BreastScreen Australia accreditation forms

Page last updated: 14 July 2017

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This page contains interactive form/s that are intended to be downloaded to complete. If you are experiencing issues filling in the interactive form/s please contact NQMC Secretariat at NQMC.Sec@stenning.com.au for assistance.

The suite of BreastScreen Australia accreditation forms below have been developed to support BreastScreen Australia Service and SCUs in applying for accreditation every four years. The NAS data report is to serve as the Annual Data Report (ADR). It is mandatory for Services and SCUs to use the below forms as they have been designed to provide the NQMC with information essential to making accreditation decisions.

Please note: You should download and save the form, then open and complete it using Adobe Acrobat or Adobe Reader. The latest version of Adobe Reader can be downloaded free of charge from the Adobe website.


Form ID#Form Title and Link to formComment
BSA001Application for accreditation (PDF 515 KB) This form will be used by Services and SCUs when re-applying for accreditation every 4 years
BSA002Commencement of Service (PDF 173 KB)This form will be used when a Service/SCU is intending on commencing a new unit within an existing BSA Service commences, or establishing a new BSA Service
BSA003NAS Accountability Framework (Word 123 KB)In multi-service jurisdictions, a ‘NAS Accountability Framework (NAF)’ is required to ensure appropriate accountability at a Service and SCU level in order that they are assessed against those accreditation Measures for which they are responsible. It must be submitted as part of an application for accreditation.
BSA004NAS Data Report (PDF 1.8 MB)This form will be used to record the Service and/or SCU’s performance against those NAS Measures in which they are responsible for. It must be submitted as part of an application for accreditation.

The NAS Data report should also be used by a Service and/or SCU to complete their Annual Data Report
BSA005Response by SCU/Service (Word 119 KB)This form is to be used by a Service and/or SCU to respond to issues identified in the Survey and Interim Survey Report and NAS Measures that are unmet, unable to be assessed or met with exception. It must be submitted as part of an application for accreditation
BSA006Quality Improvement (QI)Plan (Word 145 KB) The QI Plan should be developed and used by Service and/or SCU to identify quality improvement strategies to improve performance against any unmet NAS Measures, or when declining performance trends are identified within the Service and/or SCU. It must be submitted as part of an application for accreditation.
BSA007Request for extension to accreditation (PDF 175 KB)This form is to be used by a Service/SCU seeking an extension to their current accreditation period by up to 9 months.
BSA101Survey and Interim Survey Report (PDF 1028 KB)This form is to be used by the survey team for its assessment of the Service against the National Accreditation Standards, and to record the findings of the accreditation survey.
BSA201Appeal application (PDF 152 KB)This form is to be used by any Service/SCU appealing against an accreditation decision of the NQMC.\
TBAAdverse Events Reporting Form (Word 77 KB)This form will be used by Services and SCUs to report adverse events to the NQMC

Evaluation forms

Form ID#FormComment
BSA008NQMC Report Evaluation ToolThis form is to be used by NQMC Members to provide feedback to the survey team on the survey report.
BSA009Service Evaluation ToolThis form is to be used by a Service undergoing an accreditation survey to evaluate the conduct of the accreditation survey
BSA010Surveyor Evaluation Tool HTMLUnder development - This form is to be used for each surveyor participating in an accreditation survey team to evaluate the conduct of the accreditation survey

Data Governance and Management Assessment (DGMA) forms

Form ID #FormComment
N/ADGMA Framework (PDF 193 KB)

This document outlines a framework for the Data Governance and Management


Assessments (DGMA) that apply under the BreastScreen Australia Accreditation System.
BSA301Standard 5 Protocol Accountability Framework (PAF5) (Word 127 KB)Each multi-service jurisdiction must have a PAF5 in place which details the allocation of operational level responsibility between the Service and SCU for each area of data governance and management.
BSA302DGMA Self-assessment form (Word 146 KB)This form is to be used for a Service or SCU to undertake their own self-assessment against each DGMA requirement in this form and determine their achievement rating
BSA303DGMA Data Assessor Report Word (Word 130 KB) This form is to be used for the Data Assessor to record their findings from undertaking the DGMA during the accreditation survey of the Service or SCU.
BSA304DGMA Service/SCU response to DGMA (Word 116 KB) This form is to be used for a Service and/or SCU to provide its response to the Data Assessor’s report and any comments made by the data assessor.

Other BSA Accreditation forms

Please contact the NQMC Secretariat NQMC.Sec@stenning.com.au to receive the below forms:

  • Protocol management checklist: this form is intended as a guide to assist Services and SCU’s to undertake a self-assessment on the NAS protocols. *Please note, this form is not a mandatory requirement for Services and SCU’s to provide as part of their application for accreditation.
  • Conflict of interest/Deed Poll

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