DDU Part 2 Application Form - Australasian Society for Ultrasound in ...

ASUM is the Peak Body for Medical Ultrasound in Australia and New Zealand
Application for consideration for admission to the
DIPLOMA OF DIAGNOSTIC ULTRASOUND (DDU) PART 2 ASSESSMENTS
Applications must be legible. See the ASUM website for application closing dates.
1. Title: Given Names:
2. Surname:
3. Gender (please circle): Male / Female DOB (DD/MM/YY):
4. ASUM Membership Number:
5. Mailing Address:
State or Country:
Postcode:
6. Home Tel: ( ) Work Tel: ( )
Mobile Tel: ( ) Fax No: ( )
7. Email:
8. I passed the DDU Part 1 Assessment in (month/year):
9. I am enrolled in the in the DDU Specialty of (e.g. General, Critical Care):
NB: If you are enrolled in DDU (Emergency) please circle under which syllabus you would like
to be examined GENERAL or CRITICAL CARE.
10. Specialist Training:
OR
I am a Fellow of (College Name):
(Please attach a certified copy of your Fellowship Certificate if not submitted with your DDU Enrolment)
I am a Registrar within 6 months of completing my Fellowship with
(College Name):
I anticipate my Fellowship will be awarded in (month/year)
and understand
that I will not be eligible for the award of the DDU until such time that I have completed the
Assessment requirements and provided evidence (a certified copy of my Fellowship Certificate) that
I have completed the Fellowship requirements for the award of the DDU.
11. Diagnostic Ultrasound Experience: (Please complete the attached supervisor/candidate declaration)
OR
12. Casebook:
I have at least two years of supervised experience in Diagnostic Ultrasound
I have at least 18 months experience in Diagnostic Ultrasound and understand that I will not
be eligible for the award of the DDU until I have obtained at least two years experience in
Diagnostic Ultrasound
I have previously submitted my Casebook
OR
I am submitting my Casebook prior to the submission deadline with this application form.
DDU Part 2 Application Form 2012.12.01 V1
Australasian Society for Ultrasound in Medicine PO BOX 943, Crows Nest NSW 1585, SYDNEY, AUSTRALIA
P (61 2) 9438 2078 F (61 2) 9438 3686 E asum@asum.com.au W www.asum.com.au
ACN 001 679 161 ABN 64 001 679 161 ASUM is certified ISO 9001:2008 Quality Management System

ASUM is the Peak Body for Medical Ultrasound in Australia and New Zealand
13. I wish to:
Enrol into the DDU Part 2 Written Assessment
Enrol into the DDU Part 2 Oral (Viva Voce) Assessment (SYDNEY ONLY)
Please send your application prior to the advertised closing date by POST ONLY to:
DDU Coordinator
ASUM
PO Box 943
CROWS NEST NSW 1585
AUSTRALIA
Please allow 4-6 weeks to process your application. Full payment MUST be provided with this application form. Applications
must be received at the ASUM office prior to the closing date. Late applications will not be processed.
DDU Part 2 Assessment Fees 2013
DDU Part 2 Casebook Assessment Fee Australian Resident $638.00 (inc. GST)
DDU Part 2 Casebook Assessment Fee New Zealand Resident $580.00
DDU Part 2 Written Assessment Fee Australian Resident $638.00 (inc. GST)
DDU Part 2 Written Assessment Fee New Zealand Resident $580.00
DDU Part 2 Viva (Oral) Assessment SYDNEY ONLY
$1188.00 (inc. GST)
All fees are in Australian Dollars. GST is applicable to candidates resident in Australia or sitting an Assessment in Australia.
PRIVACY STATEMENT
The information requested in this application form is being collected by the Australasian Society for Ultrasound
in Medicine (ASUM) to process your enrolment in the DDU Part II. This information will be supplied to the
relevant administrative areas. Any statistical or other data collected for admission and enrolment will be
retained for administrative and academic purposes. The supply of this information by you is voluntary,
however, if you do not supply all the requested information we may not be able to process your enrolment.
Changes to personal information must be submitted in writing to DDU@asum.com.au.
Payment: On payment, this form becomes a tax invoice. Please retain a copy for your records.
ASUM ABN 64 001 679 161
MasterCard VISA Cheque (Australian Bank ONLY – Made Payable to ASUM)
Card Holder’s Name:
Card Holder’s Signature:
Expiry Date:
Total: $AU:

ASUM is the Peak Body for Medical Ultrasound in Australia and New Zealand
Candidate Declaration
I understand that ASUM may need to verify the accuracy of information supplied and ASUM may
exchange data with other institutions for this purpose.
I agree that all materials provided by me for the purposes of assessment (including but not restricted
to Casebooks) become the property of ASUM and may be used for the purpose of training DDU
Examiners. These materials will not be used for any other purpose except with the express
permission of the candidate.
I also understand that ASUM will communicate with me electronically and that it is my responsibility
to regularly check my DDU email address (details of my DDU email will be supplied with my
confirmation of enrolment into the DDU Part 2 Assessments).
I declare that the details that I have provided are true and correct. I have read and understand the
information provided to me in the DDU Regulations. I hereby undertake to comply with all the
conditions set out in the DDU Regulations and understand that these are subject to change.
Signature:
Date:
Supervisor Declaration (only to be completed if you have not already submitted this with your DDU Part 2 Casebook)
1. Title: Given Names:
2. Surname:
3. Business Address:
State or Country:
Postcode:
4. Work Tel: ( ) Mobile Tel: ( )
5. Email:
6. Position Held:
7. Qualifications:
I declare that
is of good professional standing and has had
sufficient training to ensure proficiency in the personal performance of those examinations related to
their field of practice.
I further declare that I have observed his/her ultrasound practice for a period of
and have found it to be of a satisfactory standard.
Supervisor’s signature:
Date: