Form B -Application for National Higher Specialist Training (HST) Programmes in Psychiatry

Form B -Application for National Higher Specialist Training (HST) Programmes in Psychiatry

JULY 2018 INTAKE

Applicants should read the information sheets accompanying this form before completing an application
SECTION A (i) – PERSONAL DETAILS (As used on Irish Medical Council documents)
Surname / ‘’Click here and type Surname’’
Forename / ‘’Click here and type Forename’’
Address for correspondence / ‘’Click here and type Address’’
‘’Address line 2’’
‘’Address line 3’’
‘’County’’
‘Country’’
Home phone number / ‘’XXXXXXXXXXXXXXX’’
Work phone number, including bleep / ‘’XXXXXXXXXXXXXXX’’
Mobile phone number / ‘’XXXXXXXXXXXXXXX’’
Personal email address / ‘’Click here and type Email Address’’

SECTION A (ii) – CITIZENSHIP

PLEASE NOTE:
If you are shortlisted for interview you will be required to:
(1) State whether or not you were an EU citizen at the date of application.
(2)Prior to the date of interview, you will be required to submit a certified colour copy of the identity page of your passport PLUS
(3)1 certified passport photograph with your name in block capitals on the reverse of same).
(4)Where appropriate, applicants must submit a copy of their Certificate of Naturalisation as issued by the Department of Justice and Equality.
You must NOTsubmit evidence of Citizenship or a photograph with this application.

SECTION B – ENGLISH LANGUAGE PROFICIENCY REQUIREMENTS

(Please refer to Section B of the Guidelines for Applicants document for more information)
Do you qualify under either of the two exemption grounds? / ''Type YES or NO''
(1)Completed the entirety of your undergraduate medical training in the Republic of Ireland / Tick “” if applicable
(2)Completed your medical degree in any of the following countries – United Kingdom, Australia, Canada, New Zealand or United States / Tick “” if applicable
Have you attached documentary evidence of the above exemption ground? / ''Type YES or NO''
If you do not qualify for exemption, have you attached a certified copy of the required IELTS Result / ''Type YES or NO''
SECTION C (i)- SCHEMES BEING APPLIED FOR
To which National Higher Training Scheme does this application apply: (Please Tick)
(1)The Specialties of Adult Psychiatry 
OR
(2)Child and Adolescent Psychiatry 
In relation to the Scheme ticked above, do you wish this application to be considered for: (Please Tick )
(a)Clinical posts only 
OR
(b)Clinical and academic posts 
Please note:
If you wish to be considered for both Schemes [(1) The specialties of Adult Psychiatry & (2) Child and AdolescentPsychiatry], please make an entirely separatesubmission for each.
SECTION C (ii) PART-TIME / FLEXIBLE TRAINING
(Please refer to Section C of the Guidelines for Applicants document for more information)
Are you interested in part-time/flexible training? / ‘''Type YES or NO''

SECTION D – IRISH MEDICAL COUNCIL REGISTRATION

(Please refer to Section D of the Guidelines for Applicants document for more information)
A mandatory requirement for entry onto the training programme is eligibility for Medical Council registration in the Trainee Specialist Division.
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? / ''Type YES or NO''
Have you successfully completed your medical qualification in one the following countries:
Austria / Belgium / Bulgaria / Croatia / Cyprus / Czech Republic / Estonia / Finland / France / Germany / Greece / Hungary / Iceland / Latvia / Netherlands / Romania / Spain / Switzerland / Slovak Republic / ''Type YES or NO''
If answered ‘YES’, which country? / ''Type Country Name if applicable'
Are you currently / were you previously registered on the Trainee Specialist Division of the Medical Council in Ireland?
If yes, please indicate Medical Council Registration Number: / ''Type YES or NO''
''Type Number if applicable"
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 Specialist Division. Please note the Medical Council cannot confirm a doctor’s eligibility for Trainee Specialist registration until an application for registration has been submitted.

AND

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.

