ACEMT Application Form for HST in Emergency Medicine

APPLICATION FORM

Read the enclosed guidelines carefully prior to completing the application form.

This application must be submitted unbound and unstapled but in the correct order as per page numbers

GUIDELINES (read carefully)

General:

Application Fee: €50

Commencement Date:July 2016

Title of Post: Specialist Registrar (SpR) inEmergency Medicine

Duration of Programme:Five Years (subject to satisfactory continuous assessments)

Curriculum:

Examinations:

Approved Hospitals

• Beaumont Hospital, Dublin
• Children’s University Hospital(Temple Street), Dublin
• Mid Western Regional Hospital, Limerick
• AMNCH, Tallaght, Dublin

• Our Lady’s Children’s Hospital, Crumlin, Dublin
• St. James Hospital, Dublin
• Sligo General Hospital
• Connolly Hospital, Blanchardstown, Dublin
• Mater Misericordiae University Hospital, Dublin

• St Vincent’s University Hospital, Dublin

• Cork University Hospital
• University Hospital,Galway
• Waterford Regional Hospital
• Midlands Regional Hospital, Tullamore
• Our Lady of LourdesDrogheda

Additional hospitals may be approved during the course of your training. Successful candidates will be required to rotate to both University and non-University Hospitals throughout Ireland.

Entry Requirements

All applicants must:

1. Have completed three years of General Professional Training by the time of commencement of the Advanced
   Programme, of which a minimum of 12 months must be spent in Emergency Medicine and a further 12 months must be in specialties relevant to Emergency Medicine.
2. Hold the Membership of the Royal College of Emergency Medicine (MRCEM) diploma by the date of appointment;
3. Be registered with the Irish Medical Council ( and are eligible for the Trainee Specialist Division.

Application Conditions & Procedures:

All of the followingshould be forwarded togethereither by post or by hand:

Completed application form (unbound and unstapled but in correct order as per page numbers)

Two passport size photographs

Verification of IMC Registration

Verification of Thesis awarded / submitted (letter from research supervisor)

€50 application fee (payable to RCSI by cheque, bank draft or credit card (authorisation form enclosed))

Structured Reference Forms:It is the responsibility of the candidate to ensure that FIVE required structured reference forms are submitted to the Administrator for Emergency Medicine Trainingby closing date

Colour copy of current passport bio page & proof of citizenship if different than nationality on passport

Confirmation you have reviewed the Allocation of Places on the Allocation of Places guidance document

Confirmation you have reviewed the guidelines for eligibility to the Trainee Specialist Division

Agreement that deferral requests if appointed to the Programme will not be granted

Please note:

Documents, with the exception of items under the ‘Research and Academic’ section, will not be accepted after the closing date. There will be a provision for applicants to submit items such as their thesis, publications, presentations, exams, etc. that are awarded after the closing date up until the date of the shortlisting meeting. Under NO circumstances will marks be given for accepted / awarded Thesis, publications or presentations after the shortlisting meeting date.

Shortlisted applicants may be asked to submit verification of any documents referred to in their application form.

Applications or parts of applications are not accepted by email or fax.

Selection Process:

The standardised marking system and selection criteria will be available to download from candidates are advised to familiarise themselves with these.

Dates for your diary: all to be confirmed

Closing Date: 4th December 2015

Shortlisting Date: 25th January 2016

Interview Date: 21st March 2016

Completed applications to:

Any attempt to provide misleading or false information to improve your score will result in automatic disqualification and may result in the matter being referred to the Medical Council.

I confirm that I have reviewed the documents relating to: Allocation of Training Places 2016, Eligibility for the Trainee Specialist Division of the Register & English Language Requirements.

Please sign here to confirm that you have read and understand the above conditions of application:

Signed: ______Date: ______

Section One:Personal Details

Applicant Details

Registration (Verification Required)

IRISH MEDICAL COUNCIL REGISTRATION

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• Contact the Medical Council to request an email attesting to your eligibility for the trainee division. Please note the Medical Council cannot confirm a doctor’s eligibility for trainee specialist registration until an application for registration has been submitted.
• Submit the email from the Medical Council with your application. Please note if you were previously registered on the Trainee Division of the Medical Council in Ireland a copy of this registration certificate will be accepted in place of an email from the Medical Council.

