Application for Specialist Anaesthesia Training July 2015

Applications which are incomplete will be notified if the application is received at least five working days before the closing date, if incomplete applications received after the closing date candidates will not be notified.

Late applications will not be accepted. Applications will be accepted only in electronic format Curriculum Vitae should not be sent All applications should include a completed credit card mandate for €110 and be submitted

electronically to mgolden@coa.ie Please read the guidance for applicant’s document in full before completing this application.

Application For Specialist Anaesthesia Training (SAT Year 1 – 6) – Regional preference

Please mark in order of preference 1, 2, 3:

Eastern RegionSouthern RegionWestern Region

Please note this is a national scheme, allocations to preference is not always possible and the regional preference is for the first 2 -3 years of the programme only.

SECTION A – PERSONAL DETAILS (as used on Irish Medical Council documents)

Surname ''Click here and type Surname''

Forename ''Click here and type Forename''

Date of birth ''DD / MM / YY''

Address for correspondence ''Click here and type Address''''Address line 2''''Address line 3'' ''County''''Country''

Home phone number ''xxxxxxxxxxxxxxxxxx''

Work phone number, including bleep ''xxxxxxxxxxxxxxxxxx''

Mobile phone number ''xxxxxxxxxxxxxxxxxx''

Email address ''Click here and type Email Address''

SECTION B – IRISH MEDICAL COUNCIL REGISTRATION

Name in which you are registered ''Click here and type''

Registration number ''xxxxxxxxxxxxxxxxxx''

Type of registration Internship ''yes or no'' Trainee Specialist ''yes or no'' General ''yes or no''

Trainee Specialist RegistrationA mandatory requirement for entry onto the training programme is eligibility for Medical Council registration on the trainee specialist division. See Section B of the guidance document for more information.In order to determine your eligibility please answer the following questions:

Have you graduated from an Irish Medical School and successfully completed your internship in Ireland

''Click here and type yes or no''

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Have you graduated from an Irish Medical School and are currently in your intern year

''Click here and type yes or no''

Have you successfully completed your medical qualification in one the following countries:

o Austriao Belgiumo Bulgariao Cypruso Czech Republico Estoniao Finlando Franceo Germanyo Greeceo Hungaryo Icelando Latviao Malaysiao Netherlandso Romaniao Sloveniao Spaino Switzerland o Slovak Republico Sudano United Kingdom

''Click here and type yes or no''

''If yes which country''

Are you currently registered on the Trainee Division of the Medical Council in Ireland?

''Click here and type yes or no''

If yes a copy of your registration certificate must be submitted.

If you have answered NO to all of the questions above you must: Contact the Medical Council to request an email attesting your eligibility for the trainee division.

Submit the email from the Medical Council with your application.

English Language RequirementsThe HSE requires that as part of the application process for training positions on specialist training programmes, all applicants are required to demonstrate their competency in the English Language in line with HSE specifications. Please see Section B of the guidance document for more information

Are you exempt from demonstrating your English Language Competency

''Click here and type yes or no''

''Reason for exemption'' (see Section B of the guidance document)

Applicants who are applying for exemption based on registration with the Medical Council in Ireland on or after the 9 th July 2012 and who can provide documentary evidence of having worked as a full time clinical NCHD in the Irish public health service for a minimum period of 6 months must complete appendix 1 of this document on page 12

I have the IELTS demonstrating a minimum score of 7.0 in each of the four domains

''Click here and type yes or no''

I have the University of Cambridge, ''Click here and type yes or no''

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ESOL Examinations – Certificate in Advanced English (CAE) demonstrating a minimum overall score of 67/100 and demonstrating an achievement of at least a “Good” level in all five skill areas

Allocation of training postsPlease see Section B of the guidance document for more information

I have submitted a colour copy of my passport

''Click here and type yes or no''

I have submitted a copy of my Certificate of Naturalisation as issued by the Department of Justice and Equality if applicable

''Click here and type yes ''

''Click here and type not applicable''

SECTION C – Examinations and Education

Undergraduate Education (Max 10 marks total)

University/Medical School Name ''Click here and type School/University''

