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* 2. What is the name of your Practice?

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* 3. What is the physical address of your practice?

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* 4. What is the postal address of your practice? (if different from above)

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* 5. Please enter the HPI ID for your practice

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* 6. Does your practice have Cornerstone Accrediation?

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* 7. Does your practice have Teaching Practice Accreditation?

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* 8. What is the name and email addresss of your Practice Manager

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* 9. What is the name and email address of your key contact for GPEP? (if different from above)

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* 10. Please list the accredited teachers that will be involved in the registrars teaching

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* 11. Please list all the years that you have had a registrar in the past

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* 12. Does your practice identify as a hauora Māori provider or Māori practice

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* 13. If yes, which of the following statements apply?

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* 14. Does your practice identify as a Pasifika Health Provider or Pasifika Health Practice?

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* 15. If yes, which of the following statements apply?

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* 16. What is the Characteristics/Demographics of your training practice?

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* 17. Does your practice offer specialist services? 
eg skin or podiatry clinics?

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* 18. Anything else that is not listed above that could be beneficial to a registrar’s learning experience?
Examples could include providing accommodation, access to wider health services, community activities or outreach services which the registrar could participate in like school/community clinics.

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* 19. Can your practice provide the registrar with after hours or on call experience?

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* 20. Are there languages your practice staff are fluent in?

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* 21. What type of registrar would you prefer?
Please note if you are interested in a College Employed registrar you will be required to complete a Health and Safety check which is our obligations under the Health and Safety Act.  Also if you are a new training practice you will be required complete a Health and Safety pre-qualification form.

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* 22. Would you prefer your registrar to be full time or part time?

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* 23. If you could take a College Employed registrar can you please advise of your capacity to host during the year

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* 24. If there is anything else you would like the College to be aware of in your ability to host a registrar please provide it below

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