4 Blenheim Walk, Leeds LS2 9AE
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Thank you for your interest in the DFSRH course of 5 training at Leeds Student Medical Practice.
Before applying for this training, please check the training requirements on the faculty website to ensure that you are eligible: http://www.fsrh.org/careers-and-training/diploma--nurse-diploma/
To book onto the course, please complete the form below. When you submit the form please contact Sarah Jemmeson to pay for your place. You can pay by either Card or Cheque. Please note, your booking is not confirmed until payment has been received.
Payment for the DFSRH Course of 5: £300
By card: Please call Sarah to take payment over the phone 0113 295 4488.
By cheque: Your payment cheque should be made payable to "Leeds Student Medical Practice" and can be posted, FAO. Sarah Jemmeson, Leeds Student Medical Practice, 4 Blenheim Court, Blenheim Walk, Leeds, West Yorkshire LS2 9AE.
You will need to send us copies of the following evidence in advance of the Course of 5; eKA pass, written confirmation of e-portfolio course pre-requisites, resuscitation and anaphylaxis training, CRB/DBS check and eSRH module 17 pass. You can do this:
By post: FAO. Sarah Jemmeson to Leeds Student Medical Practice, 4 Blenheim court, Blenheim walk, Leeds, West Yorkshire LS2 9AE
By Email: email@example.com
Please ensure that you complete all of the boxes on the booking form. If you have any questions regarding the form, please contact the Specialist Administrator
and Medicines Management Facilitator; Sarah Jemmeson, on firstname.lastname@example.org or 0113 295 4488.
First Name: (required)
Emergency Contact Person’s Name:
Relationship to Trainee:
Any known allergies:
Title and Name of Line Manager:
Please list any special requirements you have. e.g. vegan, prayer room, disabled access:
Please select which date you would like to attend: ---Thursday 10th January 2019 (9am – 5pm)
Will you require DFSRH Clinical Experience and Assessment sessions at Leeds Student Medical Practice following the Course of 5? YesNo
How did you hear about training at Leeds Student Medical Practice?
I am registered with and have a license to practice with, the UK GMC. UK GMC Registration number:
I am aware that in order to complete the DRSRH Course of 5 I must have passed the eKA in SRH (online assessment of knowledge).
I am able to demonstrate appropriate consultation skills for sexual health consultations including:
• Protecting confidentiality
• Adapting the consultation style to suit the patient
• Taking an appropriate sexual history
• Addressing patients' ideas, concerns and expectations and answering their questions
• Making appropriate offers of a chaperone
• Assessing whether a patient is competent to consent to treatment and ensuring consent is well-informed
• Demonstrating clear record-keeping
• Using time effectively in consultations
I am up to date with resuscitation and anaphylaxis training.
I am able to demonstrate the following gynaecological skills:
Assess the size, position and mobility of the uterus
Perform a genital examination, including speculum examination, digital vaginal examination and bimanual pelvic examination
Assess, investigate and initiate appropriate management of potential IUD/IUS users with:
• Abnormal findings at pelvic examination
• Heavy and/or painful periods
• Infrequent and/or absent periods
• Vaginal discharge and sexually transmitted infection
• Acute and chronic pelvic pain
I will start my Course of 5 within two years of passing the eKA.
I am aware that no more than two years should elapse between my Course of 5 pass and the award of my FSRH Diploma.
I am aware that no more than three years should elapse between my eKA pass and the award of my FSRH Diploma.
I will send evidence that I have passed the eKA and that I am up to date with resuscitation and anaphylaxis training.
I have a FSRH e-portfolio.
I am aware that the FSRH Diploma is underpinned by the SRH e-portfolio.
I agree that my entry requirements will be signed off on the e-portfolio system prior to my attendance at the Course of 5. I understand that failure to do so will make me ineligible to participate in the Course of 5 and I may lose my payment.
I have read and understand the FSRH "Training Requirements for the Diploma Assessment of the Faculty of Sexual and Reproductive Healthcare (FSRH Diploma) DFSRH/NDFSRH" -
I have read and understand the FSRH "Learning Outcomes of the FSRH diploma"-https://www.fsrh.org/documents/general-training-diploma-curriculum-document/
I have read and understand the FSRH "General Training Terminology" - https://www.fsrh.org/documents/general-training-terminology-document/
I have read and understand the FSRH "FSRH Diploma: Theory Syllabus" - http://www.fsrh.org/documents/general-training-diploma-curriculum-document/
I am aware that the eKA is available at http://www.fsrh.org/careers-and-training/e-knowledge-assessment-eka/
I have read and understand the FSRH "DFSRH/NDFSRH Recertification requirements" - http://www.fsrh.org/recertification/recertification-information/
I agree that it is my responsibility to ensure that I meet all the DFSRH Course of 5 pre-course requirements and that I fulfil the eligibility criteria for training prior to attending the course.
I agree that failure to do so may result in my training being cancelled, but that payment may still be taken.
I agree that my payment of £300 is only for the DFSRH Course of 5 training day. If I require further sessions to meet the standard required, there may be additional charges for these sessions.
I agree that I have read all of the above YesNo
I understand that on-site parking is not available at Leeds Student Medical and I will have to make alternative arrangements.
Leeds Student Medical Practice reserves the right to cancel a Course of 5 if there is insufficient demand for places. If this happens, your course payment will be returned to you.
I agree to the terms and conditions YesNo
Please AnswerWhat is 10 + 5