Applicant Training Evidence

APPLICATION FORM

Certificate of Completion of Basic Surgical Training (CCBST)

RoyalCollege of Surgeons in Ireland

Guidelines (Read Carefully):

The application rules required by the Royal College of Surgeon in Ireland to assess an applicant’s eligibility for a Certificate of Completion of Basic Surgical Training are outlined below:

1)Candidates must possess the FRCSI, Collegiate MRCS or Intercollegiate MRCS

2)Candidates who posses the FRCSI or Collegiate MRCS will be grandfathered

3)Candidates who posses the Intercollegiate MRCS must meet the following standards:

24 months approved* training in at least three different SAC specialties** (*all posts must be

approved for Basic Surgical Training by the RoyalCollege of Surgeons in Ireland. Posts recognised for BST by the RCS London, Edinburgh or Glasgow prior to August 2007 may be accepted. **sub-specialties are not counted as different specialities and therefore a maximum of one year in any one specialty or one of its sub-specialties is permitted).

A maximum of six months in Emergency Medicine is permitted.

Posts must be of six months duration unless formally approved for a lesser period (i.e. posts in a joint

department or recognised to rotate between two or more departments).

Candidates must have at least three satisfactory assessments one of which must include the

assessment for the final six month period.

Candidates registered on the RCSI National Basic Surgical Training Programme are assessed under

the CAPA process and the overall performance in the education programme and workplace assessments will be taken into consideration.

Candidates must complete a recognised Basic Surgical Skills course (verification required).

Candidates from the UK MMC programme will be deemed eligible if they have satisfactorily

completed ST1 and ST2 (not F1 or F2).

Only FULLY completed applications will be processed.

Please TYPE / PRINT CLEARLY to facilitate correspondence.

Title: ______Surname: ______First Name: ______

Address: ______

______

Email Address: ______Home Number: ______

Date of Birth: ______Work Number: ______Bleep______

Nationality: ______Mobile Number: ______

A. Did you complete an RCSI training programme?

Yes  No 

If “Yes” which Programme: ______Which Region: ______

Commencement Date: ______End Date: ______

B. If you did not complete an RCSI programme:

1) Please tick College / Deanery your posts are approved by:

Scotland

Aberdeen Deanery

DundeeDeanery

Edinburgh

Glasgow

EnglandWales

Northern Ireland

2) Please list the posts that you have completed to date:

Start Date: _ _ / _ _ / _ _ End Date: _ _ / _ _ / _ _ Post ID: ______

Specialty: ______Hospital: ______

Start Date: _ _ / _ _ / _ _ End Date: _ _ / _ _ / _ _ Post ID: ______

Specialty: ______Hospital: ______

Start Date: _ _ / _ _ / _ _ End Date: _ _ / _ _ / _ _ Post ID: ______

Specialty: ______Hospital: ______

Start Date: _ _ / _ _ / _ _ End Date: _ _ / _ _ / _ _ Post ID: ______

Specialty: ______Hospital: ______

Please submit three satisfactory assessments from your Consultant one of which must include the assessment from your final six month period assessment (blank assessment forms are available to download from ).

Candidates from the UK have you satisfactorily completed:

a) ST1

Commencement Date: ______End Date: ______

b) ST2 (not F1 or F2)

Commencement Date: ______End Date: ______

C. Please tick which College you completed your examination:

The RoyalCollege of Surgeons in Ireland

The RoyalCollege of Surgeons of Edinburgh

The RoyalCollege of Surgeons of England

The RoyalCollege of Surgeons of Glasgow

D. What examinations have you passed?

Intercollegiate Collegiate MRCS Part 1 Yes  No If ‘Yes’ when? _ _ / _ _ / _ _

Intercollegiate Collegiate MRCS Part 2 Yes  No If ‘Yes’ when? _ _ / _ _ / _ _

Intercollegiate Collegiate MRCS Part 3 Yes  No If ‘Yes’ when? _ _ / _ _ / _ _

Collegiate MRCS Part 1 Yes  No If ‘Yes’ when? _ _ / _ _ / _ _

Collegiate MRCS Part 2 Yes  No If ‘Yes’ when? _ _ / _ _ / _ _

Collegiate MRCS Part 3 Yes  No If ‘Yes’ when? _ _ / _ _ / _ _

FRCSI A Yes  No If ‘Yes’ when? _ _ / _ _ / _ _

FRCSI B Yes  No If ‘Yes’ when? _ _ / _ _ / _ _

*Please submit verification of the exams you have completed or a copy of your membership

E.Please enter your UniqueCollege Identifier Number

You will get this at the end of the letter the examinations office sent to you stating that you were successful in your exam or alternatively you can call the exams office on 01-4022223

College Identifier Number RCSI only(6-8 Numerals)______

F. Are you registered with the Irish Medical Council

I am not registered with the IMC or GMCYes  No 

I have an IMC Number – Please enter here______

I have an GMC Number – Please enter here______

If you do not have any of the above you must submit evidence that you are in fact registered with the medical council.

G. Your Basic Medical Degree:

Name of Qualification______

Country of Awarding University or MedicalCollege______

Name of University Or MedicalCollege______

Date Awarded______

H. Have you successfully completed the Basic Surgical Skills Course?

Yes  No 

If ‘Yes’ when? _ _ / _ _ / _ _ Where? ______(please submit verification)

I) The fee for processing this application is as follows:

Trainees who completed an RCSI BST Programme €30.00

Trainees who did not complete an RCSI BST Programme€150.00

Candidates who posses the FRCSI or Collegiate MRCS will not be required to pay a fee

Please tick method of payment: Credit Card Postal Order Cheque

Cheques & Postal Orders should be made payable to “Royal College of Surgeons in Ireland” For payment by Credit Card please enter details below:

Card Types Accepted only:Visa/MasterCard (Laser Cards / Cash not accepted)

Card Number:- - - - / - - - - / - - - - / - - - - Exp Date: - - - - / - - - -

Signature:______

This fee is non-refundable.

Signed ______Date: ______

Completed forms should be returned to:

Ms. Jane Cunningham

Surgical Training Office

RoyalCollege of Surgeons in Ireland

123 St. Stephen’s Green

Dublin 2

Phone: 01-402 2231 Email:

OVERSEA’S APPLICANT TRAINING EVIDENCE FORM

(It is mandatory for overseas applicants to obtain the Post ID number. This can be obtained from Medical Administration in each hospital)

Applicant name:

Start to FinishGradeSpecialtyHospital or InstitutionPost IDTrainer Trainer’s E-mail

(dates)

DECLARATION

I declare that Dr … has completed the above approved training post and confirm that I have seen a satisfactory assessment of his/her performance and progression in this training post. I also confirm that the trainee has an appropriately certified logbook/portfolio for this post.

Trainer’s Name:

Trainee’s Name:

We confirm that to the best of our knowledge, all the information provided in this approved training post form represents a true and accurate statement. We understand that any false information supplied with the intention to mislead will be reported to the GMC/IMC and GDC/IDC (if applicable).

Hospital Stamp

Trainer’s Signature:

Date of Trainer’s Signature (dd/mm/yy):

Trainee’s Signature:

Date of Trainee’s Signature: