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MEDICAL COUNCIL OF IRELAND REFERENCE NUMBER (IF KNOWN

):

INTERN TRAINING VERIFICATION FORM

VERIFICATION OF INTERN TRAINING
BENCHMARKED AGAINST THE MEDICAL COUNCIL OF IRELAND CRITERIA FOR AWARDING A
CERTIFICATE OF EXPERIENCE

To be completed by a person responsible for intern training at the training site/hospital.

PLEASE USE BLOCK CAPITALS
Name of Intern:
DD / MM / YYYY
Date of Birth:
Name of training site (eg. PLEASE USE BLOCK CAPITALS
hospital):
Number of Intern trainees
at the training site :
Address of training site:

Line 1:

Line 2:

Line 3:

Line 4:

City/State/County/Country:
Contact Details of Signatory: (PLEASE INCLUDE INTERNATIONAL CODES)
Phone:

Fax:
E-mail
address:
Type of rotation(s)
How many months’ internship training were completed at the training site and in which specialty/ies?
SPECIALTY ROTATION ROTATION ENDED TOTAL DURATION OF
COMMENCED ROTATION (MONTHS)
M M Y Y Y Y M M Y Y Y Y

M M Y Y Y Y M M Y Y Y Y

M M Y Y Y Y M M Y Y Y Y

M M Y Y Y Y M M Y Y Y Y

M M Y Y Y Y M M Y Y Y Y

M M Y Y Y Y M M Y Y Y Y

M M Y Y Y Y M M Y Y Y Y

M M Y Y Y Y M M Y Y Y Y

M M Y Y Y Y M M Y Y Y Y

M M Y Y Y Y M M Y Y Y Y

Language/s through which internship was completed:

INTERN TRAINING VERIFICATION FORM – MEDICAL COUNCIL OF IRELAND
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The intern completed his/her internship training under the supervision of the following clinician(s) who is/are of an appropriately senior level and is/are recognised as a specialist by the regulatory authority of the host country: SUPERVISING CONSULTANT(S) The training site(s) emphasised professionalism and the development and maintenance of the relevant knowledge. skills. formal and informal training. including on- call duties. in the services and responsibilities of patient-care activity in the training institution. The intern’s training comprised the following:  Practice-based training involving personal participation. the opportunity to participate in clinical audit. skills. the undersigned declare and confirm the following: (Please tick only if applicable) The training site where the person named on page 1 of this form (hereinafter called “the intern”) completed the internship training rotation(s) outlined on page 1 of this form is affiliated with a recognised medical school and / or a postgraduate training network which is accredited by the relevant authorities in this country. I confirm that the intern made satisfactory progress during his/her internship training and passed all relevant examinations (where applicable). and external courses.  Personal participation at an appropriate level in all medical activities relevant to the training. The intern was made aware of and complied with any ethical guidance provided by the relevant competent authority in this jurisdiction and / or the ethical guidance provided by the Medical Council in Ireland (insert hyperlink) The intern received regular and constructive feedback and assessment by his/her trainer / supervisor. The intern’s training comprised a combination of. The intern participated in regular.  The opportunity to exercise the degree of responsibility and clinical decision-making appropriate to the intern’s growing competency. Signed: ______________________________________ Date: _____________________ Name of Signatory: ______________________________________________________________ (Block Capitals) Authority of Signatory: __________________________________________________________ INTERN TRAINING VERIFICATION FORM – MEDICAL COUNCIL OF IRELAND Page 2 of 2 . case presentations and discussions. This / these training site(s) provided the intern with access to a sufficient number of patients and an appropriate case mix that gave him/her exposure to a broad range of appropriate clinical cases. with learning opportunities including lectures. knowledge and experience  The opportunity to work as part of a team composed of a variety of disciplinary backgrounds. The above-named training site has sufficient resources for the number of interns on site The intern had access to counselling and advice on ethical issues in the event of work-related or personal problems. attitude and behaviour. The intern was afforded the space and opportunity for private study and access to adequate professional literature. MEDICAL COUNCIL OF IRELAND REFERENCE NUMBER (IF KNOWN): I. small group tutorials. at an appropriate level. including on-line access. and training and service delivery. practical and theoretical learning. pre-arranged formal education and training sessions. and integration between.