SECTION E (i) – MEDICAL EDUCATION

Undergraduate Medical Education

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''
If you completed your medical education in an Irish Medical School, please indicate if you are a CAO/HEA Graduate / “A CAO / HEA Graduate is defined as a trainee who was entitled to free fees in an Irish Medical School and accessed the programme through the CAO process. Any student who was required to pay fees to access their degree is not considered a CAO/HEA Graduate.”
''YES / NO"'
Date of entry to Medical School / ''DD / MM / YR''
Date of graduation / ''DD / MM / YR''
Primary medical qualification / ''Click here and type Qualification''
Overall grade achieved / ''Click here and type grade''
Final year exam results /

''Click here and type subject and grade''

''Click here and type subject and grade''

''Click here and type subject and grade''

''Click here and type subject and grade''

''Click here and type subject and grade''

''Click here and type subject and grade''

''Click here and type subject and grade''

''Click here and type subject and grade''

''Click here and type subject and grade''

''Click here and type subject and grade''

Skill Courses e.g. ACLS, ATLS, BLS
Name of Course / Location of Course / Date
''Click here and type name of course'' / ''Click here and give location'' / ''DD / MM / YR''
''Click here and type name of course'' / ''Click here and give location'' / ''DD / MM / YR''
''Click here and type name of course'' / ''Click here and give location'' / ''DD / MM / YR''

Undergraduate Academic Distinctions

Please give details of any prizes, medals or scholarships received

''Click here to start Typing''

Postgraduate Medical Education

Higher Qualification/Degree/Diploma

Awarding Body

Date of Qualification

''Click here and type Qualification'' / ''Type Awarding Body'' / ''DD / MM / YR''
''Click here and type Qualification'' / ''Type Awarding Body'' / ''DD / MM / YR''
''Click here and type Qualification'' / ''Type Awarding Body'' / ''DD / MM / YR''
Postgraduate Exams / Grade Achieved / Date
''Click here and type name of exam'' / ''Click here and type grade'' / ''DD / MM / YR''
''Click here and type name of exam'' / ''Click here and type grade'' / ''DD / MM / YR''
''Click here and type name of exam'' / ''Click here and type grade'' / ''DD / MM / YR''

Postgraduate Academic Distinctions

Please give details of any postgraduate prizes, medals or scholarships received

''Click here to start Typing''

SECTION E (ii) – NON-MEDICAL EDUCATION (if applicable):

Undergraduate Education other than medical (if applicable):

University Name / ''Click here and type School/University''
Address of University / ''Click here and type Address''
''Address line 2''
''Address line 3''
''County''
''Country''
Undergraduate Course Taken / ''Click here and type Course Name"
Date of entry to University / ''DD / MM / YR''
Date of graduation / ''DD / MM / YR''
Primary qualification / ''Click here and type Qualification''
Overall grade achieved / ''Click here and type grade''
Final year exam results /

''Click here and type subject and grade''

''Click here and type subject and grade''

''Click here and type subject and grade''

''Click here and type subject and grade''

''Click here and type subject and grade''

''Click here and type subject and grade''

''Click here and type subject and grade''

''Click here and type subject and grade''

Undergraduate Academic Distinctions

Please give details of any prizes, medals or scholarships received

''Click here to start Typing''

Postgraduate Education other than medical (if applicable):

Higher Qualification/Degree/Diploma

Awarding Body

Date of Qualification

Postgraduate Academic Distinctions

Please give details of any prizes, medals or scholarships received

''Click here to start Typing''

SECTION F (i)- BASIC SPECIALIST TRAINING IN PSYCHIATRY

If you have completed BST Psychiatric Training in Ireland, please enter your details below.
All applicants must possess Membership of the Royal College of Psychiatrists or a professional qualification in Psychiatry at least equivalent thereto. Applicants with certificate of equivalent to CCBST/MRCPsychmust submit a certified copy of equivalent evidence of same.

Name of Training Body overseeing Basic Specialist Training / “DD/MM/YR” “Awarding Body”
Full name of BST Programme / “Click here and type name of Programme”
Basic Specialist Training Commenced: / “DD/MM/YR”
Basic Specialist Training Completed: / “Click here and type YES or NO”
If Yes above- Date of completion / “DD/MM/YR”
If No above- Due Date of Completion: / “DD/MM/YR”

SECTION F (ii) – MEDICAL EMPLOYMENT HISTORY

(1)Clinical Experience Relevant to Higher Specialist Training Programme

Beginning with the most recent (i.e. current position) you are required to list all previous appointments in clinical specialty(s)/sub-specialty(s) which are relevant to the HST Programme you are applying for. In relation to each period of employment, you are required to highlight clinical experience relevant to this specialty/sub-specialty including clinical practice, teaching experience, audit and management.

