versAug 2018
Trainee Registration
Please complete the all details below. This information is required for us to process your registration.
- Please tick and provide information as appropriate.
☐ / I am applying for STIFIntegrated Competency having already completed STIFIntermediate Competency Training and Assessment
My STIFIntermediate Competency Certificate is dated: INSERT DATE
☐ / I am applying for combined STIFIntermediate Competency/STIFIntegrated Competency training and assessment. I understand Integrated and Intermediate competencies can be submitted for certification either at the same time or Integrated submitted afterIntermediate.
- Trainee and trainer details
Title (Dr, Mr, Mrs, Ms etc.) / Choose a title /
First name / Enter your first name /
Surname / Enter your surname /
Your Job Title as stated in your job description (nurse/doctor is not sufficient information) / Enter your job title /
Place of Work – name of clinic, hospital or practice / Enter your place of work /
NHS TRUST / Enter your NHS trust /
Correspondence address, including POSTCODE
To which your certificate will be mailed / Enter your correspondence /
Mobile telephone number / Enter your telephone number /
Email / Enter your email address /
TRAINER INFORMATION
*** My STIFIntermediate trainer is a registered STIFIntermediate Clinical Trainer / Name of Trainer:
Enter name of trainer
*** STIFIntermediate Clinical Trainer's email
Telephone number / Enter email and telephone number
My STIFIntegrated Competency Trainer / Name of Trainer:
Enter name of trainer
STIFIntegrated Clinical Trainer's email
Telephone number / Enter email and telephone number
*** - these sections do not need to be completed if you are undertaking the Integrated Competencies only
- To be completed by trainees wishing to undertakecombined
STIFIntermediate/Integrated Competency Training and Assessment
Please select the ONE option which best relates to you.
☐ / A.I have attended a STIF Foundation Theory course in the last 3 years.Please state:
STIF Foundation Course Registration Number/ Date of course (month and year only):
Enter registration number and date
Location of course:Enter course location
☐ / B.I have completed the Faculty of Reproductive & Sexual Health 'Course of 5' in the last 3 years
Please state Date of course (month and year only): Enter date
☐ / C. I have attended an alternative theory course within the last 3 years approved by my STIFIntermediatetrainer
Please state: Date of course (month and year only): Enter date.
Details of course: Enter details of the course
☐ / D. I am currently working within a Level 3 GUM Service and have attended in-house theoretical training that is approved by my STIF Intermediate trainer*.
*a list of core knowledge covered in STIF core for equivalence is provided in the STIF Intermediate competency trainee information section of the STIF web site www,STIF.org.uk
- Registration Fees
If your place is funded and you require your NHS Trust / employer to be invoiced for your fees please do NOT use this form - please contact STIF SECRETARIAT as below.
Please tick and provide registration payment as appropriate.Cheque payable to BASHH. If you wish to pay by bank transfer please contact STIF Secretariat.
☐ / I am applying for STIFIntegrated Competency having already completed STIFIntermediate Competency Training and Assessment£180 plus VAT = £216.00 for non BASHH members and BASHH members
☐ / I am applying for COMBINED STIFIntermediate Competency/STIFIntegrated Competency training and assessment
£480 plus VAT = £576.00 for non BASHH members
£400 plus VAT =£480.00 for BASHH members
☐ I am a member of BASHH. My BASHH registration number is: ______
☐ I confirm that the above registered named STIF Competency Clinical Trainer (s) has/have agreed to undertake my training and take responsibility for overseeing the clinical sexual health and contraceptive competency assessmentsaccording to the requirements set out in the STIFIntermediate Competencyand STIFIntegratedTraining Guides.
Signed:
Date: Click here to enter a date.
Please return this form with your registration fee (cheque payable to BASHH), keeping a copy for your files, to the following address:
STIF Secretariat, PO Box 77, East Horsley, KT24 5YP
Email: