4 Blenheim Walk, Leeds LS2 9AE
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Thank you for your interest in the NDFSRH 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: https://www.fsrh.org/education-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 NDFSRH 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, eSRH module 17 pass and RCN genital exam documentation. 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: lsmp.cash@nhs.net 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; Sarah Jemmeson, on lsmp.cash@nhs.net or 0113 295 4488.
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:
Please select which date you would like to attend: ---Tuesday 5th June 2018 (9am – 5pm)
Will you require NDFSRH 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?
Entry Requirements
I am registered with and have a license to practice with, the UK NMC. UK NMC Registration number:
I am aware that in order to complete the NDFSRH 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 perform a speculum examination. This may be demonstrated either by; holding a current RCN IUT accreditation or RCN Genital Examination in Women Competencies or through this skill being signed off by a Consultant, Faculty Registered Trainer or GP. Please select:---RCN IUT accreditationRCN Genital Examination in Women CompetenciesSigned off by a Consultant, Faculty Registered Trainer or GP
Maximum Timeframes
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 NDFSRH Diploma
I am aware that no more than three years should elapse between my eKA pass and the award of my NDFSRH Diploma
Evidence
I will send evidence that I have passed the eKA and that I am up to date with resuscitation and anaphylaxis training.
E-Portfolio
I have a FSRH e-portfolio
I am aware that the FSRH Diploma is underpinned by the SRH e-portfolio, this must be completed to support an application for the NDFSRH Diploma, and that there is a fee payable to the Faculty for the 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.
Reading
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" - http://www.fsrh.org/documents/diplomatrainingrequirements/
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 NDFSRH 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 payment may still be taken.
I agree that my payment of £300 is only for the NDFSRH Course of 5 training day. If I require further sessions to meet the standard required, there may be additional charges for these.
I agree that I have read all of the above YesNo
Information
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
