The College of Intensive Care Medicine of Australia and New Zealand

Notification of Withdrawal from Training / SIMG Pathway

The College of Intensive Care Medicine of Australia and New Zealand
This form is for any trainees who wish to withdraw from the CICM training program or SIMGs who wish to withdraw from the SIMG Pathway.

Prior to completing this form and finalising your withdrawal, it is strongly recommended that you:
1. Discuss the decision to withdraw from training/SIMG pathway with your supervisor, mentor, ICU colleagues, College staff or other individuals who support you to discuss other options that are available.
2. Ensure that you download any copies of assessments as once you withdraw these assessments will no longer be accessible to you. To obtain these assessments once you have been withdrawn, a request to the College is required and a fee may be payable.
Name*

First NameMiddle NameLast Name
Member number*
Training ProgramSIMG Pathway
The College would appreciate your feedback on your thoughts and experiences as a CICM trainee or SIMG. This feedback will assist us in identifying the strengths and areas for improvement of the training program and to understand the issues experienced by trainees and SIMGs. This information will be used for continuous quality improvement, to inform and improve the program and trainee and SIMG experience.
Reason for Withdrawal
Career change: non-specialist medical career / roleCareer change: non-medical career / roleCareer change: changing specialist training pathwayUndertaking specialist training outside of Australia or Aotearoa New ZealandFinancial considerationsFamily commitmentsHealth issuesPersonal reasonsTraining program did not meet expectationsUnable to gain a suitable training placementConcerns about lack of job opportunities as an intensive care specialistPrefer not to answerOther
If you are changing specialist training pathway, what pathway are you changing to:
Program/Pathway Feedback
Answering the following questions is voluntary, all personal information will be de-identified and excluded from data analysis and reporting, with any data reported to college or external bodies only reported in the aggregate.

What was your overall satisfaction level with the following?

Rows	Very dissatisfied	Dissatisfied	Neither Dissatisfied nor Satisfied	Satisfied	Very Satisfied	Not Applicable
The Training Program or SIMG pathway overall
Technical Skills Learned
Clinical Supervision
Guidance from your Supervisors
CICM Administrative Support & Processes
CICM Resources (e.g. Online Education Program)
CICM Assessments (e.g. WBAs, ITERs)
CICM Examinations

Please provide any further comments or recommendations you may have about the CICM the training program.
Finalising your Withdrawal*
1. I understand that the withdrawal is effective from the date of the submission of this form to CICM and no further training will be accredited to my record from this date.
2. I understand that should I wish to return to the training program I would be subject to the College Regulations and policies applicable at that time.
3. I understand that I will be unable to receive a refund on any training and examination fees unless eligible under the CICM fees policy.
4. I understand that I will no longer be enrolled in the CICM Training Program on the SIMG pathway and will not have access to the CICM members portal.
5. I understand that I will no longer have access to any of my training documentation and a request will need to be submitted to CICM to access any documentation from the date of submission of this form.
The College will notify you once your application to withdraw has been finalised.

If you have any queries regarding the above, please contact the Training Team at training@cicm.org.au or SIMG team at simg@cicm.org.au.

Please confirm that you understand the above conditions of your withdrawal*
Should be Empty:

Notification of Withdrawal from Training / SIMG Pathway

Reason for Withdrawal

Program/Pathway Feedback

Finalising your Withdrawal*