Please read the Explanatory notes available on the DAA website before completing this form. Application for Assessment of eligibility to sit DSR Examinations (for applicants who have gained a Dietetic qualification outside Australia) DSR Administrator DAA 1/8 Phipps Close Deakin ACT, Australia Before completing your application form we recommend you to read the explanatory notes on the DAA website. Please complete this form in BLOCK CAPITALS using a black pen. Title First name +61 02 6189 6200 daa.asn.au E: dsr@daa.asn.au Mr Mrs Miss Ms other (please specify) Surname/family Once you have completed this application form please send your application to the DAA address above. Please ensure any payments are stapled to the front of your application form. Please make sure you have included the following documents with your application. Failure to do so will result in your application being returned to you. Checklist please check to ensure you have enclosed the following items with your application 1 A completed application form 2 *Certified copy of registration as a dietitian in a country you hold a qualification. 3 *Certified copy of evidence of completion of a tertiary dietetic program of a minimum of 4 years. Certified translation if not in English. 4 Evidence of practical placement (Individual case management, Food service management and community and Public Health Nutrition) including dates adding up to a minimum of 100 days. 5 *Certified copy of results of an eligible language test certificate (OET B or IETLS minimum of 7 in each criteria and overall). 6 Professional reference(s) 7 Certified* evidence of any change of name (if applicable) Please cross 8 2 passport sized photos (certified a true) * Please refer to explanatory notes for more information regarding certification of documents. Payment Options PAYMENT SECTION - Tax Invoice - (ABN 34 008 521 480) Amount AUD $1,300 Cheque/money order/bank draft Mastercard Visa (Amex/Diners Club not accepted) Attach a certified recent passport sized photograph of yourself here. Card Number: Expiry date: / Card Holder s Name: Cardholder s Signature: NB: all DSR fees will increase from 1 April
Section 2 Contact details Previous name (if applicable) Date of birth (DD/MM/YYYY) Nationality National Insurance number (if applicable) Country of birth Town / city of birth Gender Male Female Home contact details House / flat number Street name Town / city County / state Postcode / zipcode Country Telephone number Mobile number Email address Work contact details Department Organisation Street name Town / city County / state Postcode / zipcode Country Telephone number Mobile number Email address 2
Criteria 1 Registration as a Dietitian in Country of Qualification Is your profession subject to registration, licensing or any other form of regulation? Yes If no you must provide evidence to support this. If yes, please complete the following: The name of the Authority Dates first registered (DD/MM/YYYY): Name of Authority you are most recently registered, licensed or credentialed. Your registration / license number The professional title under which you are registered Dates of registration (DD/MM/YYYY): from to Have you ever been refused registration as a dietitian or had registration withdrawn? Yes 3
Criteria 2 Tertiary Dietetic Program Please provide details of your professional qualification Name of educational institution Title of your qualification (as it appears on your certificate) Course start date (DD/MM/YYYY) Course end date (DD/MM/YYYY): What is the normal length of a full-time course including compulsory practical experience? Either your undergraduate or postgraduate course should include human systems physiology and metabolic biochemistry at least at the equivalent of second year level. Did this course include human systems physiology? Yes Year level Is it listed on your transcript? Yes Did this program include metabolic biochemistry? Yes Year level Is it listed on your transcript? Yes If you have gained a further professional qualification relevant to your qualification, please provide details Title of your relevant qualification Course start date (DD/MM/YYYY) Course end date Name of educational institution Please continue on a separate sheet if necessary. 4
Criteria 3 Practical Placement You must have completed a minimum total of 100 days of relevant practical placement in individual case management, food service management and community and public health nutrition dietetic settings throughout your program. Practical Placement Individual Case Management Food Service Management Community and Public Health Nutrition Additional placements (please specify which domain) 5
Criteria 4 Language proficiency Demonstrate completion of a tertiary dietetics qualification in one of the following countries; United States of America, Canada (except Quebec), Ireland, New Zealand or United Kingdom; OR have passed all four sections of the Occupational English Test (OET) and achieved an average result of B; OR have passed the International English Language Testing Scheme (IELTS) examination (Academic Module) and achieved a minimum score of seven (7.0) in each of the four components (Listening, Reading, Writing and Speaking) with a minimum overall band score of seven (7.0). See English Language Proficiency for more information. Which English Language test have you completed? IELTS OET Date of test Please list your scores against the relevant component Reading Writing Speaking Listening Overall 6
Criteria 5 Recency of Practice Did you obtain your dietetic qualification within the last 3 years Yes Date of program completion Have you worked as a dietitian within the last 3 years Yes Please include a copy of your current CV along with the required 2 references in your package. Migration Data Will you require this Assessment to apply for permanent residency in Australia Yes Declarations To ensure applicants will be able to practise safely and effectively within the dietetic profession, we must check the character of everyone that applies. We can also take action against an applicant if their assessment raises concerns about their ability to practise safely and effectively. If your answer to any of the questions below is yes, please indicate by placing a cross in the appropriate box and give details on a separate sheet. Have you been convicted of a criminal offence or received a police caution (other than a protected caution or protected conviction)? Have you been disciplined by a professional or regulatory body or your employer? Have you had civil proceedings (other than a divorce / dissolution of marriage or civil partnership) brought against you? Do you have any physical or mental health condition that would impair your fitness to practise as a dietitian? I declare that the information I have supplied on this application and in required documentation is complete, correct and upto-date. I undertake to inform the Dietitian Association of Australia (DAA) of any changes to my circumstances (eg. Address) while my application is being considered. I authorise the DAA to make any enquiries necessary to assist in the assessment of my qualifications and to use any information provided in this application for that purpose. I have read and understood the information available in the explanatory notes on the DAA website. I have read and understood the DAA By-Law Dietetic Skills Recognition Yes If you do not agree to this declaration your application will not be processed. Date (DD/MM/YYYY) Signature... Print name 7