ST4/5 MATCHING FORM - North LondonPaediatrics

1. PERSONAL DETAILS

NAME / NTN
CONTACT
ADDRESS
(where you currently reside) / E-mail
Mobile
Home Tel
Are you progressing to ST4 in Sept 2018 or March 2019? Please specify / Sept 2018/ March 2019
Do you intend to work full time or less than full time? / Fulltime / Part-time
M
R
C
P
C
H / Date full MRCPCH passed
Date passed part 2 written
Date passed Part 1b
Date passed Part 1a
Most recent ARCP Outcome
O
O
P
E /

Are you applying to go out of programme in Sept 2018/March 19

/ Yes / No
If Yes, have you sought Deanery approval? (You will need to give six months notice to the programme if you intend to take OOP – applications for September 2018 close on Wednesday 28th February 2018) / Yes / No
If you intend to be out of programme, give details of your planned post, including planned return date (It is expected that you will return on the rotation date which would be either the first Monday in March or September:

2. TRAINING HISTORY

Please confirm exact dates of maternity leave and sick leave

Please confirm sessions for each post if LTFT i.e. 0.6, 0.7, 0.8

Training Posts (Start with most recent post first)
Trust / Please note:
  • Sub-specialty (e.g. neonates)
  • Periods of sick leave (dates if more than 10 days)
  • Periods of maternity leave and OOP.
/ Training Level
i.e. ST4 / Start date / End date / Full time or Part Time?
% WTE
Career intentions (short & long term)brief summary
Any Other Information to support your applicationincluding exceptional circumstances for the panel’s consideration.

3. PREFERENCES

Please rank all of the units in order to preference, where 1 is your first choice. Do not leave any unit unranked as this will delay your placement allocation.

Please note that all placements are for TWO YEARS unless specifically stated

Unit / Patch / Rank
Barking, Havering & Redbridge NHS Trust (BHR) including Queen’s, King George Hospitals / NCEL
Barnet General Hospital (4 posts) / NCEL
Homerton ST4 12m /BHR 12m / NCEL
Homerton 12m / Newham 12m / NCEL
Newham General Hospital / NCEL
North Middlesex Hospital / NCEL
Whittington Hospital / NCEL
Whipps Cross Hospital / NCEL
Ealing Hospital / NWL
Brent Community and Northwick Park Neonates ST4 / Ealing ST5 / NWL
Hillingdon Hospital / NWL
North West London Hospitals NHS Trust - Northwick Park Hospital & Brent PCT / NWL
West Middlesex University Hospital / NWL
St Mary's ST4 (Including neonates) /Ealing ST5 (Including Community)/ North West London / NWL
St Mary’s ST4 (Including neonates)/ West Middlesex ST5 (Including Community) / NWL

4. DISCLAIMER

Disclaimer:
By signing & submitting this application form you are confirming your acceptance of the conditions below:
  1. The availability of any listed training posts is subject to change.
  1. The decision of the ST4-5 Programme Matching Panel regarding placements is final.
  1. Whilst every effort is made to accommodate applicant preference, the ST4-5 Programme Matching Panel, supported by the Head of School for Paediatrics, reserve the right to place trainees in accordance to educational requirements and the needs of the Training Programme(s).
  1. Although less than full time training is supported, it can be limited to either slot shares or training in a full time post on reduced sessions.

NAME
DATE