Appendix E -Currency and Number of Attempts in MRCPCH Examinations (Form)

Appendix E -Currency and number of attempts in MRCPCH examinations (form)

MRCPCH Further Attempt Application Form

Please read the 6 and 7 attempt guidance notes before completing this form.
Please complete all sections and ensure that you date and sign the Agreement.
Please complete the form clearly and in BLOCK CAPITALS.
Please send the completed form to the RCPCH Examinations Team in advance of the next available examination application opening date.

All personal information held by the Examinations Department of the Royal College of Paediatrics and Child Health (RCPCH) will be held in accordance with the Data Protection Act of 1998

Personal data on this form is collected for the purpose of providing evidence in order for the RCPCH to determine if additional examination attempts for MRCPCH examinations can be granted. Any data collected may be exchanged between key staff / teams within the RCPCH Education and Training Division for the purpose of verifying the need for any additional examination attempts. Details of any additional examination attempt request or outcome may be included on individual’s e-portfolio accounts. This data will not be released elsewhere without your permission. If you have any queries about how your personal data is used please email

RCPCH Code Number:

Family/Last name:

______

Forename(s):

______

Place of work:

______

Mobile Phone No:

______

Home Phone No:

______

Email:

______

Details of the examination you would like to apply for

(please tick the relevant box)

Foundation of Practice

Theory and Science

Applied Knowledge in Practice

MRCPCH Clinical Examination

Examination date/s applying to:

______

Confirmation of additional educational experience (to be completed by the educational supervisor or equivalent)

I confirm that the candidate named above has undertaken additional educational experience to prepare them for the above examination, and I endorse their request for an additional attempt *

Educational supervisor name

______

Place of work:

______

Work Phone No:

______

Signature:

______

Work email:

______

Please provide a brief but detailed summary of the additional educational experience that has been undertaken here providing specific examples:

------

*Please note that as an educational supervisor supporting an additional attempt you may be contacted to verify this form

Confirmation of additional educational experience (to be completed by the training programme director or equivalents)

I confirm that the candidate named above has undertaken additional educational experience to prepare them for the above examination as specified in section 3, and I endorse their request for an additional attempt

Training Programme Director name

______

Place of work:

______

Work Phone No:

______

Signature:

______

Work email:

______

Please provide a brief but detailed summary of the additional educational experience that has been undertaken here providing specific examples:

------

*Please note that as a training programme director supporting an additional attempt you may be contacted to verify this form

MRCPCH examination agreement.Further attempt form

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 the Colleges for administrative purposes, and to meet its statutory obligations.

Candidate name:

______

Date of Birth: ___/___/______

Signature:

______

Date: _____ / _____ /_____

Royal College of Paediatrics and Child Health

Examinations Department

5-11 Theobald’s Road

Tel: 0207 092 6000

Fax: 0207 092 6193

Email:

RCPCH Currency and number of attempts in MRCPCH examinations.v.1.4

To see all MRCPCH and DCH examination rules and regulations, go to