Application for Specialist Anaesthesia Training July 2015

Applications which are incomplete will be notified if the application is received at least five working
days before the closing date, if incomplete applications received after the closing date candidates will
not be notified.
Late applications will not be accepted.
Applications will be accepted only in electronic format
Curriculum Vitae should not be sent
All applications should include a completed credit card mandate for 110 and be submitted
electronically to mgolden@coa.ie
Please read the guidance for applicants document in full before completing this application.
Application For Specialist Anaesthesia Training (SAT Year 1 6) Regional preference

Please mark in order of preference 1, 2, 3:

Eastern Region
Southern Region
Western Region
Please note this is a national scheme, allocations to preference is not always possible and the regional
preference is for the first 2 -3 years of the programme only.
SECTION A PERSONAL DETAILS (as used on Irish Medical Council documents)
Surname

''Click here and type Surname''

Forename

''Click here and type Forename''

Date of birth

''DD / MM / YY''

Address for correspondence

''Click here and type Address''

''Address line 2''
''Address line 3''
''County''
''Country''

Home phone number

''xxxxxxxxxxxxxxxxxx''

Work phone number, including bleep

''xxxxxxxxxxxxxxxxxx''

Mobile phone number

''xxxxxxxxxxxxxxxxxx''

Email address

''Click here and type Email Address''

SECTION B IRISH MEDICAL COUNCIL REGISTRATION

Name in which you are registered

''Click here and type''

Registration number

''xxxxxxxxxxxxxxxxxx''

Type of registration

Internship ''yes or no'' Trainee Specialist ''yes or no'' General ''yes or

no''

Trainee Specialist Registration

A mandatory requirement for entry onto the training programme is eligibility for Medical Council registration on
the trainee specialist division. See Section B of the guidance document for more information.
In order to determine your eligibility please answer the following questions:
Have you graduated from an Irish
Medical School and successfully

''Click here and type yes or no''

completed your internship in Ireland

Have you graduated from an Irish
Medical School and are currently in
your intern year
Have you successfully completed
your medical qualification in one the
following countries:
o Austria
o Belgium
o Bulgaria
o Cyprus
o Czech Republic
o Estonia
o Finland
o France
o Germany
o Greece
o Hungary
o Iceland
o Latvia
o Malaysia
o Netherlands
o Romania
o Slovenia
o Spain
o Switzerland
o Slovak Republic
o Sudan
o United Kingdom
Are you currently registered on the
Trainee Division of the Medical
Council in Ireland?

''Click here and type yes or no''

''Click here and type yes or no''

''If yes which country''

''Click here and type yes or no''

If yes a copy of your registration certificate must be submitted.

If you have answered NO to all of the questions above you must:

Contact the Medical Council to request an email attesting your eligibility for the trainee division.

Submit the email from the Medical Council with your application.

English Language Requirements

The HSE requires that as part of the application process for training positions on specialist training programmes,
all applicants are required to demonstrate their competency in the English Language in line with HSE
specifications. Please see Section B of the guidance document for more information
''Click here and type yes or no''
''Reason for exemption'' (see Section B of the guidance document)
Are you exempt from demonstrating
your English Language Competency

I have the IELTS demonstrating a

minimum score of 7.0 in each of the
four domains

Applicants who are applying for exemption based on registration with

the Medical Council in Ireland on or after the 9 th July 2012 and who can
provide documentary evidence of having worked as a full time clinical
NCHD in the Irish public health service for a minimum period of 6
months must complete appendix 1 of this document on page 12
''Click here and type yes or no''

I have the University of Cambridge,

ESOL Examinations Certificate in
Advanced English (CAE)
demonstrating a minimum overall
score of 67/100 and demonstrating
an achievement of at least a Good
level in all five skill areas

''Click here and type yes or no''

Allocation of training posts

Please see Section B of the guidance document for more information
I have submitted a colour copy of my
passport

''Click here and type yes or no''

I have submitted a copy of my

Certificate of Naturalisation as issued
by the Department of Justice and
Equality if applicable

''Click here and type yes ''

''Click here and type not applicable''

SECTION C Examinations and Education

Undergraduate Education (Max 10 marks total)
University/Medical School Name

''Click here and type School/University''

Address of University/Medical School

''Click here and type Address''

''Address line 2''
''Address line 3''
''County''
''Country''

Date of entry to Medical School

''DD / MM / YY''

Date of graduation

''DD / MM / YY''

Primary medical qualification

''Click here and type Qualification''

Overall grade achieved

''Click here and type grade''

Rank in Class

''Click here and type rank in class''

Marks:
1st 10 marks
2nd 9 marks
3rd 8 marks
In top 10% of class (other than 1st, 2nd and 3rd) 6 marks
In top 25% of class (but not in top 10%) 4 marks

For office use

Please provide proof of ranking in class with your application or marks will not be awarded.

Postgraduate Exams (max 5 marks)

Higher Qualification

Awarding Body

Date of Qualification

''Click here and type Qualification''

''Type Awarding Body''

''DD / MM / YY''

''Click here and type Qualification''

''Type Awarding Body''

''DD / MM / YY''

''Click here and type Qualification''

''Type Awarding Body''

''DD / MM / YY''

Marks:
Primary CAI or equivalent 5 marks
Primary MCQ 3 marks
Relevant degree 2 marks
MD 3 marks

For office use

PhD 5 marks
Fellowship FCAI or equivalent 5 marks
MRCS/MRCP 3 marks
Please provide proof of any qualifications claimed with your application or marks will not be awarded.

Postgraduate Experience (max 5 marks)

Beginning with the most recent (i.e. current position) you are required to list all previous appointments up to
and including your present appointment. In relation to each period of employment, you are required to
highlight clinical experience relevant to this specialty including clinical practice, teaching experience,
audit and management. You can add extra lines if needed.
Clinical Site
Supervising
Months
(If overseas please
Grade
Specialty
Consultant
From To
indicate country)
Example:
01/07/04
Intern
Surgery
6
St. Jamess Hospital
Mr. Joe Bloggs
31/12/04
''Click here and type
Information''

''Grade''

''Speciality''

''Consultant''

''dd/mm/yy''''dd/mm/yy''

''xx''

''Consultant''

''dd/mm/yy''''dd/mm/yy''

''xx''

''Consultant''

''dd/mm/yy''''dd/mm/yy''

''xx''

''Consultant''

''dd/mm/yy''''dd/mm/yy''

''xx''

''Highlight clinical experience in the above post here"

''Click here and type

Information''

''Grade''

''Speciality''

''Highlight clinical experience in the above post here"

''Click here and type

Information''

''Grade''

''Speciality''

''Highlight clinical experience in the above post here"

''Click here and type

Information''

''Grade''

''Speciality''

''Highlight clinical experience in the above post here"

Marks:
Anaesthesia Intern Year 3 marks
Foundation year 6/12 3 marks 12/12 5 marks
Anaesthesia Training Hospital Ireland /UK 3 marks

Anaesthesia other hospital Ireland/UK 2 marks

Non Anaesthesia training programmme 3 marks ''Insert training post number here''
Non Anaesthesia non programme 1 marks
The above marks are based on 12 completed months; marks will be reduced after 24 months by 50%. > 3 year
0 marks
For office use

Please provide proof of completion of anything claimed in this section with your application or marks
will not be awarded.
Skill Courses e.g. ACLS, ATLS, BASIC, etc (max 10 marks)
2 mark per course to a max of 10
Name of Course

Location of Course

''Click here and type name of

course''

''Click here and give location''

Date
''DD / MM / YY''

''Click here and type name of

course''

''Click here and give location''

''DD / MM / YY''

''Click here and type name of

course''

''Click here and give location''

''DD / MM / YY''

''Click here and type name of

course''

''Click here and give location''

''Click here and type name of

course''

''Click here and give location''

''DD / MM / YY''
''DD / MM / YY''

Please provide proof of attendance at courses with your application.

For office use

Section D - Academic Achievement (max 10 marks)

Please indicate where appropriate
Presentations

Yes/No
''Type YES or NO''

Publications in peer review journal

''Type YES or NO''

Number
''xx''
''xx''

Completed Audit

''Type YES or NO''

