Application for Specialist Registrar Post

IRISH SURGICAL POSTGRADUATE TRAINING COMMITTEE

Specialty Training for

Specialist Registrar in Vascular Surgery

Commencing July 2017

APPLICATION FORM (A)

This Application is for use by Candidates who commenced Basic Surgical Training

on /after

1st July 2009

Standardised Selection Process for Route (A)

Closing Date: Friday 2nd December 2016

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

Documents, with the exception of items under “Research and Academic”, will not be accepted after the closing date. There will be a provision for applicants to submit items such as Thesis, publications, presentations etc. that have been awarded after the closing date up until the date of the shortlisting meeting. Under NO circumstances will marks be given after the shortlisting meeting date based on accepted / awarded Thesis, Publications or Presentations.

GUIDELINES

Vascular:

Application Fee: €50

Skills Assessment Fee: n/a

Surgical Aptitude Fee: n/a

Commencement Date: July 2017

JCST Enrolment: Successful candidates will be required to enrol with the JCST

Title of Post: Specialist Registrar (SpR) – Vascular Surgery

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

Curriculum: www.jcst.org

Examinations: www.intercollegiate.org.uk

Successful candidates will be required to rotate to both University and non-University Hospitals throughout Ireland.

Entry Requirements:

§ All applicants must hold the award of the CCBST or equivalent.

§ All candidates must be registered with the Irish Medical Council (www.medicalcouncil.ie) or any other EU medical regulatory registration body.

§ Please see important information regarding allocation of training places for 2017 at http://www.rcsi.ie/apply_st3

Selection Process:

The Standardised Selection Process (A) is available to download from

http://www.rcsi.ie/apply_st3 . All candidates are advised to familiarise themselves with this.

Applicants shortlisted for interview may be required to undertake an “Surgical Aptitude” test.

Dates for your diary:

Closing Date: Friday 2nd December 2016

Shortlisting Date: TBC

Surgical Aptitude: TBC

Interview Date: Week commencing March 20th 2017

Completed applications to:

Denise Colgan
National Surgical Training Centre
Royal College of Surgeons in Ireland
RCSI House
121 St Stephens Green
Dublin 2
Ireland / Queries to: Denise Colgan
Email:
Telephone: +353 1 402 2188
Fax: +353 1 402 2459

Note:

Shortlisted applicants may be asked to submit verification of other documents outlined in the application form.

Shortlisted applicants will be required to bring their official consoldiated logbook along to the interview.

Any attempt to provide misleading or false information to improve your score will result in automatic disqualification.

All information contained in this document is deemed to be a record held by RCSI and is subject to the provisions of the Freedom of Information Acts 1997 and 2003. The RCSI hold scanned copies of all applications for 1 year following the closing date. No originals are held or returned unless specifically requested by the applicant.

No deferrals of commencement of programme in July 2017 are permitted

SECTION ONE – Personal Details

Applicant Details
Title: / ''Click here and type''
Surname: / ''Click here and type Surname''
First Name: / ''Click here and type Forename''
Date of Birth / ''DD / MM / YY''
Gender: / “Click here and type”
Nationality: / ''xxxxxxxxxxxxxxxxxx''
Citizenship (if different from
nationality) / ''xxxxxxxxxxxxxxxxxx''
Country of graduation: / ''xxxxxxxxxxxxxxxxxx''
CAO/HEA Graduate or other; / ‘’xxxxxxxxxxxxxxxxxx’’
Graduate or direct entrant: / ''xxxxxxxxxxxxxxxxxx''
Country where internship completed if different than country of graduation: / ''xxxxxxxxxxxxxxxxxx''
Place of Birth: / ''xxxxxxxxxxxxxxxxxx''
Address for Correspondence / ''Click here and type Address''
''Address line 2''
''Address line 3''
''Country''
Home telephone number / ''xxxxxxxxxxxxxxxxxx''
Work telephone number / ''xxxxxxxxxxxxxxxxxx'' / Mobile number: / ''xxxxxxxxxxxxxxxxxx''
E-mail Address: / ''Click here and type Email Address''
REGISTRATION DETAILS (Verification Required, please refer to guidelines on our website)
Registration Number / ''xxxxxxxxxxxxxxxxxx''
Name in which you are registered / ''Click here and type''
Type of registration (Tick one) / Trainee Specialist Registration ''TICK '
Vascular Registration ''TICK '
Registration Body (Tick one) / Irish registration (IMC) ''TICK '
UK registration (GMC) ''TICK '
Other (please specify) / ''Click here and type''

All applicants are required at the time of application to demonstrate their ENGLISH LANGUAGE COMPETENCY either by means of submitting the required IELTS Certificate / University of Cambridge Certificate in Advanced English documentation or by declaring themselves exempt under one of the exemptions outlined in the guidance document and providing the required documentary evidence of same (Please refer to guidelines on our website)

Do you qualify under either of the exemption grounds – YES or NO If Yes, which ground?

