4 Blenheim Walk, Leeds LS2 9AE
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Thank you for your interest in DFSRH Clinical Experience and Assesment at Leeds Student Medical Practice. To apply for training, please first check the Faculty website to ensure you are eligible on http://www.fsrh.org/pages/diploma_of_the_FSRH.asp
Then please complete this form and post or scan/email any copies of requested certificates to 'Leeds Student Medical Practice' FAO Chloe Rankin to Leeds Student Medical Practice, 4 Blenheim Court, Blenheim Walk, Leeds, West Yorkshire LS2 9AE. Scanned Items email: chloe.rankin@nhs.net Please ensure that you complete all of the following boxes.
If you have any questions regarding this form, please contact the Clinical Services Administrator; Chloe Rankin, on chloe.rankin@nhs.net or 0113 2954488
Title (required)---MrMrsMsMissDr First Name (required) Surname (required) Occupation: Work Address Work Postcode: Work Tel: Work Email: Home Address: Home Postcode: Home Tel: Emergency Contact Person’s Name
Relationship to Trainee
Tel:
Any known allergies:
Title and Name of Line Manager:
Please list any special requirements you have. E.g. vegan, prayer room, disabled access:
How did you hear about training at Leeds Student Medical Practice?
Entry Requirements
I am registered with the UK GMC:yesno
UK GMC Registration Number:
I have a license to practice with the UK GMC:yesno
I am aware that in order to complete the DFSRH clinical Experience and Assessment sessions i must first have completed the DFSRH Course of 5 at Leeds Student Medical Practice:yesno
I will complete the DFSRH within three years of passing the eKA or Iwill complete the DFSRH within three years of completing the e-SRH if my course of 5 was completed before the 1st April 2014:yesno
I will have completed the entry requirements : GMC registration, consultation sills, gynaecological examination, and resuscitation and anaphylaxis training before attending my DFSRH Clinical Experience and Assessment sessions:yesno
I will have successfully completed at least seven of the nine Course of 5 assessments before attending my DFSRH Clinical experience and assessment sessions:yesno
I will have completed the entry requirements and Course of 5 assessment forms in my FSRH Diploma e-portfolio before attending my DFSRH clinical experience and assessment sessions:yesno
Reading
I have read and understand the FSRH "Guidelines for Trainees Commencing the clinical experience and assessment stage of the FSRH Diploma (DFSRH/NDSRH)" - www.fsrh.org/pdfs/diplomaguidelinestraineesclinicalexperiecneassessment.pdf
I agree i have read all the suggested reading: yesno
Information
I agree that it is my responsibility to ensure that I meet all the DFSRH clinical experience and assessment pre-course requirements and that I fulfill the eligibility criteria for training prior to attending my sessions
I agree that failure to do so may result in my training being cancelled and that my payment may still be taken. I agree that my payment for £300 is for the DFSRH clinical assessment and experience originally booked sessions only, and that if i require further additional sessions in order to meet the standard required, there may be additional charges for these sessions
I understand that in order to obtain a parking place in the visitors car park at Leeds Student Medical Practice I must collect a parking permit from reception and display it in my vehicle before commencing training. Failure to do so may result in a fine of £80
I understand that parking may not always be available at Leeds Student Medical and in these circumstances I will have to make my own alternative arrangements
I agree to the terms and conditions of the Fees section yesno
