Application for Clinical Fellow in Sports Medicine / Emergency

Medicine at University Hospital of North Tees

Thank you for your interest in the above post. Please complete this form and submit it alongside
your CV.

1. Qualifications

What is your primary qualification?

Where did you obtain your primary qualification?
Year of Qualification

Have you completed any of these qualifications?

MRCP MRCEM MRCS Other
(please
state)
Have you completed part of these qualifications (please state which part)
MRCP MRCEM MRCS Other
(please
state)

Do you have GMC Yes No Applied

registration for

Post Graduate Training

Have you successfully completed any of the following (or equivalent - please state)
ALS ATLS / APLS /
ETC PALS
HMIMMS BLS ATMIFF

Level 3 Child Level 2 or

protection other Child
protection

2. Clinical Experience

Do you have experience of Running an Emergency department and Yes No

supervising junior staff with no direct supervision

How much post qualification experience do you have (as a whole 0 - 1 year
time equivalent) 1 - 2 years
i.e 3 years at 60% less than full time = 1.8 years
2 - 3 years
please include pre-registration posts / internships (after completing
final exams) 3 - 4 years
4 - 5 years
> 5 years
How much Experience in Emergency Medicine do you have? 0 - 3 months
4 - 6 months
6 - 12 months
1 - 2 years
> 2 years
 3. Sport and Exercise Medicine Experience

Please list any clinical experience (Clinical observership, Clinical Attachment, Work in MSK / SEM
environment, Volunteer in Activity related role

Please list any academic experience related to SEM (Member of relevant society, post graduate training /
qualifications

Is there anything else you wish to be considered regarding SEM knowledge / skills / attributes?
 4. Personal Statement

Please give any further information that you feel valid in support of your application for this post including
reasons for application and future career ambitions.

Application Date

Application Number