Clinical Site

(If overseas please indicate country) /

Grade

Specialty

/ Supervising Consultant / From – To /

Months in post

Example:
St. James’s Hospital / Intern / Surgery / Mr. Joe Bloggs / 01/07/04 –
31/12/04 / 6
''Click here and type Information'' / ''Grade'' / ''Speciality'' / ''Consultant'' / ''dd/mm/yr''-
''dd/mm/yr'' / ''xx''
''Highlight clinical experience in the above post here"
''Click here and type Information'' / ''Grade'' / ''Speciality'' / ''Consultant'' / ''dd/mm/yr''-
''dd/mm/yr'' / ''xx''
''Highlight clinical experience in the above post here"
''Click here and type Information'' / ''Grade'' / ''Speciality'' / ''Consultant'' / ''dd/mm/yr''-
''dd/mm/yr'' / ''xx''
''Highlight clinical experience in the above post here"
''Click here and type Information'' / ''Grade'' / ''Speciality'' / ''Consultant'' / ''dd/mm/yr''-
''dd/mm/yr'' / ''xx''
''Highlight clinical experience in the above post here"
''Click here and type Information'' / ''Grade'' / ''Speciality'' / ''Consultant'' / ''dd/mm/yr''-
''dd/mm/yr'' / ''xx''
''Highlight clinical experience in the above post here"
''Click here and type Information'' / ''Grade'' / ''Speciality'' / ''Consultant'' / ''dd/mm/yr''-
''dd/mm/yr'' / ''xx''
''Highlight clinical experience in the above post here"

(2)Other Clinical Experience

Beginning with the most recent (i.e. current position) you are required to list allother previous clinical appointments in clinical specialty(s)/sub-specialty(s) which you have not accounted for above. In relation to each period of employment, you are required to highlight clinical experience relevant to this specialty/sub-specialty including clinical practice, teaching experience, audit and management.

Clinical Site

(If overseas please indicate country) /

Grade

Specialty

/ Supervising Consultant / From – To /

Months in post

SECTION F (iii) – NON-MEDICAL EMPLOYMENT HISTORY (if applicable):

Beginning with the most recent position you are required to list all previous appointments.

Employer

(If overseas please indicate country) / Role/Job Title / From – To /

Months in post

Example:
AA Architects, UK / Architectural Technician / 01/01/14 - 30/06/14 / 6
''Click here and type Information'' / ''Role/Job Title'' / ''dd/mm/yr''-
''dd/mm/yr'' / ''xx''
''Click here and type Information'' / ''Role/Job Title'' / ''dd/mm/yr''-
''dd/mm/yr'' / ''xx''
''Click here and type Information'' / ''Role/Job Title'' / ''dd/mm/yr''-
''dd/mm/yr'' / ''xx''
''Click here and type Information'' / ''Role/Job Title'' / ''dd/mm/yr''-
''dd/mm/yr'' / ''xx''

SECTION G – PUBLICATIONS, AUDIT & PRESENTATIONS

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.

Publications

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 / YR''

Abstract Text

Please paste your abstract text here

''Click here and start typing''

Audits

Full descriptive title of audit / ''Click here to start Typing''
Completed audit (unpublished) / ''Type YES or NO''
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 (if published) / ''Click here to start Typing''
Volume and page number (if published) / ''Click here to start Typing''
Publication date (if published) / ''DD / MM / YR''

Summary of Audit

Please describe your Audit here

''Click here and start typing''

(Form B - Updated Nov.2017) Page 1 of 15

Presentations

Only a presentation at a National or International Meeting may be included here.
Full descriptive title of presentation / ''Click here to start Typing''
Presented at National Meeting / ''Type YES or NO''
Poster presentation at National Meeting / ''Type YES or NO''
Presented at International Meeting / ''Type YES or NO''
Poster presentation at International Meeting / ''Type YES or NO''
Authors (Initial and surname only, no titles) / ''Click here to start Typing''
Name of meeting / ''Click here to start Typing''
Location / ''Click here to start Typing''
Presentation date / ''DD / MM / YR''

Summary of Presentation 1

Please describe your presentation here

''Click here and start typing''

Teaching Experience

Please list and provide a brief description of formal teaching duties you have undertaken to date including location of such teaching duties, target audience and what agency or educational partner or training programme such teaching was affiliated to.

‘Click here’

(Form B - Updated Nov.2017) Page 1 of 15

SECTION H – AIMS & CAREER OBJECTIVES

Outline your career objectives, why you wish to participate in the Higher Specialist Training Programme and what you will contribute to the specialty.

''Click here and start typing''

SECTION I – 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 interviews.

''Click here and start typing''

SECTION J – 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.
Please note that all referees must use the standard reference template provided.
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''

SECTION K – NOTES

Please 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 and Police clearance as required, 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 L – APPLICATION CHECKLIST