''xx''
SECTION E AIMS & CAREER OBJECTIVES
Marks:
Outline your career objectives, why you wish to participate in the SAT Programme and what you hope to contribute
Hospital
Meeting Presentation/Poster 0.5 marks
to the specialty.
National/International Meeting Presentation/Poster 2 marks
''Click here
andReport/Abstract
start typing''
Published
Case
2 marks
For office use
Letter 1 mark
Full paper Co author - 3 marks First author 6 marks
Completed audit 1 mark
No marks will be claimed in this section unless full details are provided below.
Presentations
List the presentations you have given at hospital level, National or International Meetings - Complete
SECTION F ADDITIONAL INFORMATION
bibliographical information must be given
Use this section to highlight any non-academic achievements which you consider relevant / significant for example
Example:
electives, volunteer work, sporting, creative or musical achievements, non-academic awards or any other
Wallace R,
Smith J. you
Provision
Anaesthesia
Journal
of Irreproducible
Results.
Dublin
11
additional
information
think is of
relevant
to your underwater,
application. Do
not leave
this section blank,
but keep
it concise
Nov
2005.
and factual; you will have the opportunity to elaborate at the interview.
''Click here and start typing''
''Authors''

''Title of Presentation''

''Name and Date of Meeting''-

''Authors''

''Title of Presentation''

''Name and Date of Meeting''-

''Authors''

''Title of Presentation''

''Name and Date of Meeting''-

''Authors''

''Title of Presentation''

''Name and Date of Meeting''-

''Authors''

''Title of Presentation''

''Name and Date of Meeting''-

Publications
List Publications giving complete bibliographical information including PMID
Example:
Smith, J, Wallace R, Doe, J. Article Title. Journal Name. Page, Volume, Year, PMID
''Click here''
SECTION G REFEREES
''Click here''
Please give the name, job title and address of the two referees who will provide you with a reference. One of
these referees must be your present or most recent supervising consultant. Do NOT include details of consultants
''Click
here'' you worked prior to graduation or in a supernummary/ clinical attachment capacity.
with whom
''Click
here''
Please
note that all referees must use the standard reference template. This reference form can be emailed along
with the application
Referee Number One
Referee Number Two
Completed
Audit
Name: ''Click here and type name''
Name: ''Click here and type name''
List Audit giving complete bibliographical information
Title: here''
''Click here and type title''
Title: ''Click here and type title''
''Click
Clinical Site: ''Click here and type clinical site''
Clinical Site: ''Click here and type clinical site''
''Click
''Clickhere''
here and address line 1''
''Click here and address line 1''
''Click here and type address line 2''
''Click here''
Phone: ''xxxxxxxxxxxxxxxx''
''Click
Fax: here''
''xxxxxxxxxxxxxxxx''

''Click here and type address line 2''

Phone: ''xxxxxxxxxxxxxxxx''
Fax: ''xxxxxxxxxxxxxxxx''

E-mail: ''xxxxxxxxxxxxxxxx''
I have forwarded a reference from the
above named doctor, enclosed in an
envelope which he/she has signed
across the seal.

E-mail: ''xxxxxxxxxxxxxxxx''
''Type YES or
NO''

I have forwarded a reference from the

above named doctor, enclosed in an
envelope which he/she has signed
across the seal.

''Type YES or
NO''

SECTION H NOTES
Please read the following notes carefully and confirm your understanding of each and every one.
Please confirm that you understand that if your application is successful, that this
application form in its entirety and your appraisal / reference forms will be made
available to the relevant employers / clinical sites that facilitate the delivery of this
''Type YES or NO''
specialist training programme.
Please confirm that you understand that if your application is successful, that in addition
to meeting the requirements of the training body, participation in this programme
throughout its duration is dependent on you meeting the relevant employers
requirements. Such requirements include formal Garda clearance, induction,
satisfactory completion of occupational health assessments and provision in a timely
manner of the relevant documentation required by employers for employment purposes.
Failure to meet the requirements of any relevant employer may result in your removal
from the programme as you will be unable to assume training slots required for
participation in this programme.
Please confirm that you understand that any information supplied by you in this form
may be held on computer.

''Type YES or NO''

''Type YES or NO''

SECTION I APPLICATION CHECKLIST

Please indicate what supporting documents you are enclosing with your application
Copy of Medical Council Certificate of Registration or email confirming
''Type YES or NO''
registration from IMC
Colour copy of your passport
''Type YES or NO''
Proof of English Language Competence if relevant

''Type YES, NO, Not Relevant''

Copy of transcript of exam results from your Medical School / University

''Type YES or NO''

Copy of other degrees / diplomas (if applicable)

''Type YES, NO, Not Relevant''

Application Fee
1 passport sized photograph

''Type YES or NO''

''Type YES or NO''

Two references

''Type YES or NO''

Proof of anything else claimed in the application

''Type YES or NO''

