Centre Name: Address: Street Suburb State Postcode Postal Address: PO Box Suburb State Postcode Contact: Title First Name Last Name Telephone: ( ) Fax: ( ) Email: Web: ☐ ☐ ☐ Classification Level: 1 (MPC incl teaching & research) 2 (PMS) 3 (Pain Practice) (Refer Level definitions on APS website: ) ☐ ☐ Paediatric Service: Yes No Services ☐ ☐ Individual Allied Health Therapy: Yes No ☐ ☐ Group Pain Management Programs: Yes No ☐ ☐ Inpatient beds: Yes No Other Services: (Please specify) Staff APS Member Name (must list at least 1 per staff category selected) ☐ ☐ Medical: Yes No ______________________________________ APS/FPM (circle) ☐ ☐ Physiotherapy: Yes No ______________________________________ ☐ ☐ OT: Yes No ______________________________________ ☐ ☐ Psychology: Yes No ______________________________________ ☐ ☐ Psychiatry: Yes No ______________________________________ ☐ ☐ Nursing: Yes No ______________________________________ ☐ ☐ Administration: Yes No Other Staff: (Please specify) Other current APS Members at this centre: Title First Name Last Name Title First Name Last Name Form completed by: Position:
Centre Name: Address: Street Suburb State Postcode Postal Address: PO Box Suburb State Postcode Contact: Title First Name Last Name Telephone: ( ) Fax: ( ) Email: Web: Classification Level: ☐ 1 (MPC incl teaching & research) ☐ 2 (PMS) ☐ 3 (Pain Practice) (Refer Level definitions on APS website: ) Paediatric Service: ☐ Yes ☐ No Services Individual Allied Health Therapy: ☐ Yes ☐ No Group Pain Management Programs: ☐ Yes ☐ No Inpatient beds: ☐ Yes ☐ No Other Services: (Please specify) Staff APS Member Name (must list at least 1 per staff category selected) Medical: ☐ Yes ☐ No ______________________________________ APS/FPM (circle) Physiotherapy: ☐ Yes ☐ No ______________________________________ OT: ☐ Yes ☐ No ______________________________________ Psychology: ☐ Yes ☐ No ______________________________________ Psychiatry: ☐ Yes ☐ No ______________________________________ Nursing: ☐ Yes ☐ No ______________________________________ Administration: ☐ Yes ☐ No Other Staff: (Please specify) Other current APS Members at this centre: Title First Name Last Name Title First Name Last Name Form completed by: Position:
Facility_Directory_Update-Application_Form_MAY17.docx