Address of University/Medical School

''Click here and type Address''''Address line 2''''Address line 3'' ''County''''Country''

Date of entry to Medical School ''DD / MM / YY''

Date of graduation ''DD / MM / YY''

Primary medical qualification ''Click here and type Qualification''

Overall grade achieved ''Click here and type grade''

Rank in Class ''Click here and type rank in class''

Marks: 1st – 10 marks2nd – 9 marks3rd – 8 marksIn top 10% of class (other than 1st, 2nd and 3rd) – 6 marks

In top 25% of class (but not in top 10%) – 4 marks For office use

Please provide proof of ranking in class with your application or marks will not be awarded.

Postgraduate Exams (max 5 marks)

Higher Qualification Awarding Body Date of Qualification

''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''

Marks: Primary CAI or equivalent – 5 marksPrimary MCQ – 3 marksRelevant degree – 2 marksMD – 3 marks For office use PhD – 5 marks

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Fellowship FCAI or equivalent – 5 marksMRCS/MRCP – 3 marks

Please provide proof of any qualifications claimed with your application or marks will not be awarded.

Postgraduate Experience (max 5 marks)

Beginning with the most recent (i.e. current position) you are required to list all previous appointments up to and including your present appointment. In relation to each period of employment, you are required to highlight clinical experience relevant to this specialty including clinical practice, teaching experience, audit and management. You can add extra lines if needed.

Clinical Site(If overseas please

indicate country)Grade Specialty

Supervising Consultant From – To

Months in post

Example: St. James’s Hospital

Intern SurgeryMr. Joe Bloggs

01/07/04 –31/12/04

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''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"

Marks: Anaesthesia Intern Year – 3 marksFoundation year – 6/12 3 marks 12/12 5 marks Anaesthesia Training Hospital Ireland /UK – 3 marks Anaesthesia other hospital Ireland/UK – 2 marks Non Anaesthesia training programmme – 3 marks ''Insert training post number here''

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Non Anaesthesia non programme – 1 marks The above marks are based on 12 completed months; marks will be reduced after 24 months by 50%. > 3 year – 0 marks

For office use

Please provide proof of completion of anything claimed in this section with your application or marks will not be awarded.

Skill Courses e.g. ACLS, ATLS, BASIC, etc (max 10 marks) 2 mark per course to a max of 10

Name of Course Location of Course Date

''Click here and type name of course'' ''Click here and give location''

''DD / MM / YY''

''Click here and type name of course''

''Click here and give location'' ''DD / MM / YY''

''Click here and type name of course''

''Click here and give location'' ''DD / MM / YY''

''Click here and type name of course'' ''Click here and give location''

''DD / MM / YY''

''Click here and type name of course'' ''Click here and give location''

''DD / MM / YY''

Please provide proof of attendance at courses with your application. For office use

Section D - Academic Achievement (max 10 marks)

Please indicate where appropriate Yes/No Number Presentations ''Type YES or NO'' ''xx''

Publications in peer review journal ''Type YES or NO'' ''xx''

Completed Audit ''Type YES or NO'' ''xx''

Marks:Hospital Meeting Presentation/Poster – 0.5 marksNational/International Meeting Presentation/Poster – 2 marks

Published Case Report/Abstract – 2 marks For office use

Letter – 1 mark

Full paper – Co author - 3 marks First author – 6 marks Completed audit – 1 mark No marks will be claimed in this section unless full details are provided below.

PresentationsList the presentations you have given at hospital level, National or International Meetings - Complete bibliographical information must be givenExample:

Wallace R, Smith J. Provision of Anaesthesia underwater, Journal of Irreproducible Results. Dublin 11 Nov 2005.

