Higher Surgical Training For

IRISH SURGICAL POSTGRADUATE TRAINING COMMITTEE

Higher Surgical Training for

Senior Specialist Registrar in Otolaryngology (Yrs 5&6)

Commencing January & July 2014

APPLICATION FORM

Closing Date: Friday 23rd August 2013

Read the enclosed guidelines carefully prior to completing the application form.

This application must be submitted unbound and unstapled but in the correct order as per page numbers

GUIDELINES (read carefully)

General:

Application Fees: €100

Commencement Date:January & July 2014

JCST Enrolment:Successful candidates will be required to enrol with the JCST.

Title of Post: Senior Specialist Registrar (SSpR) in Otolaryngology

Duration of Programme:Two Years (subject to satisfactory continuous assessments)

Curriculum:

Examinations:

Approved Hospitals:

Beaumont Hospital, Dublin

Mater Hospital, Dublin

Royal Victoria Eye & Ear Hospital, Dublin

Our Lady’s Children’s Hospital Crumlin, Dublin

St. James/ Tallaght Hospital, Dublin

St Vincent’s Hospital, Dublin
South Infirmary Victoria University Hospital, Cork

Additional hospitals may be approved during the course of your training. Successful candidates will be required to rotate to both Universtiy and non-UniversityHospitals throughout Ireland.

Entry Requirements:

All applicants must have completed four year Specialist Registrar Training in SAC approved posts.

Salary:

In accordance with approved Department of Health scales (

Application Conditions & Procedures:

Applications must include all of the following together by post:

Completed application form (unbound and unstapled in correct order as per page numbers)

Signed, dated, consolidated logbook (must be in format enclosed)

Verification of IMC Registration

Verification of Postgraduate Qualifications

Verification of completion of surgically relevant courses (certificate level)

Structured reference forms X 3 (attached)

Verification of Thesis awarded / submitted (letter from research supervisor)

Verification of Publications, Reviews, Case Reports, Book Chapters (work in progress is not accepted)

Verification of presentations and research prizes.

€100 application fee (payable to RCSI by cheque, bank draft or credit card (authorisation form enclosed)

Structured Reference Forms: It is the responsibility of the candidate to ensure that the structured reference forms(x3) are submitted to the Surgical Training Office on or before the closing date: Friday 23rdAugust 2013.

Verifcation of the above items are required for awarding points for the selection process. Failure to submit these items with your application form will result in you losing out on points you may be entitled to otherwise. These items, with the exception of items under “Research and Academic”, will not be accepted after the closing date. There will be a provision for applicants to submit items such as Thesis, publications, presentations etc. that have been awarded after the closing date up until one week prior to the shortlisting meeting.

Applications or parts of applications are not accepted by email or fax. Any such documents received by this method will be disgarded.

Shortlisted applicants will be required to bring their offical logbook along to the interview.

Selection Process:

The marking system and selection criteria are currently unavailable. A copy will be forwarded to all applicants in due course.

Dates for your diary:

Closing Date: Friday 23rd August 2013

Shortlisting Date: Thursday 12th September 2013

Interview Date: TBC

Completed applications to:

Lisette Biggins

Otolaryngology
HST Administration
Surgical Training Office
RCSI House
121 St. Stephens Green
Dublin 2
Ireland / Queries to:

Name: Lisette Biggins
Email:
Phone: +353 1 402 2233

Any attempt to provide misleading or false information to improve your score will result in automatic disqualification.

Please sign here to confirm that you have read and understand the above conditions of application:

Signed: ______Date: ______

Section One:Personal Details

Applicant Details

Name
Title:
Surname:
First Name:
Personal Details
Date Of Birth:
Age:
Place Of Birth:
Nationality:
Contact Details (Telephone & Email)
Home:
Work:
Mobile:
Email:
Current Mailing Address

Registration (Verification Required)

Registration / Temporary / Full / Registration Number
Irish Registration (IMC):
UK Registration (GMC):
Other (please specify):

Section Two:Educational / Academic Record

Postgraduate:

Please specify the Fellowship / Membership you have obtained (Verification Required)

