ACEMT Application Form for HST in Emergency Medicine
Irish Committee for Emergency Medicine Training
Advanced Specialist Training Programme
Specialist Registrar in Emergency Medicine
Commencing July 2018
APPLICATION FORM
Closing Date: Friday 1st December 2017Read 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 2018
Title of Post: Specialist Registrar (SpR) in Emergency Medicine
Duration of Programme: Four Years (subject to satisfactory continuous assessments)
Curriculum: www.emergencymedicine.ie
Examinations: www.emergencymedicine.ie
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 Lourdes Drogheda
*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
1. Three years post-internship clinical experience with:
- a minimum of 18 months in Emergency Medicine in Ireland, UK , South Africa or Australasia
- a minimum of 6 months in Anaesthesia/Intensive Care Medicine or evidence that the applicant has achieved the CSTEM competencies in this area by submission of the relevant work place assessments (http://emnow.ie/em-stat/ – airway management, rapid sequence intubation, organ support, central venous cannulation, arterial cannulation).
- a minimum of 6 months in Paediatric EM or acute paediatrics (desirable 2018 intake)
- the remaining 12 to 18 months in EM or specialties relevant to EM – medicine, surgery, orthopaedics
- Experience must be within 5 years of application for ASTEM
2. Hold the Membership of the Royal College of Emergency Medicine (MRCEM/Intermediate FRCEM) diploma by the date of Interview;
3. Be registered with the Irish Medical Council (www.medicalcouncil.ie) and are eligible for the Trainee Specialist Division.
Application Conditions & Procedures:
All of the following should be forwarded together either by post or by hand:
¨ Completed application form (unbound and unstapled but in correct order as per page numbers)
¨ One passport size photograph
¨ 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 Training by 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 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
¨ Agreement that you have read the English Language Requirements Document
¨ Agreement that Training posts will be offered, in the first instance, to successful candidates from the NEMTP CSTEM Year 3 trainees. Should posts remain unfilled from the NEMTP CSTEM Year 3 Candidates, then posts may be offered to suitable candidates from non-training applicants.
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 www.rcsi.ie. All candidates are advised to familiarise themselves with these.
Dates for your diary: all to be confirmed
Closing Date: 1st December 2017
Shortlisting Date: March 2018
Interview Date: 20th March 2018
Completed applications to:
Specialist AdministratorEmergency Medicine Training
Royal College of Surgeons in Ireland
123 St. Stephens Green
Dublin 2
Ireland / Queries to:
Name: Ms. Orla Mockler
Email:
Phone: 353 1 402 2240
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 2018, 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
Name /Title:
Surname:
First Name:
Personal Details /
Date Of Birth:
Age:
Place Of Birth:
Nationality:
Contact Details (Telephone & Email) /
Home:
Work:
Mobile:
Email:
Current Mailing Address /
Graduation Details /
Country of Graduation
Name of Medical School
Direct Entry to Medical School i.e. CAO / ''Type YES or NO''
Graduate Entry Candidate to Medical School / ''Type YES or NO''
Registration (Verification Required)
Registration / Temporary / Full / Registration Number /Irish Registration (IMC):
UK Registration (GMC):
Other (please specify):
IRISH MEDICAL COUNCIL REGISTRATION
A mandatory requirement for entry onto the training programme is eligibility for Medical Council registration on the trainee specialist division. See RCSI website http://www.rcsi.ie guidelines for more information.Have you graduated from an Irish Medical School and successfully completed your internship in Ireland / ''Type YES or NO''
Have you successfully completed your medical qualification in one the following countries?
Austria Estonia Hungary Croatia
Belgium Finland Iceland Spain
Bulgaria France Latvia Switzerland
Cyprus Germany Netherlands Slovak Republic
Czech Republic Greece Romania
If yes which country? /
''Click here to start Typing''
Are you currently registered on the Trainee Division of the Medical Council in Ireland / ''Type YES or NO''If you have answered NO to all of the questions above you must:
· 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.
