Application for Specialist Registrar Post

IRISH SURGICAL POSTGRADUATE TRAINING COMMITTEE

Specialty Training for

Specialist Registrar in General Surgery

Commencing July 2015

APPLICATION FORM (B)

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

before 1st July 2009

Completed BST outside of Ireland

Standardised Selection Process for Route (B)

Closing Date: Friday 5th December 2014

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

General:

Application Fee: €100

Skills Assessment Fee:n/a

Surgical AptitudeFee:n/a

Commencement Date:July 2015

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

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

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

Curriculum:

Examinations:

Approved Hospitals:

Adelaide & Meath INCH

Beaumont Hospital

Connolly Hospital

Cork University Hospital

Drogheda/Dundalk

Kerry General Hospital

Letterkenny General Hospital

Mater Misericordiae Hospital

Mayo General Hospital

Mercy University Hospital

University Hospital Limerick

Sligo General Hospital

St. James’s Hospital

St. Luke’s Hospital

University College Hospital, Galway

St. Michael’s Hospital

St. Vincent’s University Hospital

Portiuncula Hospital

Waterford Regional Hospital

Wexford General Hospital

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 hold the award of the CCBST or equivalent.

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

Please see important information regarding allocation of training places for 2015 at

Selection Process:

The Standardised Selection Process (B) is available to download from All candidates are advised to familiarise themselves with this.

Applicants shortlisted for interview maybe required to undertake an “Objective Assessment of Operative Skills” and a “Surgical Aptitude” test. All shortlisted candidates will be charged a fee for the objective assessment of operative skills.

Dates for your diary:

Closing Date: Friday 5th December 2014

Shortlisting Date: TBC

Skills Assessment Date / Surgical Aptitude: TBC

Interview Date: Week commencing March 23rd 2015

Completed applicationsto:

Denise Colgan
National Surgical Training Centre
RCSI
123 St. Stephens Green
Dublin 2
Ireland / Queries to:Denise Colgan
Email:
Phone: 353-1-402 2188

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 2015 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''
Nationality: / ''xxxxxxxxxxxxxxxxxx''
Citizenship (if different from
nationality): ''xxxxxxxxxxxxxxxxxx''
/ ''xxxxxxxxxxxxxxxxxx''
Country of graduation: / ''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 '
General 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 any four 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 9th July 2012 / ''TICK '
Worked minimum 6 months as full time clinical NCHD since 9th July 2012 / ''TICK '
Achieved Membership examinations / ''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 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 BSTonly)
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 RCSI.
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 TrainingProgrammeare required to submit Four 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 Trainer Assessment Forms are available to download from

Region

Start Date

End Date

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

Structured References Forms

Applicants are required to ensure that threestructured reference forms are submitted directly by the Referee to the Surgical Training Office before the 5th December 2014 (One Structured Reference Form must be from you current Trainer)

This is in addition to the 4 TrainerAssessment Forms relating to your recognised BST Clinical experience referred to in box (4) (if not completed through RCSI)

Structured Reference Forms can be located at

5. 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''
6. 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''
7. OTHER RELEVANT COURSES YOU HAVE COMPLETED

Course

Date

Venue

8. 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

/ Awarding Body / Date of Qualification
''Click here and type name of exam'' / ''Click here and type grade'' / ''DD / MM / YY''
''Click here and type name of exam'' / ''Click here and type grade'' / ''DD / MM / YY''
''Click here and type name of exam'' / ''Click here and type grade'' / ''DD / MM / YY''
''Click here and type name of exam'' / ''Click here and type grade'' / ''DD / MM / YY''
4. RELEVANT CERTIFICATES – PLEASE SPECIFY /

ECTS Credits

Office Use

Certificates

5. PUBLICATIONS, BOOK CHAPTERS, PRESENTATIONS & TEACHING EXPERIENCE

Only complete these sections if they are applicable to you. Do not delete any pages. If you have more than one entry per category, copy and paste the relevant sections as needed.
Original Peer Reviewed Scientific Papers ( DO NOT INCLUDE ABSTRACTS)
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

PEER REVIEWED FULL LENGTH PAPERS

Office Use

Full descriptive title of published abstract / ''Click here to start Typing''
Published in National Journal / ''Type YES or NO''
Published in National Journal
– 1st Author / ''Type YES or NO''
Published in International Journal / ''Type YES or NO''
Published in International Journal
– 1st Author / ''Type YES or NO''
Authors (Initial and surname only, no titles) / ''Click here to start Typing''
Department(s), Institution(s),
city(ies), country / ''Click here to start Typing''
Name of Journal / ''Click here to start Typing''
Volume and page number / ''Click here to start Typing''
Publication date / ''DD / MM / YY''
Impact Factor of Journal / ''Click here to start Typing''

PEER REVIEWED FULL LENGTH PAPERS

Office Use

Full descriptive title of published abstract / ''Click here to start Typing''
Published in National Journal / ''Type YES or NO''
Published in National Journal
– 1st Author / ''Type YES or NO''
Published in International Journal / ''Type YES or NO''
Published in International Journal – 1st Author / ''Type YES or NO''
Authors (Initial and surname only, no titles) / ''Click here to start Typing''
Department(s), Institution(s), city(ies), country / ''Click here to start Typing''
Name of Journal / ''Click here to start Typing''
Volume and page number / ''Click here to start Typing''
Publication date / ''DD / MM / YY''
Impact Factor of Journal / ''Click here to start Typing''
6. BOOK CHAPTERS – no marks awarded unless ISBN number is included.
Chapter Title /

Book Title

Publisher

/ Author/s
In order / Date & Pages /

ISBN

Office Use

''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing''
''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing''
''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing''
''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing''
''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing''
''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing''
''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing''
7. INVITED REVIEW ARTICLES IN PEER REVIEW JOURNALS– points only awarded for 1st authorship.
Review Title /

Journal

Reference

/ PMID No. / Author Status / Office Use
''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing''
''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing''
''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing''
''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing''
''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing''
''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing''
''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing'' / ''Click here to start Typing''
8. CASE REPORTS
Title /

Journal