Qualification / Date / College / Office Use

Please specify any Surgical Relevant Degrees you have obtained through Full Time Study (Verification Required)

Qualification / Date from: / Date to: / College / Office Use

Please specify any Surgical Relevant Degrees / Diplomas you have obtained through Part Time Study (Verification Required)

Qualification / Date from: / Date to: / College / Office Use

Please specify any Surgically Relevant Theoretical Skills Courses (Certificate Level) you have completed (Verification Required)

Qualification / Date / College / Office Use

Please specify any other Surgically Relevant Technical Skills Courses (Certificate Level) you have completed (Verification Required)

Qualification / Date / College / Office Use

Section Three:Postgraduate Professional Development

Clinical Surgery:

Specialist Registrar Training in Otorhinolaryngology/ Head & Neck Surgery

Please list in chronological order with most recent first. Only full-time clinical surgical posts at Specialist Registrar level will qualify. Posts that are part research / part clinical do not qualify for marks here.

Hospital: / Specialty Interest: / Consultants: / Total Period (months): / Dates: (From – To)
Office Use

Research / Academic Development:

Thesis (Verification Required)

Please tick / University / Office Use
Thesis awarded by University?
Thesis submitted to University?
Office Use

Documentation (receipt) of your thesis status much be submitted with this application.

Publications in Peer-Reviewed Journals (Verification Required)

Name of Journal / Impact Factor / Title of Paper / PMID Number / Author Status (i.e. 1st, Senior, 2nd)
Office Use

If the publication is not yet on PubMed there must be a letter of acceptance from the editor of the journal submitted with the application.

Book Chapters

Publisher / Book Title; Chapter Title / ISBN Number / 1st Author Only
Office Use

Points are only awarded for first authorship

Invited Review Articles in Peer Review Journals

Publisher / List Reviews in Peer Review Journals / PMID Number / Author Status
Office Use

Points are only awarded for first authorship

Case Reports

Publisher / List Case Reports in Peer Review Journals / PMID Number / Author Status
Office Use

Points are only awarded for first authorship

Presentations

Please indicate where appropriate / Score
International Meetings
National Meetings
Office Use

No points are awarded for poster presentations. Each specialty will comprise its own list of recognised scientific meetings

Prizes

Please indicate where appropriate / Score
International Research Prizes
National Prizes
Office Use

Each specialty will compile its own list of recognised prizes

Additional Information

If you wish to include any additional information relating to your application please use the space provided below
(i.e. teaching experience, membership of societies, audit experience, management experience, IT experience)

Extra-curricular Interests, Hobbies

I certify that all information provided in this application is, to the best of my knowledge true and accurate.

Signature:Date:

Higher Surgical Training Programme Application

Intake Jan & July 2014– Otolaryngology

Must be from Recent Clinical Posts

Structured Referees Assessment Form (1)

Name of Candidate:______Referee Name: ______

HospitalSpecialty GradeFrom: To:

______/ _ _ / ______/ _ _ / _ _ _ _

Assessment:

(It is expected that most candidates will score “3”. Only exceptional candidates should score 4 or 5)

Poor 1

Inadequate 2

Satisfactory 3

Above Average4

Excellent5

Please complete the following sections based on the above marking system:

Personal / Score (1-5) / Professional / Score (1-5)
Integrity / Professionalism
Intelligence & Initiative / Skill in Diagnosis
Technical Skills / Attitude to Patients
Common Sense / Attitude to Nursing Staff
Appearance / Diligence in Record Taking
Communication Ability / Emergency Management
Attendance & Performance at Conferences / Punctuality & Attendance

Did this doctor perform well in his / her post with you? ______

Do you think he / she is suitable for a career in Surgery? ______

Has he / she any outstanding characteristics? ______

Overall Comments:

______

Signed: ______Date ______

Please return completed form with Application before Friday, 23rdAugust 2013

Lisette Biggins, Otolaryngology Administration, Surgical Training Office,

RCSI House, 121 St. Stephen’s Green, Dublin 2

Higher Surgical Training Programme Application

Intake Jan & July 2014 – Otolaryngology

Must be from Recent Clinical Posts

Structured Referees Assessment Form (2)