Are you eligible to be registered on the Trainee Division of the Irish Medical Council? / ''Type YES or NO''
Are you a European Economic Area (EEA) national? / ''Type YES or NO''
If no, do you hold a work visa or work authorisation permitting you to work in this sector? /
''Click here to start Typing''
SECTION C – ENGLISH LANGUAGE REQUIREMENT
Do you qualify under either of the following exemptions? / ''Click here and type''If Yes, please confirm (select one) / ''Country of Graduation''
“Registered with the Medical Council prior to 1st January 2015”
''DD / MM / YR''
Please confirm details of the award of membership of the royal college of emergency medicine
Qualification / Date Passed / College / Office Use /MRCEM Part A / ''DD / MM / YY'' / ''Click here and type''
MRCEM Part B / ''DD / MM / YY'' / ''Click here and type''
MRCEM Part C / ''DD / MM / YY'' / ''Click here and type''
Primary FRCEM / ''DD / MM / YY'' / ''Click here and type''
Intermediate FRCEM SAQ / ''DD / MM / YY'' / ''Click here and type''
Intermediate FRCEM SJT / ''DD / MM / YY'' / ''Click here and type''
Section Two:
A.1 CLINICAL 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 2018)
Hospital: / Specialty and Grade / Consultants: / Total Period (months): / Dates: (From – To) / Office use /Please indicate if you have completed an: /
Irish BST Programme / ''Type YES or NO''
Other / ''Type YES or NO''
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. One reference must be from your current trainer. Reference forms must, where possible, relate to recent clinical or research appointments (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)
Course / Date /Duration / Venue / Office Use /A.2 Research and Academic Development in Emergency Medicine
1. Thesis (Verification Required)
/ Please tick / University / Office Use /Thesis awarded by University?
Thesis submitted to University?
Office Use
Documentation (receipt) of your thesis status much be submitted with this application.
2. Please specify any Other Relevant Degree(s) you have obtained
Qualification / Date from: / Date to: / College / Office Use /3. Please specify any Relevant Diploma(s) you have obtained
Qualification / Date from: / Date to: / College / Office Use /ICEMT Application Form for Advanced Specialist Training in Emergency Medicine V1/OM/OCT17
Page 2 of 17
Publications
Original Peer-Reviewed Scientific Papers
Name of Journal / Impact Factor / Title of Paper / Reference / PIMD Number / Author Status 1st, 2nd / Office UseIf 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
Chapter Title / Book Title / Publisher / Author status 1st, 2nd etc / Date & Pages / ISBN / Office UseInvited Review Articles in Peer Review Journals
Review Title / Journal / Reference / PIMD No. / Author status 1st, 2nd etc / Office UseEvidence based publications (e.g. cochrane review or protocol, bestbet)
Title / Journal / Author status 1st, 2nd etc / Date / Reference / Office UseElectronic only Publications (e.g. cem enlightenme learning module)
Title / Journal / Author status 1st, 2nd etc / Date / Reference / Office UseCase Reports
Title / Journal / Reference / PIMD No. / Author status 1st, 2nd etc / Office UsePresentations - ORAL
National / International Presentations
Name of Meeting / Date / Venue / Title of Presentation / Office UsePresentations – Moderated Poster
National / International Moderated Poster Presentations
Name of Meeting / Date / Venue / Title of Presentation / Office UseOral presentations should only be listed where the applicant has personally presented at an EM relevant meeting (Appendix 1)
Presentations – Poster
National / International Poster Presentations
Name of Meeting / Date / Venue / Title of Presentation / Office UsePRIZES and Research Grants
International
International Research Prizes / Grants / Date / Amount / Office UseNATIONAL
National Research Prizes / Grants / Date / Amount / Office Use
Audit
Additional Information
If you wish to include any additional information relating to your application please use the space provided below /(i.e. teaching experience, membership of societies, management experience, IT experience)
Have you applied for the National SpR/SR Academic Fellowship Programme? / Please tick
Yes □ No □
ICEMT Application Form for Advanced Specialist Training in Emergency Medicine V1/OM/OCT17
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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 2018 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
o Irish Association for Emergency Medicine Annual Scientific Meeting
o College of Emergency Medicine Annual Scientific Meeting
o European Society for Emergency Medicine Annual Scientific Meeting
o The Mediterranean Emergency Medicine Congress
o International Conference on Emergency Medicine
o American College of Emergency Physicians (ACEP) Annual Scientific Meeting
o Society of Academic Emergency Medicine Annual Scientific Meeting
o Canadian Association of Emergency Physicians Annual Scientific Meeting
o Australasian College of Emergency Medicine Annual Scientific Meeting