4 Blenheim Walk, Leeds LS2 9AE

Booking form for LoC IUT and SDI – Nurses

No jobs are currently available.

Thank you for your interest in LoC IUT and LoC SDI training at Leeds Student Medical Practice. To apply for training, please first check the Faculty website to ensure you are eligible on www.fsrh.org/pages/Letter_of_Competence_IUT

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: 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)

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?

Evidence

I enclose a copy of my eKA pass certificate, DFSRH, MFSRH or FFSRH certificate / recertification from within the last five years: yesno

I enclose certificates of completion of anaphylaxis training and basic life support training: yesno

UK NMC Registration Number:

I enclose evidence that I have completed the RCN genital examination in women competencies and have been
assessed as competent: yesno

I enclose evidence of completion of e-SRH Modules 17 and 18: yesno

I am competent in consultation skills: yesno

I am RN Level 2 (please note that if you answer yes to this question you are not eligible for the course): yesno

Timeframes

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:
yesno

Insurance

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:
yesno

Previous Coil Experience

Have you fitted any coils previously? yesno
If ‘yes’; how many coils have you fitted? (please write the number in the following free text box):

Reading

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 Intrauterine Techniques” - Learning outcomes

I have read and understand the FSRH “General Training Terminology” - General Training Terminology

I have read and understand the FSRH “Record of Training for the Letter of Competence in Intrauterine Techniques (LoC IUT)” - IUT Training Record

I have read and understand the FSRH “Update to Faculty of Sexual and Reproductive Healthcare (FSRH) Training Programme Changes to the FSRH Diplomat Assessment /
Letters of Competence Frequently Asked Questions” FAQ`s FSRH Training Programme

I have read and understand the FSRH “Training Requirements for the Letter of Competence in Subdermal Contraceptive Implant Techniques (LoC SDI)” -SDI Training Requirements

I have read and understand the FSRH “Learning Outcomes for the Letter of Competence in Subdermal Contraceptive Implant Techniques (LoC SDI)” - SDI Learning Outcomes
I have read and understand the FSRH “Record of Training for the Letter of Competence in Subdermal Implant Techniques (LoC SDI)” - SDI Training Record

I agree i have read all the suggested reading: yesno

Fees

I am aware that there is a fee payable to the Faculty for the LoC IUT and LoC SDI

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 £650 is for three practical training sessions of IUT and two of SDI - 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.

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

 

 

Opening Times

Monday 07:00 – 19:00
Tuesday 07:00 – 19:00
Wednesday 07:00 – 19:00
Thursday 07:00 – 19:00
Friday 07:00 – 19:00
Saturday 09:00 – 13:00
Sunday 09:00 – 13:00

For information on how to book an appointment, please click here

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Leeds Student Medical Practice,
4 Blenheim Court,
Blenheim Walk,
Leeds LS2 9AE

Tel: 0113 295 4488

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