Name of Candidate:______Referee Name: ______

HospitalSpecialty GradeFrom: To:

______/ _ _ / ______/ _ _ / _ _ _ _

Assessment:

(It is expected that most candidates will score “3”. Only exceptional candidates should score 4 or 5)

Poor 1

Inadequate 2

Satisfactory 3

Above Average4

Excellent5

Please complete the following sections based on the above marking system:

Did this doctor perform well in his / her post with you? ______

Do you think he / she is suitable for a career in Surgery? ______

Has he / she any outstanding characteristics? ______

Overall Comments:

______

Signed: ______Date ______

Please return completed form with Application before Friday, 23rd August 2013

Lisette Biggins, Otolaryngology Administration, Surgical Training Office,

RCSI House, 121 St. Stephen’s Green, Dublin 2

Higher Surgical Training Programme Application

Intake Jan & July 2014 – Otolaryngology

Must be from Recent Clinical Posts

Structured Referees Assessment Form (3)

Name of Candidate:______Referee Name: ______

HospitalSpecialty GradeFrom: To:

______/ _ _ / ______/ _ _ / _ _ _ _

Assessment:

(It is expected that most candidates will score “3”. Only exceptional candidates should score 4 or 5)

Poor 1

Inadequate 2

Satisfactory 3

Above Average4

Excellent5

Please complete the following sections based on the above marking system:

Did this doctor perform well in his / her post with you? ______

Do you think he / she is suitable for a career in Surgery? ______

Has he / she any outstanding characteristics? ______

Overall Comments:

______

Signed: ______Date ______

Please return completed form with Application before Friday, 23rd August 2013

Lisette Biggins, Otolaryngology Administration, Surgical Training Office,

RCSI House, 121 St. Stephen’s Green, Dublin 2

Consolidated Logbook Otolaryngology Year 5&6

Name:

P = (personal unsupervised)

S = (personal supervised)

A = (assistant)

Procedure: Otology / Actual NumberP / Actual NumberS / Actual NumberA
Micro Ear
Grommet insertion
Canalplasty
Tympanotomy
Atticotomy
Cortical Mastoidectomy
Myringoplasty
Ossiculoplasty
Stapedotomy
Combined approach Tympanoplasty
Modified radical mastoidectomy
Facial Nerve decompression
Meatoplasty
Gentamicin Vestibular Ablation
Saccus Decompression
Posterior semicircular canal occlusion
BAHA
Cochlear Implant
Excision of acoustic neuroma (translab, retrosigmoid, middle fossa)
Excision of Glomus

Verified by: ______Date: ______

Name (Block Capitals):

NB: Your logbook must be signed/Verified by your Supervising Consultant
Consolidated Logbook Otolaryngology Year 5&6

P = (personal unsupervised)

S = (personal supervised)

A = (assistant)

Procedure: Rhinology / Actual NumberP / Actual NumberS / Actual NumberA
Nasendoscopy / biopsy / cautery
Reduction of Inferior turbinates
Antral washouts
Septoplasty
Septorhinoplasty (Closed, Open)
Nasal polypectomy
ESS – Uncinectomy, Middle meatal antrostomy, Ethmoidectomy
Frontal sinusotomy, trephine
Sphenoidotomy
Closure of CSF leak
Lateral Rhinotomy
External Frontoethmoidectomy
Caldwell Luc
Facial Degloving
Excision of Inverting papilloma (endoscopically, open approach)
Excision of Angiofibroma (endoscopically, open approach)
Osteoplastic flap

Verified by: ______Date: ______

Name (Block Capitals):

NB: Your logbook must be signed/Verified by your Supervising Consultant

Consolidated Logbook Otolaryngology Year 5&6

P = (personal unsupervised)

S = (personal supervised)

A = (assistant)