Please ensure to provide documentary evidence

ENGLISH LANGUAUGE COMPETENCY (Verification Required, please refer to guidelines on our website)
Tick appropriate box
Country of graduation: / ''TICK '
Registered with Medical Council prior to 1st January 2015 / ''TICK '
FELLOWSHIP / MEMBERSHIP OBTAINED (Please Specify)

Qualification

Awarding College

Date of Qualification

SECTION two

A.1 CLINICAL SURGERY

1. Specialist Training Undertaken to Date
If you have completed or are currently in the process of undertaking structured specialist training under the formal auspices of one of the postgraduate medical training bodies for example RCSI BST (Basic Surgical Training) or RCSI BSpT (Basic Specialist Training) or other please enter the required details below.
Name of Training Body / ''Click here and type name'
Full Name of Specialist Training Programme / ''Click here and type name'
Date Specialist Training Programme Commenced / ''Click here and type date'
Date of completion / ''Click here and type date'
2. CERTIFICATE OF COMPLETION OF BASIC SURGICAL TRAINING (CCBST) (Verification required)
/

Date

College

CCBST Certification Awarded / ''DD / MM / YY'' / ''Click here and type''
3. RECORD OF BASIC SURGICAL TRAINING (RCSI BST only)
Applicants who completed an RCSI Basic Surgical Training Programme are not required to submit their Trainer Assessment Forms as these are on file in the National Surgical Training Centre.
If you completed an RCSI BST programme Please complete the following section

Region

Start Date

End Date

''Click here and type'' / ''DD / MM / YY'' / ''DD / MM / YY''
Office Use / 1. ------2. ------3. ------4. ------
4. RECORD OF BASIC SURGICAL TRAINING (Other)
Applicants who did not complete an RCSI Basic Surgical Training Programme are required to submit their 4 Trainer Assessment Forms relating to their recognised BST clinical experience (Senior House Officer – SHO). Please list the posts in which you carried out your Basic Surgical Training (blank Trainee Assessment Forms are available to download from http://www.rcsi.ie/apply_st3

Region

Specialty

Start Date

End Date

''Click here and type'' / ''Click here and type'' / ''DD / MM / YY'' / ''DD / MM / YY''
''Click here and type'' / ''Click here and type'' / ''DD / MM / YY'' / ''DD / MM / YY''
''Click here and type'' / ''Click here and type'' / ''DD / MM / YY'' / ''DD / MM / YY''
''Click here and type'' / ''Click here and type'' / ''DD / MM / YY'' / ''DD / MM / YY''
5. RECORD OF BASIC SPECIALITY TRAINING (RCSI BSpT only)
Applicants who completed an RCSI Basic Specialty Training Programme are not required to submit their Trainer Assessment Forms as these are on file in the National Surgical Training Centre.
If you completed an RCSI BSpT Programme please complete the following section

Region

Specialty

Start Date

End Date

''Click here and type'' / ''Click here and type'' / ''DD / MM / YY'' / ''DD / MM / YY''
''Click here and type'' / ''Click here and type'' / ''DD / MM / YY'' / ''DD / MM / YY''

Please Note

4 Trainer Assessment Forms relating to your recognised BST Clinical experience referred to in box (4) must be included in your application – (if not completed through RCSI)

6. POST BASIC SURGICAL TRAINING – RELEVANT CLINICAL EXPERIENCE

Beginning with the most recent (i.e. current employment position) Please list all previous clinical appointments. In relation to each period of employment, you should highlight clinical experience relevant to this specialty/sub-specialty including Full -Time Clinical Surgical Posts or University Lecturer Posts

