Aspen Medical Verification | Travel Experience Credentials "*" indicates required fields Form Instructions: Thank you for your assistance in providing us with details on your travel medicine experience. We will craft your responses into a brief CV, and send to you for your approval. Please provide all relevant information and attach any relevant forms.Clinic DetailsClinic Name*Clinic Address* Street Address State / Province / Region PhoneEmail* Practitioner DetailsName* Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last PhoneEmail* 1. Please confirm your AHPRA registration number:*2. Please confirm your registration type and list any specialities:*3. How many years have you worked in travel medicine services?* Under 5 years Over 5 years 4. Please outline the nature of all of your experiences.4.1 Travel medicine for leisure travelers, corporate travelers, defence or other industry:*4.2 Estimated volume of travel consultations completed:*4.3 Any leadership roles in travel medicine?* Yes No Enter Details of Leadership Role/s:*4.4 Relevant specialised areas, eg. tropical diseases:*4.5 Pre and post deployment consultation experience:*4.6 Academic achievements, papers or presentations:*5. Do you have any formal qualifications in travel medicine? Eg. ISTM course, post graduate qualifications in tropical or travel medicine, public health etc.* Yes No Enter Details: Including Year completed and Institution*6. Have you completed any informal education or short courses? eg. conference attendance, or CPD programs.* Yes No Enter Details:*7. Do you hold any travel medicine related memberships? eg. ISTM, ACTM, APTHS.* Yes No Enter Details:*8. Please describe any other occupational health experience that we can include, including number of years of experience.*9. Are you accredited to provide immunisations (Nurses)?* Yes No If Yes, Document Year of Certification and Institution.*10. Have you completed yellow fever accredited training?* Yes No Please describe when and course name/provider.*11. Please attach a copy of your CV and any certificates. Drop files here or Select files Max. file size: 200 MB.
