MEDICAL COUNCIL OF IRELAND REFERENCE NUMBER (IF KNOWN):

TRAINING SITE VERIFICATION FORM

VERIFICATION OF TRAINING SITE WHERE INTERN TRAINING WAS COMPLETED To be completed by the competent authority responsible for setting and monitoring standards for internship training in the jurisdiction where the internship training took place.

Name of Intern:

PLEASE USE BLOCK CAPITALS DD / MM / YYYY

Date of Birth: Name of Training Site (eg. PLEASE USE BLOCK CAPITALS hospital): Name of competent authority: Address of competent authority:
Line 1: Line 2: Line 3: Line 4: City/State/County/Country:

Contact Details of Signatory: Phone: Fax: E-mail address:

I, the undersigned declare and confirm the following:

(PLEASE INCLUDE INTERNATIONAL CODES)

(Please tick only if applicable)

The above-named training site(s) where the above-named person (hereinafter called the intern) completed internship training rotation(s) is affiliated with a recognised medical school and / or a postgraduate training network which is accredited by the relevant authorities in this country. The above-named training site(s) is/are in a position to provide their interns with access to a sufficient number of patients and an appropriate case mix that give exposure to a broad range of appropriate clinical cases. The above-named training site(s) is/are in a position to provide access to adequate professional literature, including on-line access. The above-named training site(s) provide(s) interns with access to counselling and advice on ethical issues in the event of work-related or personal problems. The above-named training site has sufficient resources for the number of interns on site.

Signed:

______________________________________ Date: _____________________

Name of Signatory: ______________________________________________________________

(Block Capitals)

Authority of Signatory: __________________________________________________________

HOSPITAL VERIFICATION FORM MEDICAL COUNCIL OF IRELAND

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