Margaret Pyke Centres

for study and training in contraception, sexual and reproductive health

Letter of Competence in Subdermal Implants (LoC SDI)

Do you hold the Diploma of the Faculty of Sexual and Reproductive Healthcare ((N)DFSRH) or are you a member (MFSRH) or fellow (FFSRH) of the FSRH?
OR
Have you completed the eKA in SRH? / please specifyYesNo
Have you completed SDI e-learning module 17? / please specifyYesNo
Do you currently work in a relevant clinical practice e.g GP, GUM, SRH? / please specifyYesNo
Can you commit to attendance as set out on the CNWL SRH training website? / please specifyYesNo
Do you have evidence of up to date basic life support and anaphylaxis training? / please specifyYesNo

If you have answered yes to all questions, you are eligible to train at MPC. Please complete the application and return it with the required documentation by email to

If you have answered ‘NO’ to any of the four questions but think you could be eligible, please contact the Training Administration Manager

Full name

Contact address

Email

Telephone

Your current post

Date you leave your current post (if fixed-term contract)

Employer’s name

Employer’s address

Your Educational Supervisor

Have you been or are you currently the subject of fitness to practice proceedings by a UK or an overseas regulatory body? / please specifyYesNo
If yes, please give details and continue on a separate sheet if necessary:

I confirm that, to the best of my knowledge, the information given on this application form is accurate and true.

Signature of applicant Date

* Applications submitted by e-mail are deemed to have also confirmed acceptance of this declaration by the sending of the application form. You may be asked to sign your form in your first training session.

NB: Please note that all applications to undertake practical training at the Margaret Pyke Centre are assessed on an individual basis. Completion of this form does not guarantee a place in the training programme

Letter of Competency in Subdermal Implants (Loc SDI)

Document Check

In order to be accepted for this training, you must provide the following documents. Please tick the boxes to show which documents you have included with your application:

All applicants

A copy of your DFSRH/NDFSRH/MFSRH/FFSRH certificate

OR

Proof of eKA pass

Proof of completion of SDI e-learning module 17

Letter of recommendation – must be from your educational supervisor, clinical line manager or a referee, indicating your suitability to undertake training in sexual and reproductive healthcare

Your up-to-date CV

Evidence of current basic life support and anaphylaxis training

If you are not employed by CNWL NHS Foundation Trust you must be issued with an honorary contract so you are permitted to see patients within our service. Please provide the following additional documentation:

Completed occupational health confidential health questionnaire

Completed honorary contract application form

2nd letter of recommendation from appropriate professional referee

Copy of CRB/DBS enhanced disclosure which was requested by an NHS organisation within the last 3 years

Proof of GMC/RCN accreditation

(Office Use Only):

Date received

Reviewed by

Outcome

Head office: Stephenson House, 75 Hampstead Road, LondonNW1 2PL|

LoC SDI Application Form 2014