''Authors'' ''Title of Presentation'' ''Name and Date of Meeting''-

''Authors'' ''Title of Presentation'' ''Name and Date of Meeting''-

''Authors'' ''Title of Presentation'' ''Name and Date of Meeting''-

''Authors'' ''Title of Presentation'' ''Name and Date of Meeting''-

''Authors'' ''Title of Presentation'' ''Name and Date of Meeting''-

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PublicationsList Publications giving complete bibliographical information including PMID

Example:

Smith, J, Wallace R, Doe, J. Article Title. Journal Name. Page, Volume, Year, PMID''Click here''

''Click here''

''Click here''

''Click here''

Completed AuditList Audit giving complete bibliographical information

''Click here''

''Click here''

''Click here''

''Click here''

SECTION E – AIMS & CAREER OBJECTIVESOutline your career objectives, why you wish to participate in the SAT Programme and what you hope to contribute to the specialty.

''Click here and start typing''

SECTION F – ADDITIONAL INFORMATION Use this section to highlight any non-academic achievements which you consider relevant / significant for example electives, volunteer work, sporting, creative or musical achievements, non-academic awards or any other additional information you think is relevant to your application. Do not leave this section blank, but keep it concise and factual; you will have the opportunity to elaborate at the interview.

''Click here and start typing''

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SECTION G – REFEREES Please give the name, job title and address of the two referees who will provide you with a reference. One of these referees must be your present or most recent supervising consultant. Do NOT include details of consultants with whom you worked prior to graduation or in a supernummary/ clinical attachment capacity.

Please note that all referees must use the standard reference template. This reference form can be emailed along with the application

Referee Number One Referee Number Two

Name: ''Click here and type name'' Name: ''Click here and type name''

Title: ''Click here and type title'' Title: ''Click here and type title''

Clinical Site: ''Click here and type clinical site'' Clinical Site: ''Click here and type clinical site''

''Click here and address line 1'' ''Click here and address line 1''

''Click here and type address line 2'' ''Click here and type address line 2''

Phone: ''xxxxxxxxxxxxxxxx'' Phone: ''xxxxxxxxxxxxxxxx''

Fax: ''xxxxxxxxxxxxxxxx'' Fax: ''xxxxxxxxxxxxxxxx''

E-mail: ''xxxxxxxxxxxxxxxx'' E-mail: ''xxxxxxxxxxxxxxxx''

I have forwarded a reference from the above named doctor, enclosed in an envelope which he/she has signed across the seal.

''Type YES or NO''

I have forwarded a reference from the above named doctor, enclosed in an envelope which he/she has signed across the seal.

''Type YES or NO''

SECTION H– NOTESPlease read the following notes carefully and confirm your understanding of each and every one. Please confirm that you understand that if your application is successful, that this application form in its entirety and your appraisal / reference forms will be made available to the relevant employers / clinical sites that facilitate the delivery of this specialist training programme.

''Type YES or NO''

Please confirm that you understand that if your application is successful, that in addition to meeting the requirements of the training body, participation in this programme throughout its duration is dependent on you meeting the relevant employers’ requirements. Such requirements include formal Garda clearance, induction, satisfactory completion of occupational health assessments and provision in a timely manner of the relevant documentation required by employers for employment purposes. Failure to meet the requirements of any relevant employer may result in your removal from the programme as you will be unable to assume training slots required for participation in this programme.

''Type YES or NO''

Please confirm that you understand that any information supplied by you in this form may be held on computer. ''Type YES or NO''

SECTION I – APPLICATION CHECKLISTPlease indicate what supporting documents you are enclosing with your application

Copy of Medical Council Certificate of Registration or email confirming registration from IMC

''Type YES or NO''

Colour copy of your passport ''Type YES or NO''

Proof of English Language Competence if relevant ''Type YES, NO, Not Relevant''

Copy of transcript of exam results from your Medical School / University ''Type YES or NO''

Copy of other degrees / diplomas (if applicable) ''Type YES, NO, Not Relevant''

Application Fee ''Type YES or NO''

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1 passport sized photograph ''Type YES or NO''

Two references ''Type YES or NO''

Proof of anything else claimed in the application ''Type YES or NO''

SECTION J - SIGNATURE

I declare that to the best of my knowledge and belief that all the particulars furnished in connection to this application are true and accurate. I understand that I may be required to submit documentary evidence in support of any particulars given by me on my Application Form. I understand that any false or misleading information submitted by me may render any offer of a training position and associated employment offers as null and void. (electronic signature will suffice for section J and K)

Signature Date ''dd/mm/yy''

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SECTION K- DECLARATIONSPlease read the following three declarations carefully and sign and date your agreement with the text of each of the declarations.

