Dermoscopy for Victorian General Practice Program 2019 – Application Form

Thank you for your interest in the Dermoscopy for Victorian General Practice Program. This form must be completed in full in order to submit your application.

This application form is separated into five sections:

  •     Part A – Personal information
  •     Part B – Terms and conditions (including agreement to media release and media coverage)
  •     Part C – Dermoscopy rationale and justification
  •     Part D – Declaration
  •     Part E – Personal confirmation

You must fill in all mandatory sections marked with an asterisk (*).

Part A - Personal Information

Must be a nominated practising and fully qualified GP (at the above practice) who will undertake the required training

Please ensure this is a direct phone number of the GP or practice manager, not the generic practice phone number. Please include an area code for landlines

Please ensure this email address is regularly monitored as this will be used to confirm your place in the course

Practice Address

*Note: only applicants from Victoria are eligible to apply

Privacy collection statement

Privacy Statement: By providing us with personal information, you consent to its collection and use in accordance with Cancer Council Victoria’s Privacy Policy and Collection Notice, available to view at Privacy Policy and Collection Notice.*

Part B - Terms and Conditions

Please read and agree to our terms and conditionsThis is a required field.

Terms and conditions

1. Dermoscopy for Victorian General Practice Program includes the provision of 1 x Heine Delta 20T dermatoscope and training component delivered by the Australasian College of Dermatologists. Training will be delivered from June to September 2019 with a full-day face-to-face workshop in Melbourne on Saturday 24 August 2019. Attendance at this training is an essential criteria for participants.

2. Cancer Council will notify successful applicants of the training and equipment details by email on Thursday 9 May 2019.

Dermatoscope requirements

3. A certificate will be provided by Cancer Council to the successful applicants. The certificate must be displayed at the practice of each dermatoscope.

4. Dermatoscopes provided to successful applicants become the property of their practice, and ongoing maintenance and any liability arising from the unit is the responsibility of that practice.

5. It is the responsibility of each successful practice to ensure that all GPs at the practice who use the dermatoscope have undertaken appropriate training.

Media and reporting

6. Each successful practice must obtain Cancer Council’s prior written consent to:

    • publish any marketing materials, newsletters, media releases, public announcements or promotional collateral in connection with the Dermoscopy for Victorian General Practice Program.

Approvals and legal requirements

7. Each successful practice must, prior to the use of their dermatoscope, have all licenses, authorisations, consents, approvals and permits required by applicable laws in order to use the dermatoscope.

8. Dermatoscopes cannot be onsold and must remain an asset of the practice.

Privacy and intellectual property rights

9. Cancer Council will collect the personal information included in applications in order to conduct the Cancer Council’s Dermoscopy for Victorian General Practice Program. Cancer Council will handle your practice's personal information in accordance with its privacy policy, which can be accessed at: www.cancervic.org.au/about/about-this-site/privacy .

Liability

10. To the maximum extent permitted by law, Cancer Council excludes any liability for any loss, damage, injury or costs (including consequential loss, damage, injury or costs) arising in connection with a successful practice's use of the dermatoscope. 
Each successful practice indemnifies Cancer Council in relation to any claim made against Cancer Council in connection with any loss, damage, injury or costs arising in connection with that practice's use of the dermatoscope, including without limitation any malfunction of the dermatoscope or any failure by the practice to comply with any training provided or manufacturer instructions.

Defined terms

11. For the purpose of these terms and conditions the following terms have the meanings set out below:

    • "Cancer Council" means Cancer Council Victoria (ABN 61 426 486 715).
    • "Dermoscopy for Victorian General Practice" means the provision of dermatoscope and training under these terms and conditions to a successful practice by Cancer Council for the purpose of increased access to skin cancer detection and treatment for the public.
    • "Practice" (also "General Practice") is a company which provides people with part or all of their health care needs.

Agreement to media release and media coverage


Part C - Dermoscopy rationale and justification

About your practice





One unit will be provided per practice

Successful practices will nominate one GP to undertake training. This section collects information regarding the nominated GP.

Please estimate, for the nominated GP

No. of skin examinations conducted

No. of lesions excised

No. of BCCs/SCCs excised (with histopathological confirmation)

No. of melanoma excised (with histopathological confirmation)



*Training provided by the Australasian College of Dermatologists is essential criteria for receiving this dermatoscope. Further details are provided in the FAQ section. Training details will be provided after successful applicants are advised of the outcome of their application.


Skin cancer education details

Part D - Declaration

I certify that the dermatoscope is appropriate for my organisation and my practice is prepared to maintain the unit accordingly if I am to be successful.

I understand that in order to receive the unit, I must complete compulsory training (provided).

I understand any dermatoscope granted will remain the property and maintenance responsibility of the practice

Part E - Personal confirmation

I confirm that the information provided in this application is true and correct.

Next Steps

Please submit your application by 5pm Tuesday 30 April 2019. Late applications will not be accepted.

Successful applicants will be notified by email on Thursday 9 May 2019.

Please read the FAQs on the website and call our office on (03) 9514 6417 or email dermoscopy@cancervic.org.au if you have any queries or would like further information about the Dermoscopy for Victorian GPs General Practice Program.

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