Your first name: Last name: Application ID:

EVIDENCE SUMMARY FORM Medical Specialty ST3 interviews (required for Application & Evidence Station)

You are required to bring any evidence you have quoted on the application form to the selection centre. The evidence you are required to bring is in two sections. Firstly you are required to show proof of your eligibility (eg proof of name, address, medical qualification etc). Please follow the deanery instructions regarding the evidence (and number of copies) you are required to bring to the assessment centre. This information will be checked at the ‘document checking’ desk in the assessment centre.Secondly, you are required to provideevidence for all the achievements you have quoted on your application form and summarise your experience. Please use this form (Evidence Summary form) for these purposes.

Instructions for completion of the Evidence Summary Form and assembly of your Evidence Folder

  • the interviewers will wish to inspect all the evidence you have quoted on your application form
  • you must bring to the interview an ‘Evidence Folder’ which shows all the evidence you have quoted on your application form, in the order in which it is quoted. Please try to use any original documents, but copies may be acceptable (only one copy required)
  • do NOT bring your personal training portfolio (or a full print-out of your ePortfolio)
  • if you do not bring sufficient evidence for achievements claimed on the application form, your application may be discounted; serious probity issues may be reported to the GMC
  • you may provide any additional evidence (eg MSF summary, evidence of skills etc) that is of relevance to your application, as long as it is listed below and filed in the correct section – you may expand the form if required
  • you must not include any patient identifiable data – this would be a serious breach of patient confidentiality
  • you must put this form at the front of your evidence folder, so the interviewers can see, at a glance, what you evidence you have brought to support your application and your previous experience
  • use dividers, or other markers, to identify the relevant sections and pages.

Evidence folders which do not follow the structure as defined and incomplete Evidence Summary Forms may not be looked at.

You must take the evidence folder into the relevant interview station. It will be returned to you after the interview – please do not leave the assessment centre without it, as it might not be possible to post it back to you.

Evidence quoted on your application form
If you wish to show additional evidence not quoted on your application form, please list it in the appropriate row, and write in the page number / Tick if evidence is quoted in your application form / Page in folder / Confirmed correct by interview panel or comments if evidence is inadequate / dishonest
(for interviewers’ use only)
Copy of your application form
(do not include your personal details) / N/A
Additional undergraduate degrees and qualifications
Postgraduate degrees and qualifications
Additional achievements e.g. prizes, honours etc
Training courses attended
Achievements outside medicine
Presentations
Publications
Teaching experience
Clinical audit
Commitment to specialty
ST3 level skills
List below any other relevant evidence which does not come into the above categories:
Evidence folder complete? Yes / No
Interviewer name:Signature:
Deanery:Date:

Medical qualification details; postgraduate exam and experience

In order for the interviewers to see your medical qualification, relevant postgraduate qualification and previous medical experience at a glance, please complete the details below. For posts, startwith your first post after qualification. For part-time work, calculate the whole time equivalent (WTE). Include any posts you are due to rotate to. For each post, tick whether the main focus of the post was to gain Foundation orCore or Specialty (ST3) competences. You do not need to list non-medical appointments.Add more rows if required.

name of institution awarding your primary medical qualification / date of qualification (mm/yy)
name of postgraduate exam you have passed relevant to your Core Training or equivalent
(eg MRCP(UK), MRCPCH) / date full exam passed
(mm/yy)
post start date
(mm/yy) / post end date
(mm/yy) / time in post in months
(WTE) / post grade (eg Foundation CMT, LAT) / specialty / hospital name and locality
(full address is not required) / foundation comps. gained? / CMT comps gained? / ST3 level comps gained?

This form to be retained by interviewing panel and deanery

FORM – Evidence Summary for medical specialty ST3 Interviewv1.0 RCP-SRO March 2012