Declaration One - Garda/Police

• I declare that I have not at any time been convicted (i.e. probation, fine, sentence, penalty) of a criminal offence (e.g. assault, public order, sexual assault) in the Republic of Ireland and/or in any other jurisdiction nor are there any charges relating to criminal offences outstanding or pending. I have never been the subject of a Caution or Bound over order. I accept that making a false or misleading declaration may render any offer of a training position and associated employment offers as null and void.

Signed: __________________________ Date:_______________

OR• I declare that I have been convicted (i.e. probation, fine, sentence, penalty) of a criminal offence (e.g. assault, public order, sexual assault) in the Republic of Ireland and/or in any other jurisdiction. I have been the subject of a Caution or Bound over order. I accept that making a false or misleading declaration may render any offer of a training position and associated employment offers as null and void.

Date Court Country Offence Court Outcome

Signed: __________________________ Date:_______________

Declaration Two - Training Organisation / Programme

• I declare that I currently am not nor was I the subject of an investigation by any professional medical training body or its equivalent in the Republic of Ireland and/or in any other jurisdiction. I accept that making a false or misleading declaration may render any offer of a training position and associated employment offers as null and void.

Signed: __________________________ Date:_______________

OR• I declare that I currently am or was the subject of an investigation by a professional medical training body or its equivalent in the Republic of Ireland and/or in any other jurisdiction. I accept that making a false or misleading declaration may render any offer of a training position and associated employment offers as null and void.

Date Organisation Offence Status/Outcome

Signed: __________________________ Date:_______________

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Declaration Three - Medical Council/Licensing Body

• I declare that I am not nor have I been the subject of any investigation by a medical registration or licensing body or authority in any jurisdiction with regard to my medical practice or conduct as a practitioner. I have not been suspended from registration , nor had any restrictions on practice nor had my registration or licence cancelled or revoked by any medical registration or licensing body or authority in any jurisdiction nor am I the subject of any current suspension or any restrictions on practice. I accept that making a false or misleading declaration may render any offer of a training position and associated employment offers as null and void.

Signed: __________________________ Date:_______________

OR• I declare that I am or was the subject of an investigation by a medical registration or licensing body or authority in any jurisdiction with regard to my medical practice or conduct as a practitioner. I am or have been suspended from registration, have/had restrictions on practice and/or my registration or licence cancelled or revoked by a medical registration or licensing body or authority in any jurisdiction and/or am the subject of any current suspension and/or have any restrictions on practice. I accept that making a false or misleading declaration may render any offer of a training position and associated employment offers as null and void.

Date Country Medical Council/ Licensing Body

Offence Status/ Outcome

Signed: __________________________ Date:_______________

Payment Details If you want to pay the Application Fee by credit/debit card, please complete this section. .

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Name of Cardholder:

Card Number Visa MasterCard Expiry Date CCV number

Amount € ___________________ Signature _____________________________________________

Appendix 1Declaration of English Language Competencies

Note: Sections A of this form must be completed in full by the applicant, whilst Section B must be completed and stamped by the relevant medical manpower personnel / HR personnel.

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Section A - Statement by ApplicantI hereby seek an exemption from formally demonstrating my English Language Competencies on the grounds of having registered with the Medical Council on or after 9 th July 2012 and having worked as a full time clinical NCHD in the Irish public health service for a minimum of six months since such registration. During the course of this employment I demonstrated the required English Language competencies required of an NCHD.

Details of Employment:Place of Employment:Grade of Employment:Date From:Date To:

Signature of Applicant: ___________________________

Name of Applicant: ___________________________

Medical Council Number: ___________________________

Date: ____________________________

Section B - Verification by Employer I hereby verify the above statement and information provided by the applicant as accurate and true.

Signature: _____________________________

Name: ______________________________

Job Title: ______________________________

Date: ______________________________

Hospital / Clinical Site Stamp:

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