Intercollegiate Mrcs Examination

V9. CONFIDENTIAL

INTERCOLLEGIATE MRCS EXAMINATION

Application to become a Lay Examiner

Personal Details
Please complete all pages of the application
Name:
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Surname Initials Preferred first name

Title: ------
Home Address:
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Post code
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Home phone Home e-mail
Work Address:
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Post Code
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Work telephone number Work fax number
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Mobile number Work e-mail address

Education

Exam/Qualification / Grade /

Year

Employment(current employment first)
Name and Address / Position held / Dates
From / To
Personal Statement
Please explain why you are interested in being a lay examiner and what qualities you would bring to the position
Referees
Please supply the names, addresses and telephone numbers of two referees who can provide an independent view on how you meet the person specification (see page 4)
1st Referee / 2nd Referee
Contact Name: / Contact Name:
Employing Organisation: / Employing Organisation:
Address: / Address:
Telephone Number: / Telephone Number:
Fax Number: / Fax Number:
E-mail address: / E-mail address:
Data Protection Act of 1998 and Freedom of Information Act 1998
I understand that, if I am appointed, personal information about me will be computerised for personnel/administrative purposes and statutory returns.

I confirm that I will, if appointed, honour examining commitments. I certify that the information I have given above is to the best of my knowledge correct.

Signed:______Date:______

For official use:
Date Received
/ / / Date Acknowledged
/ / / Criteria Met
Yes / No

Please continue to next page

Lay Examiner Person Specification

Knowledge of the rationale, expected standard and structure of the MRCS as defined in the regulations for the examination.

High levels of integrity and professional standards as an examiner.

A commitment to ongoing assessment, training and development as an examiner.

Ability to understand appropriate examination techniques.

A commitment to the examination process.

Effective oral and written communication skills.

A commitment to equality and diversity.

Able to remain objective and dispassionate where necessary.

NOTE: Lay Examiners should not be qualified in professions allied to medicine or have received previous medical training.

This completed application form should be returned under confidential cover to the College, as follows:

Ms Valerie Hogg

Head of Examinations and Assessment

The Royal College of Physicians and Surgeons of Glasgow

232-242 Vincent Street

Glasgow

G2 5RJ

0141 221 6072

Fax: 0141 241 6222

E-mail:

Web:

Please continue to next page

V9. CONFIDENTIAL

EQUAL OPPORTUNITIES MONITORING (OPTIONAL)

In line with UK legislation and good practice guidelines, we are asking everyone to complete this section. You are not obliged to provide any of the information in this section, but if you do so, it will enable us to monitor our business processes and ensure that we provide equality of opportunity to all.

V9. CONFIDENTIAL

Gender

Female

Male

Nationality

……………………......

Do you consider your first language to be English?

? Yes

? No

Do you have a disability under the terms of the Disability Discrimination Act 1995 (a person with a physical or mental impairment that affects your ability to carry out normal day to day activities which are substantial, adverse and long term)?

Yes

No

What is your sexual orientation?

Bisexual

Heterosexual

Lesbian or Gay

What is your religion or belief?

Buddhist

Christian

Hindu

Jewish

Muslim

Sikh

Other religion/belief

Indicate a more specific category here:

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Ethnicity

Choose one selection from the list below to indicate your cultural background.

a) White

British

Irish

Any other White background

b) Mixed

White and Black Caribbean

White and Black African

White and Asian

Any other mixed background

c) Asian or Asian British

Indian

Pakistani

Bangladeshi

Any other Asian background

d) Black or Black British

Caribbean

African

Any other Black background

e) Chinese or other ethnic group

Chinese

Any other background

f)Middle Eastern/Arabic

Arabic

Any other Middle Eastern Background

Indicate a more specific category here:

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V9. CONFIDENTIAL

This information will be recorded electronically with your other data in accordance with the Data Protection Act 1998, but used only for monitoring our business practices.