Please give all names in full EXACTLY as they appear in the GMC register

Faculty Reference Number[1] GMC Number

Title Forename 1 Forename 2

Initials Surname

Date of Birth Male Female

Address 1

Address 2

Address 3

Town/City County/State

Postcode This address is: Permanent Exams only

Telephone number

E-mail Address

i. Please provide the date(s) of previous attempts at the FFICM Final MCQ:

1. 2. 3. 4. 5.

ii. I am currently registered with the GMC

(You must be currently registered with the GMC to sit this exam)

ii.I am registered with the Faculty of Intensive Care Medicine

(You must be registered with the Faculty of Intensive Care Medicine to sit this exam)

If you are an Affiliate Fellow then you must attach copy of FICM Affiliate Fellowship certificate

iii. Please specify which one of the following applies to you:

a.I am a trainee in a Deanery approved training post on a GMC approved training programme in
ICM, who has completed either Intermediate (Joint) or Stage 1 (Single/Dual) ICM training.

If yes, please specify which ICM CCT programme you have been appointed to:

Joint CCT The previous training system of completing Basic, Intermediate and Advanced ICM training blocks within an ICM CCT programme.
Joint CCT parent specialty:

Single CCT The ongoing standalone ICM CCT curriculum implemented from August 2012

Dual CCTs Undertaking the standalone curriculum in partnership with another specialty. (Joint CCT trainees should notselect this option).
Dual CCTs partner specialty:

b.I am an Affiliate Fellow in a Deanery approved training post on a GMC approved training programme in the specialty of which is a specialty of
one of the FICM’s parent Colleges.

c.I am a specialty/SAS Grade Doctor who is awho is currently practicing Intensive Care Medicine in the NHS UK and Ihold a satisfactory NHS Appraisal (proof of appraisal attached)

d. I am a former UK ICM trainee or a non-UK ICM trainee who has been employed continuously in a UK NHS post in Intensive Care Medicine for at least 12 months and I hold a satisfactory appraisal (proof of appraisal attached).

e.I am sponsored under the MTI IP, I have been employed in Intensive Care Medicine in a NHS post for six months immediately prior to this exam date and I hold a satisfactory appraisal. (proof of appraisal attached).

If you have not ticked one of boxes above you are not eligible to sit this examination.

4.Please indicate which of the following examinations you have been awarded:

I confirm that I have passed one of the following examinationswithin the last seven years:

*FRCA Primary/*FRCA Final
MRCP (UK)
MCEM Parts A, B and C

EDIC

None of the above, I have passed one of the exemption qualifications listed in the regulations of
*The Royal College of Physicians / * The Royal College of Anaesthetists / *The College of Emergency Medicine within seven years of the published start date of the FFICM MCQ Exam.

(*Delete as applicable):

Please state which examination:

The Faculty will hold a record of your pass in the FRCA Final or Primary examinations. For all other examinations applicants must provide a copy of their pass letter/qualification along with their application form.

If you have ticked no boxes above you are not eligible to sit this examination.

I certify that:

  • I agree to abide by the Faculty Examination Regulations.
  • I am adequately prepared for and eligible in all respects to enter this examination.
  • All statements provided in Parts 1 and 2 of this application form are correct.
  • I enclose a chequemade payable to: The Royal College of Anaesthetists, drawn on a UK clearing bank, sterling draft, or postal order for the appropriate fee.
  • I agree to the processing and disclosure of my personal data in line with the Data Protection Act.
    I understand that information provided on this form and my examination results may be processed and passed to examiners, my Faculty Tutor, postgraduate dean, employer, etc. for the legitimate purposes connected with my training.
  • I understand that if I am registered or anticipate being registered with the GMC then my personal data, including data about my exam results, will be passed to the GMC for quality assurance and research purposes and to facilitate the awarding of certificates of completion of training (CCTs).

Signature Date

CHECKLIST: (Check as applicable)

Completed and signed application form, with all appropriate boxes ticked

Attached copy of appropriate examination certificate

Attached a cheque for the appropriate fee made payable to ‘The Royal College of Anaesthetists’. Please ensure the cheque is signed and dated.

ICM Joint CCT trainee: Must provide the above only; the FFICM is optional for Joint trainees.

ICM Single/Dual CCTs trainee: Must attach copy of signed Stage 1 certificate

Non-ICM CCT trainee: Must attach copy of FICM Affiliate Fellowship certificate

Doctors eligible under Part 2 iii c. d. or e.: Must attach copy of their most recent NHS appraisal. This need not be the full report but must be identifiable as a ‘satisfactory’ appraisal.

To ensure compliance with the Equality Act 2010 and as part of the College’s Equal Opportunities Policy, the Faculty monitors exam results in relation to the candidate population.

This information will only be used to assist in the provision of equal opportunities for all.You are requested to complete the form below, although this is not mandatory. Whatever your decision, it will have no effect on your exam results.

All information will be held in the strictest confidence and in accordance with the Data Protection Act 1998.

Your ethnic group:

The ethnic groups are based on the Census 2011 categories.

Asian or Asian British:

Black or Black British:

Mixed:

White:

Other Ethnic Group:

Is English your first language?

Your religion or belief (please select the group you most identify with):

Your sexual orientation:

Do you consider yourself to have a disability according to the terms given in the Equality Act 2010?

The Faculty is committed to ensure that all candidates have equal opportunity to demonstrate their ability in all FFICM exams in accordance with the Equality Act 2010. To this aim the Faculty will make ‘Reasonable adjustment’ to examination arrangements as appropriate for individual disabled candidates. The College Disability policy in regard to all FRCA examinations is set out at Appendix 11 of the FFICM Examination and Appeal Regulations.

Please return the completed form and the examination fee to:

EXAMINATIONS DEPARTMENT

FACULTY OF INTENSIVE CARE MEDICINE

CHURCHILL HOUSE

35 RED LION SQUARE

LONDON WC1R 4SG

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[1]If you are registered with the Royal College of Anaesthetists, your Faculty Reference Number is the same as your College Reference Number.