Clinical Site

(If overseas please indicate country) /

Grade

Specialty

/ Supervising Consultant / From – To /

Months in post

Example:
St. James’s Hospital / SHO / Surgery
(GS, T&O, Plastic etc) / Mr. Joe Bloggs / 10/07/2011 - 08/01/2012 / 6
''Click here and type Information'' / ''Grade'' / ''Speciality'' / ''Consultant'' / ''DD / MM / YY''
''DD / MM / YY'' / ''xx''
''Highlight clinical experience in the above post here"
''Click here and type Information'' / ''Grade'' / ''Speciality'' / ''Consultant'' / ''DD / MM / YY''
''DD / MM / YY'' / ''xx''
''Highlight clinical experience in the above post here"
''Click here and type Information'' / ''Grade'' / ''Speciality'' / ''Consultant'' / ''DD / MM / YY''
''DD / MM / YY'' / ''xx''
''Highlight clinical experience in the above post here"
''Click here and type Information'' / ''Grade'' / ''Speciality'' / ''Consultant'' / ''DD / MM / YY''
''DD / MM / YY'' / ''xx''
''Highlight clinical experience in the above post here"
''Click here and type Information'' / ''Grade'' / ''Speciality'' / ''Consultant'' / ''DD / MM / YY''
''DD / MM / YY'' / ''xx''
''Highlight clinical experience in the above post here"
''Click here and type Information'' / ''Grade'' / ''Speciality'' / ''Consultant'' / ''DD / MM / YY''
''DD / MM / YY'' / ''xx''
7. RECORD OF RELEVANT TECHNICAL SKILLS COURSES YOU HAVE COMPLETED

Course

Date

Venue

''Click here and type'' / ''DD / MM / YY'' / ''Click here and type''
''Click here and type'' / ''DD / MM / YY'' / ''Click here and type''
''Click here and type'' / ''DD / MM / YY'' / ''Click here and type''
''Click here and type'' / ''DD / MM / YY'' / ''Click here and type''
''Click here and type'' / ''DD / MM / YY'' / ''Click here and type''
''Click here and type'' / ''DD / MM / YY'' / ''Click here and type''
8. OTHER RELEVANT SKILLS COURSES YOU HAVE COMPLETED

Course

Date

Venue

9. VALIDATED LOGBOOK / CONSOLIDATION SHEETS

Please complete and return validated consolidation sheet (template attached).

(Please copy and paste sheet if required)

Consolidated Logbook Template(you must provide separate logbooks for BST & BSpT)
Name:
Specialty:
P = to indicate that you performed the operation without senior supervision
S = to indicate that you performed the operation with senior supervision
A = to indicate that you assisted at the operation
Procedure / Actual Number
P / Actual Number
S / Actual Number
A
''Click here and type'' / ''Click here and type'' / ''Click here and type'' / ''Click here and type''
''Click here and type'' / ''Click here and type'' / ''Click here and type'' / ''Click here and type''
''Click here and type'' / ''Click here and type'' / ''Click here and type'' / ''Click here and type''
''Click here and type'' / ''Click here and type'' / ''Click here and type'' / ''Click here and type''
''Click here and type'' / ''Click here and type'' / ''Click here and type'' / ''Click here and type''
''Click here and type'' / ''Click here and type'' / ''Click here and type'' / ''Click here and type''
''Click here and type'' / ''Click here and type'' / ''Click here and type'' / ''Click here and type''
''Click here and type'' / ''Click here and type'' / ''Click here and type'' / ''Click here and type''
''Click here and type'' / ''Click here and type'' / ''Click here and type'' / ''Click here and type''
''Click here and type'' / ''Click here and type'' / ''Click here and type'' / ''Click here and type''
''Click here and type'' / ''Click here and type'' / ''Click here and type'' / ''Click here and type''
''Click here and type'' / ''Click here and type'' / ''Click here and type'' / ''Click here and type''
''Click here and type'' / ''Click here and type'' / ''Click here and type'' / ''Click here and type''
''Click here and type'' / ''Click here and type'' / ''Click here and type'' / ''Click here and type''
''Click here and type'' / ''Click here and type'' / ''Click here and type'' / ''Click here and type''
''Click here and type'' / ''Click here and type'' / ''Click here and type'' / ''Click here and type''

Please note your Logbook must be validated by your Consultant Trainer

Signature: ______Date: ______

Name: (Block Capitals) ______IMC Number: ______

A.2 RESEARCH AND ACADEMIC SURGERY

1. THESIS (VERIFICATION REQUIRED)

Please Tick

University

ECTS Credits

Office Use

Thesis awarded by University? / ''TICK ' / ''Click here and type''
Thesis submitted to University? / ''TICK ' / ''Click here and type''

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

2. RELEVANT DEGREE/S YOU HAVE OBTAINED – PLEASE SPECIFY

Degree

Awarding Body

Date of Qualification

ECTS Credits

Office Use

''Click here and type Qualification'' / ''Type Awarding Body'' / ''DD / MM / YY''
''Click here and type Qualification'' / ''Type Awarding Body'' / ''DD / MM / YY''
''Click here and type Qualification'' / ''Type Awarding Body'' / ''DD / MM / YY''
''Click here and type Qualification'' / ''Type Awarding Body'' / ''DD / MM / YY''
3. RELEVANT DIPLOMA/S YOU HAVE OBTAINED – PLEASE SPECIFY /

ECTS Credits

Office Use

Diploma