4 Blenheim Walk, Leeds LS2 9AE
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Thank you for your interest in LoC IUT training 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/training.asp
Then please complete this form and post or scan and 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: firstname.lastname@example.org
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 email@example.com or 0113 2954488
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:
How did you hear about training at Leeds Student Medical Practice?
UK GMC Registration Number:
I have a license to practice with the UK GMC: YesNo
I have passed the eKA or I hold one of the following:a DFSRH, NDFSRH or FFSRH that was gained or has been recertified within the last five years.
Please select which of the options applies to you from the following drop-down box:
I have posted/emailed a copy of my:---eKA pass certificateDFSRHMFSRHFFSRH
I am competent in consultation skills
I will complete e-SRH Module 18 before my clinical training session at Leeds Student Medical Practice
I have posted or emailed evidence of e-SRH Module 18
I am up to date with resuscitation and analphylaxis including competent to give intramuscular injections
I have posted or emailed cericates of completion of anaphylaxis training and basic life support training
I am competent in assessing the size, position and mobility of the uterus
I am competent in assessing, investigating and managing potential IUS users with abnormal findings at a pelvic exam, heavy and /or painful periods, infrequent and / or absent periods, vaginal discharge and sexual transmitted infections and acute and chronic pelvic pain
I agree that I meet all the entry requirements: yesno
I will apply for my LoC within three years of passing the eKA: yesno
I will start model uterus / clinical assessments within two years of my eKA pass: yesno
I will start model uterus / clinical assessments within six months of completing the e-SRH Module 18:
I have read and understand the FSRH "Training requirements for the letter of competence in Intrauterine Techniques (Loc IUT) IUT Training Requirements
I have read and understand the FSRH "Learning Outcomes for the Letter of Competence in Intraterine Techniques IUT Learning Outcomes
I have read and understand the FSRH "General Training Terminology"-http://www.fsrh.org/pdfs/general training terminology
I have read and understand the FSRH "Record of Training for the Letter of Competence in Intrauterine Techniques (LoC IUT)"- http://www.fsrh.org/pdfs/IUT Trainingrecord
I have read and understand the FSRH 2Uodate to Faculty of Sexual and Reproductive Healthcare (FSRH) Training Programme Changes to the FSRH Diplomat Assessment/Letters of Competence Frequently Asked Questions" - http://www.fsrh.org/pdfs/FAQsUpdateFSRHTrainingProgramme
I agree i have read all the suggested reading: yesno
I am aware that there is a fee payable to the Faculty for the LoC IUT
I agree that if I attend my sessions unprepared, my training may be cancelled and my payment may still be taken.
I agree that my payment for £450 is for three practical training sessions which is the usual number of sessions it takes in order to reach the satisfactory standard required to complete the training. Should I require further training in order to meet the required standard there may be additional charges.
I understand that should I require any additional sessions following this, Leeds Student Medical Practice will charge me £100 for each additional practical training session.
Medical defence organisation (please write the name of the organisation you are covered by):
I confirm that I am covered by my medical defence organisation for the duration of my training:
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.
Leeds Student Medical Practice reserve the right to cancel LoC IUT training sessions if there are insufficient patient numbers and /or in the event of unforeseeable
circumstances adversely affecting your training sessions.
I agree to the terms and conditions of the Fees section yesno