this occurs.(Required)

Yes

Acknowledges that trainees must be employed a minimum of three days per week for appropriate training(Required)

Yes

Agrees to provide supporting documents, records and other information requested by the ANZBP in connection with monitoring, audit, review, renewal, governance, training quality or patient safety;(Required)

Yes

Acknowledges that training unit accreditation is not automatic, is not indefinite, and must be renewed.(Required)

Yes

Will notify the ANZBP as soon as practicable of any material change relevant to accreditation, including changes to supervision arrangements, staffing, case volume, trainee numbers, service capability, equipment, governance, institutional support, or significant patient safety concerns(Required)

Yes

Accepts responsibility for ensuring that trainees are appropriately supervised at all times, including during on-call periods, and are never required to practise without an available supervisor in accordance with ANZBP policy.(Required)

Yes

Acknowledges that direct supervision requires the supervising perfusionist to be physically present in the same room as the trainee whilst the trainee is performing clinical cases for a minimum of 125 cases.(Required)

Yes

Acknowledges that after 125 cases, indirect supervision can occur, and indirect supervision requires the supervising perfusionist to be on-site, immediately contactable, able to attend within minutes, and not simultaneously responsible for another procedure, in accordance with ANZBP policy.(Required)

Yes

Has read and understands all requirements of the ANZBP International Site Approval Policy(Required)

Yes

Acknowledges that the ANZBP may audit units to ensure adherence to the ANZBP International Site Approval Policy and ANZBP Clinical Supervision Policy(Required)

Yes

Acknowledges that International Site Approval does not confer CCP (ANZ) certification, OTP credentialling or eligibility for employment in Australia or New Zealand.(Required)

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; I am authorised to submit this application and accept these declarations on behalf of the Hospital or Service Provider.

Additional Supporting Documentation (where relevant)

Any additional supporting documentation.

Max. file size: 32 MB.

Website

ANZBP International Site Approval Application