Procedure: Head & Neck / Actual NumberP / Actual NumberS / Actual NumberA
Excision / biopsy lymph node
Submandibular gland excision
Superficial Parotidectomy
Total Parotidectomy
Pharyngeal pouch repair
Facial reanimation (static, dynamic)
Thyroid lobectomy
Total Thyroidectomy
Selective neck dissection
Modified radical neck dissection
Mandibulotomy
Transoral excision Oropharyngeal lesion
Partial Glossectomy
Total Glossectomy ± free flap reconstruction
Resection Oropharyngeal tumour ± free flap reconstruction
Partial Laryngectomy
Total Laryngectomy ± TOP
Excision of stomal stenosis / recurrence
Pharyngolaryngo-oesophagectomy with reconstruction
Maxillectomy ± reconstruction
Craniofacial resection
Excision of skin cancer ± flap ± SSG
Excision of lip lesion ± flap

Verified by: ______Date: ______

Name (Block Capitals):

NB: Your logbook must be signed/Verified by your Supervising Consultant

Consolidated Logbook Otolaryngology Year 5&6

P = (personal unsupervised)

S = (personal supervised)

A = (assistant)

Procedure: Paediatric / Actual NumberP / Actual NumberS / Actual NumberA
Microlaryngoscopy & Bronchoscopy – Diagnostic and therapeutic
Excision of Thyroglossal duct cyst
Excision of Cystic Hygroma
Excision of Ranula
Branchial anomalies repair
Tracheostomy
Aryepiglottoplasty
Laryngotracheal reconstruction
Cricotracheal resection
Excision Laryngeal Papillomatosis
Laryngofissure
Repair Laryngeal cleft
Excision subglottic haemangioma
Submandibular relocation
Excision nasal dermoid
Repair meningocoele

Verified by: ______Date: ______

Name (Block Capitals):

NB: Your logbook must be signed/Verified by your Supervising Consultant

Consolidated Logbook Otolaryngology Year 5&6

P = (personal unsupervised)

S = (personal supervised)

A = (assistant)

Procedure: General/ Laryngology/ Airway / Actual NumberP / Actual NumberS / Actual NumberA
Tonsillectomy/adenoidectomy
Tracheostomy
Direct Laryngoscopy
Oesophagoscopy
Bronchoscopy
Microlaryngeal surgery
Laser excision of airway lesions
Laser Cordectomy / arytenoidectomy
Thyroplasty
Injection / Augmentation of vocal cord
Excision / marsupialisation of Laryngocoele

Verified by: ______Date: ______

Name (Block Capitals):

NB: Your logbook must be signed/Verified by your Supervising Consultant
Consolidated Logbook Otolaryngology Year 5&6

P = (personal unsupervised)

S = (personal supervised)

A = (assistant)

Procedure: Emergencies / Actual NumberP / Actual NumberS / Actual NumberA
Nasal packing under GA
Sphenopalatine artery ligation
Anterior ethmoidal aa ligation
External carotid artery ligation
Control of secondary Tonsillar bleed
Drainage of Haematoma
Drainage of subperiosteal abscess
Drainage of parapharyngeal abscess
Tracheostomy
Removal Foreign Body from oesophagus
Bronchoscopy and removal of FB from airway

Verified by: ______Date: ______

Name (Block Capitals):

NB: Your logbook must be signed/Verified by your Supervising Consultant

Credit Card Authorisation

Higher Surgical Training Programme – Otolaryngology

Intake Jan & July2014

Name of Card Holder: ______

Name of Applicant (If different):______

Type of Card (Please tick one): Visa Mastercard Other ______

Card Number: _ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _

Expiry Date: _ _ / _ _

Security Code (last three digits on back of card) _ _ _

Amount to Debit: €100.00 (Application Fee)

Signature: ……………………………………………………………..

If you have any queries on your credit card payment please contact:

Lisette Biggins

Otolaryngology Administration

Surgical TrainingOffice

RCSI House

121 St. Stephen’s Green

Dublin 2

Telephone: + 353 1 402 2233

Fax: + 353 1 402 2459

E-mail

Quoting – Higher Surgical Training Programme – Otolaryngology

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All information contained in this document is deemed to be a record held by RCSI and is subject to the provisions of the Freedom of Information Acts 1997 and 2003. The RCSI hold scanned copies of all applications for 1 year following the closing date. No originals are held or returned unless specifically requested by the applicant.