SECTION J - SIGNATURE
I declare that to the best of my knowledge and belief that all the particulars furnished in connection to this
application are true and accurate. I understand that I may be required to submit documentary evidence
in support of any particulars given by me on my Application Form. I understand that any false or
misleading information submitted by me may render any offer of a training position and associated
employment offers as null and void. (electronic signature will suffice for section J and K)
Date ''dd/mm/yy''
Signature

SECTION K- DECLARATIONS
Please read the following three declarations carefully and sign and date your agreement with the text of each of
the declarations.
Declaration One - Garda/Police

I declare that I have not at any time been convicted (i.e. probation, fine, sentence, penalty) of a criminal
offence (e.g. assault, public order, sexual assault) in the Republic of Ireland and/or in any other
jurisdiction nor are there any charges relating to criminal offences outstanding or pending. I have never
been the subject of a Caution or Bound over order. I accept that making a false or misleading
declaration may render any offer of a training position and associated employment offers as null and
void.
Signed:

__________________________

Date:_______________

OR
I declare that I have been convicted (i.e. probation, fine, sentence, penalty) of a criminal offence (e.g.
assault, public order, sexual assault) in the Republic of Ireland and/or in any other jurisdiction. I have
been the subject of a Caution or Bound over order. I accept that making a false or misleading
declaration may render any offer of a training position and associated employment offers as null and
void.
Date

Signed:

Court

Country

__________________________

Offence

Court Outcome

Date:_______________

Declaration Two - Training Organisation / Programme

I declare that I currently am not nor was I the subject of an investigation by any professional medical training
body or its equivalent in the Republic of Ireland and/or in any other jurisdiction. I accept that making a
false or misleading declaration may render any offer of a training position and associated employment
offers as null and void.
Signed:

__________________________

Date:_______________

OR
I declare that I currently am or was the subject of an investigation by a professional medical training body or
its equivalent in the Republic of Ireland and/or in any other jurisdiction. I accept that making a false or
misleading declaration may render any offer of a training position and associated employment offers as
null and void.
Date

Signed:

Organisation

Offence

__________________________

Status/Outcome

Date:_______________

Declaration Three - Medical Council/Licensing Body

I declare that I am not nor have I been the subject of any investigation by a medical registration or licensing
body or authority in any jurisdiction with regard to my medical practice or conduct as a practitioner. I
have not been suspended from registration , nor had any restrictions on practice nor had my registration
or licence cancelled or revoked by any medical registration or licensing body or authority in any
jurisdiction nor am I the subject of any current suspension or any restrictions on practice. I accept that
making a false or misleading declaration may render any offer of a training position and associated
employment offers as null and void.
Signed:

__________________________

Date:_______________

OR
I declare that I am or was the subject of an investigation by a medical registration or licensing body or
authority in any jurisdiction with regard to my medical practice or conduct as a practitioner. I am or have
been suspended from registration, have/had restrictions on practice and/or my registration or licence
cancelled or revoked by a medical registration or licensing body or authority in any jurisdiction and/or am
the subject of any current suspension and/or have any restrictions on practice. I accept that making a
false or misleading declaration may render any offer of a training position and associated employment
offers as null and void.
Date

Signed:

Country

Medical Council/
Licensing Body

__________________________

Offence

Date:_______________

Status/ Outcome

Payment Details
If you want to pay the Application Fee by credit/debit card, please complete this section. .

Name of Cardholder:

Visa
MasterCard
Expiry Date
CCV number
Card Number

Amount ___________________ Signature _____________________________________________

Appendix 1
Declaration of English Language Competencies
10

Note: Sections A of this form must be completed in full by the applicant, whilst Section B
must be completed and stamped by the relevant medical manpower personnel / HR
personnel.

Section A - Statement by Applicant

I hereby seek an exemption from formally demonstrating my English Language
Competencies on the grounds of having registered with the Medical Council on or
after 9th July 2012 and having worked as a full time clinical NCHD in the Irish public
health service for a minimum of six months since such registration. During the
course of this employment I demonstrated the required English Language
competencies required of an NCHD.
Details of Employment:
Place of Employment:
Grade of Employment:
Date From:
Date To:
Signature of Applicant: ___________________________
Name of Applicant:

___________________________

Medical Council Number:

___________________________

Date:

____________________________

Section B - Verification by Employer

I hereby verify the above statement and information provided by the applicant as
accurate and true.
Signature:

_____________________________

Name:

______________________________

Job Title:

______________________________

Date:

______________________________

Hospital / Clinical Site Stamp:

11