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Please confirm details of the award of membershipof the royal college of emergency medicine

Section Two:

A.1CLINICAL EXPERIENCE

1.Record of Clinical Experience

Please list in chronological order your record of post internship clinical experience(inclusive of your post between january – july 2016)

Marks will only be awarded for posts recognised by ICEMT

2.Structured References

Applicants are required to submit five structured referee assessment forms (attached) with their application. Onereference must be from your current trainer. Reference forms must, where possible, relate to recent clinical or researchappointments (i.e. no more than three years old)

3.PROFESSIONAL AND TECHNICAL SKILLS COURSES YOU HAVE COMPLETED (COURSES SHOULD BE OF DIRECT RELEVANCE TO EMERGENCY MEDICINE)

A.2Research and Academic Development in Emergency Medicine

1.Thesis (Verification Required)

Documentation (receipt) of your thesis status much be submitted with this application.

2.Please specify any Other Relevant Degree(s) you have obtained

3.Please specify any Relevant Diploma(s) you have obtained

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Publications

Original Peer-Reviewed Scientific Papers

If the publication is not yet on PubMed there must be a letter of acceptance from the editor of the journal submitted with the application

Book Chapters

Invited Review Articles in Peer Review Journals

Evidence based publications (e.g. cochrane review or protocol, bestbet)

Electronic only Publications (e.g. cem enlightenme learning module)

Case Reports

Presentations - ORAL

National / InternationalPresentations

Presentations– Moderated Poster

National / International Moderated Poster Presentations

Oral presentations should only be listed where the applicant has personally presented at an EM relevant meeting (Appendix 1).

Presentations – Poster

National / International Poster Presentations

PRIZES and Research Grants

International

NATIONAL

Audit

Additional Information

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Extra-curricular Interests, Hobbies

I certify that all information provided in this application is, to the best of my knowledge true and accurate.

Signature:Date:

All information contained in this document is deemed to be a record held by the Advisory Committee on Emergency Medicine training and is subject to the provisions of the Freedom of Information Acts 1997 and 2003

Credit Card Authorisation

Advanced Specialist Training in Emergency Medicine

July 2016 Intake

Name of Card Holder: ______

Name of Applicant (If different):______

Type of Card (Please tick one): Visa Mastercard Other* ______

Card Number: _ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _

Expiry Date: _ _ / _ _

Security Code (last three digits on back of card)_ _ _

Amount to Debit: €50.00 (application fee)

Signature: ______

If you have any queries on your credit card payment please contact:

*Please note we can no longer accept payments by Laser Card.

Emergency Medicine Administration

C/o Ms. Orla Mockler

Dept of Surgical Affairs

Royal College of Surgeons in Ireland

121/122 St. Stephen’s Green

Dublin 2

Telephone:01 402 2240

E-mail:

Appendix 1: List of Relevant Scientific Meetings

Please note that this list is merely indicative of the meetings of relevance and is not exhaustive. The shortlisting committee will adjudicate definitively on the relevance of a presentation at a meeting not listed below.

• Emergency Medicine meetings
• Irish Association for Emergency Medicine Annual Scientific Meeting
• College of Emergency Medicine Annual Scientific Meeting
• European Society for Emergency Medicine Annual Scientific Meeting
• The Mediterranean Emergency Medicine Congress
• International Conference on Emergency Medicine
• American College of Emergency Physicians (ACEP) Annual Scientific Meeting
• Society of Academic Emergency Medicine Annual Scientific Meeting
• Canadian Association of Emergency Physicians Annual Scientific Meeting
• Australasian College of Emergency Medicine Annual Scientific Meeting

• Paediatric Emergency Medicine meetings
• Association of Paediatric Emergency Medicine Annual Scientific Meeting
• RCPCH Annual Scientific Meeting
• ACEP Paediatric Emergency Medicine Assembly
• American Academy of Paediatrics Annual Scientific Meeting

• Other meetings
• Resus Biannual Conference
• Irish Society for Immediate Care Biannual Conference
• British Trauma Society Annual Meeting

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