Diplomate Fellowship application form V2
This application form is ONLY for use by medical practitionerswhoa)have obtained a postgraduate examination (other than the FRCA); b) have satisfactorily completed Advanced Pain Training within a UK Anaesthetics CCT programme; c) have completed the Faculty’s examination.
Please read the Regulations in Appendix C before completing the form.
The application form must be completed online in full using the Word version of the document. All information must be submitted electronically. Do not alter the format.
Please read the guidelines in this form carefully and note the supporting documentation required for your application to be considered.
Please submit your completed application to . Large applications should be electronically zipped before sending. The submission will be acknowledged by return email.
1.1 Title1.2 First name(s)1.3 Last name
1.4 Address and postcode1.5 Telephone number (home)
1.6 Telephone number (work)
1.7 Gender1.8 Date of birth 1.9 Email address
These following details are used to confirm the applicant is in good standing with the Royal College of Anaesthetists (RCoA).
1.10 College (RCoA) reference number(if applicable)1.11 GMC number
1.12 Date passed the DFPMRCA examination?
I wish to have my application for the Diplomate Fellowship of the Faculty of Pain Medicine considered by the Board of the Faculty of Pain Medicine.
I enclose all the following documentation:
Completed and signed application form
Full and current CV, which can contain a personal portfolio
Completed RAPM Certificate (Appendix A)
DFPMRCA Examination pass letter
I agree that the Board of the Faculty of Pain Medicine may seek any further information that it considers is relevant to my application, and that my personal details may be made available to a third party(ies), as required, for the purposes of considering my application.
I understand that before an assessment of my application can proceed, letters from all signatories must have been received by the Board of the Faculty of Pain Medicine.
I confirm that, to the best of my knowledge, all of the information that I have provided in this application represents a true and accurate statement. I understand that any serious misrepresentation or false information supplied with the intention to mislead is a probity issue that may be reported to the GMC.
I agree that the information provided by me may be processed, in accordance with the Data Protection Act, for legitimate purposes connected with my application.
4.1 Name of applicant4.2 Signature of applicant*
4.3 Date declaration signed
This certificate must be completed and signed by the applicant’s current Regional Advisor in Pain Medicine.
The document can either be completed electronically with an electronic signature or signed in hard copy and scanned into a PDF for submission electronically.
(Regional Advisor)
of (name of Region)
at (work address)
Confirm that (name of applicant)
(Check as applicable)
has completed 12 months of Advanced Pain Medicine Training (Route 1)
Please complete if applicant is applying through route 1:
I confirm that the following workplace based assessments have been satisfactorily completed:
DOPSA-CEXCbD
MSF Case Reports Quarterly appraisal
I fully support the above Doctor’s application for fellowship by assessment and they fulfil the requirements as described in Appendix D.
Signature* Date (DD/MM/YYYY)
* Signature: Please either include an electronic signature or print this page out, sign it in hard copy and scan it for submission electronically.
1The applicant must:
a)have obtained a postgraduate examination (other than the FRCA);
b)have satisfactorily completed such a period of training as may from time to time be prescribed by the Faculty;
c)have completed the Faculty’s examination;
d)have otherwise satisfied the Faculty as to their suitability by the submission of appropriate paperwork relating to the form of application as specified by the Faculty assessors.
2The application will be reviewed by the Faculty and, if approved, a certificate of Diplomate Fellowship will be sent to the applicant.
3Rights and privileges include the following:
a)Subject to the provisions of Ordinance 3.2, use of the post-nominal DFPMRCA and the description ‘Diplomate Fellow of the Faculty of Pain Medicine of the Royal College of Anaesthetists’;
b)to vote in Faculty elections respective to any residential qualifications;
c)to attend, speak and vote at General Meetings of the Faculty;
d)to be nominated for election to membership of the Board;
e)to be appointed to Committees, Working Parties and other groups of the Faculty;
f)to be nominated by the Faculty under the auspices of the Royal College of Anaesthetists for appointment to any Advisory Appointment Committee;
g)to be appointed to a Court of Examiners;
h)to be appointed a Regional Advisor in Pain Medicine;
i)to use the facilities of the RCoA buildings;
j)to attend available Faculty events;
k)to benefit from the arrangements organised by the Faculty for participating in Continuing Professional Development;
l)to receive copies of the British Journal of Anaesthesia, the College Bulletin, the Faculty Transmitter and other publications the College or Faculty may issue from time to time.
Notes:
(1)Pain Medicine describes the work of specially qualified medical practitioners who undertake the comprehensive management of patients with acute, chronic and cancer pain using physical, pharmacological, interventional and psychological techniques in a multidisciplinary setting.
(2)The Faculty of Pain Medicine of the Royal College of Anaesthetists in the United Kingdom.
(3)No Fellow who is deprived of privileges for whatever reason, shall be eligible, while so deprived, to sign a certificate for the purpose of sub-paragraph (c) of this regulation.
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