DFCASA (LFFLM SOM)Submission Form

tick as appropriate:

☐Compendium of Validated Evidence (COVE)

☐Case Portfolio

Cove (no fee) / Case Portfolio (fee – see section 5)
Please send this completed form with your COVE (recorded delivery recommended) to:
DFCASA COVE Submission
Faculty of Forensic & Legal Medicine
1 White Horse Yard
78 Liverpool Road
London N1 0QD / Please email this completed form with your Case Portfolio to with the subject line “DFCASA Case Portfolio Submission”.
If you have any queries, please email the office at the same address.
All personal information held by the Examinations Department of the Faculty of Forensic and Legal Medicine of the Royal Colleges of Physicians of the UK Administration Office will be held in accordance with the Data Protection Act of 1998 and the Freedom of Information Act 1998. Any data will not be released elsewhere without your permission. Data will be used in data comparisons to verify qualifications and to prevent fraudulent activity, and may be retained for this purpose.
SECTION 1 – Personal details
SURNAME
(as shown on medical diploma, unless changed by marriage or Deed Poll) / Click here to enter text. /
FORENAME(S)
(IN FULL, as shown on medical diploma, unless changed by marriage or Deed Poll) / Click here to enter text. /
FORMER / MAIDEN NAME
(If applicable) / Click here to enter text. /
EMAIL ADDRESS / Click here to enter text. /
CORRESPONDENCE ADDRESSClick here to enter text.
CONTACT TELEPHONE
Home Click here to enter text.Work Click here to enter text. Mobile Click here to enter text.
DATE OF BIRTH Click here to enter a date.GENDERClick here to enter text.
CURRENT POST Click here to enter text.SPECIALTYClick here to enter text.
EMPLOYER Click here to enter text.Intended P2Choose an item.
SECTION 2 – Qualifications
Primary Medical or Nursing Qualification – See Notes for WHO and Certificate instructions
DEGREE Click here to enter text. / DATE CONFERRED Click here to enter a date.
ISSUING UNIVERSITY Click here to enter text. / CITY Click here to enter text.
MEDICAL/NURSING SCHOOL Click here to enter text. / COUNTRY Click here to enter text.
SECTION 3 – Registration with the General Medical Council (GMC), Nursing and Midwifery Council (NMC) or equivalent body
Are you currently registered with the GMC, NMC or equivalent body? / Choose an item.
CATEGORY Choose an item. / DATE OBTAINED Click here to enter a date.
Registration No. Click here to enter text. / For office use
Reg checked: Click here to enter text.
SECTION 4 – DFCASA Examination
Date Passed DFCASA Part 1 ExaminationClick here to enter a date.
Comments:
Click here to enter text.
SECTION 5 – Submission Fee (Case Portfolio Only)
The Case Portfolio fee can be paid by cheque, banker’s draft or BACS transfer. The fee is £80.To arrange a BACS transfer, please contact the office at request the FFLM account details.
Please indicate type of payment:
☐BACS transfer
☐Cheque on UK bank (payable to ‘Faculty of Forensic & Legal Medicine’)
☐ Banker’s draft
SECTION 6 – Agreement
NAME Click here to enter text.DATE OF BIRTH Click here to enter a date.
I confirm that the information given on this form is true, complete and accurate and no information requested or other material information has been omitted. I understand that information requested will be used by FFLM for administrative purposes, and to meet its statutory obligations.
SIGNATURE DATE: Click here to enter a date.
Equal Opportunities Monitoring
FFLM aims to ensure fair treatment in relation to admission and assessment of examination candidates. In line with UK legislation and good practice guidelines we would like to monitor our statistics and ensure that we are not discriminating in any way.
Please help us do this by completing this section. Your answers are voluntary, confidential and will be recorded electronically with your other data in accordance with the Data Protection Act 1998. The information will only be used to monitor our administrative practices, carry out statistical analysis and ensure that we provide equality of opportunity to all.
Gender
☐ Female
☐ Male
☐ Prefer not to say / Disability
Do you have a disability under the terms of the Disability Discrimination Act? (The DDA defines a disabled person as someone who has a physical or mental impairment that has a substantial and long-term effect on his or her ability to carry out normal day to day activities.)
☐ Yes ☐ No
If the answer to the above is yes, would you be prepared to specify which of the areas below is substantially affected in carrying out normal day-to-day activities?
☐ Ability to concentrate, learn or understand (e.g. dyslexia)
☐ Ability to lift, carry or move everyday objects
☐ Continence
☐ Eyesight
☐ Hearing
☐ Manual dexterity
☐ Memory
☐ Mobility
☐ Physical co-ordination
☐ Speech
☐ Understanding of the risk of physical danger
☐ Other: Click here to enter text.
☐ Prefer not to say
Ethnic origin
Asian or British
☐ Bangladeshi
☐ Indian
☐ Pakistani
☐ Any other Asian background
please write Click here to enter text.
Black or Black British
☐ African
☐ Caribbean
☐ Any other Black background
please write Click here to enter text.
Chinese or other ethnic group
☐ Chinese
☐ Any other
please write Click here to enter text.
Mixed Heritage
☐ White and Asian
☐ White and Black African
☐ White and Black Caribbean
☐ Any other Mixed background
please write Click here to enter text.
White
☐ British
☐ English
☐ Irish
☐ Scottish
☐ Welsh
☐ Any other White background
please write Click here to enter text.
☐ Prefer not to say
Age
☐ 21-30
☐ 31-40
☐ 41 to 50
☐ 51 to 60
☐ 61 and over
☐ Prefer not to say / Religion and belief
☐ Buddhist
☐ Christian
☐ Hindu
☐ Jew
☐ Muslim
☐ Sikh
☐ Other Religion or Belief
please state:
Click here to enter text.
☐ No Religion
☐ Prefer not to say
Sexual Orientation
☐ Bisexual
☐ Gay man
☐ Gay Woman / Lesbian
☐ Heterosexual / Straight
☐ Other
☐ Prefer not to say
Country of nationality
Click here to enter text.
First language
Click here to enter text.

DFCASA/LICENTIATE of the Faculty of Forensic & Legal Medicine (LFFLM) Part 1 Application Form, 27 June 2014Page 1 of 3