ES 2023-2024 IUD Insertion Training - Eligibility Form

Pre-course Survey

Thank you for your interest in Family Planning Australia - IUD Insertion Training.

This course is designed for experienced practitioners working in NSW. In order for us to assess that you meet the entry requirements and to ensure this course is suitable for you, please complete this survey. This eligibility form is current for 6 months, if you are not accepted into a course, you may need to reapply.

If you have any questions regarding your application, please contact us by email on clinicaleducation@fpnsw.org.au .

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* 1. Contact Information

Full name as appears on AHPRA

Current workplace

Address of workplace

City/town

Postcode

Email address

Phone number

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* 2. Please indicate if you are

Nurse and/or midwife

Other

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* 3. Have you completed a Reproductive and Sexual Health Course, Family Planning Certificate or equivalent within the last five years?

YES

If yes, please provide the name of course and the date of completion

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* 4. How many sexual and reproductive health consultations do you typically see in your current practice per week?

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* 5. Please indicate your confidence level with the following:

	Very confident	Somewhat confident	Not confident
Speculum examinations	Speculum examinations Very confident	Speculum examinations Somewhat confident	Speculum examinations Not confident
Bimanual examinations	Bimanual examinations Very confident	Bimanual examinations Somewhat confident	Bimanual examinations Not confident

Please explain the reasons for your rating.

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* 6. Please indicate your confidence level with the following:

	Very confident	Somewhat confident	Not confident
Insertion of IUDs in multiparous women	Insertion of IUDs in multiparous women Very confident	Insertion of IUDs in multiparous women Somewhat confident	Insertion of IUDs in multiparous women Not confident
Insertion of IUDs in nulliparous women	Insertion of IUDs in nulliparous women Very confident	Insertion of IUDs in nulliparous women Somewhat confident	Insertion of IUDs in nulliparous women Not confident

Please explain the reasons for your rating.

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* 7. Please indicate your confidence level with the following:

	Very confident	Somewhat confident	Not confident
Removal of IUDs	Removal of IUDs Very confident	Removal of IUDs Somewhat confident	Removal of IUDs Not confident
Please explain the reasons for your rating.

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* 8. Please indicate your confidence level with the following:

	Very confident	Somewhat confident	Not confident
Management of IUD problems, including PID	Management of IUD problems, including PID Very confident	Management of IUD problems, including PID Somewhat confident	Management of IUD problems, including PID Not confident
Please explain the reasons for your rating.

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* 1. Contact Information

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* 2. Please indicate if you are

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* 3. Have you completed a Reproductive and Sexual Health Course, Family Planning Certificate or equivalent within the last five years?

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* 4. How many sexual and reproductive health consultations do you typically see in your current practice per week?

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* 5. Please indicate your confidence level with the following:

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* 6. Please indicate your confidence level with the following:

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* 7. Please indicate your confidence level with the following:

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* 8. Please indicate your confidence level with the following:

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* 9. Tell us why you want to enrol into this course.