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CANDIDATE PACK - Paediatric Cardiothoracic July 2010

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					THE LONDON DEANERY




Application to Paediatric Cardiothoracic Junior Surgical Fellowship for 2010 - a sub specialty Training
                          Placement in Paediatric Cardiothoracic Surgery
Thank you for applying to a training programme in the London Deanery. This letter explains the
appointment process we use.
This pack contains:
   a)       A person specification which describes the attributes for which we are looking. This is based
            around the GMC's document “Good Medical Practice”. Please note that you must be able to
            offer all of those attributes described as essential if you are to be considered for shortlisting and
            . or appointment.
   b)       An application form.
   c)       A shortlisting score sheet (for information only) which will show you how the shortlisting
            committee will judge your application against the requirements of the person specification.
Please read this pack carefully. As you fill out the application form you are advised to answer the
questions and complete the form with reference to the person specification. Please note:
              CVs and additional pages will not be accepted and therefore the application form should be
              fully and carefully completed.
             When completing the applications form you must not make any adjustments to the spaces
              allowed for the responses.
             The minimum type size which can be used is 10 point.
             Application forms must be returned to the Deanery in Word format – no other format (eg
              PDF) will be accepted.
             Failure to comply with the above instructions will result in your application being rejected.
             Where equivalent qualifications or experience are being offered, it is essential that the
              candidate should provide written confirmation of this from the relevant College or Faculty in
              the UK at interview. Candidates cannot be appointed without this confirmation.
             The number of applicants called for interview will depend both on the number of the
              vacancies in the programme and on the shortlisting scores achieved by applicants during this
              recruitment.
             The interview process will explore those areas included in the specification about which we
              need further information
             Please email the completed application form to :

Dr Fiona Moss
Acting Dean Director of Postgraduate Medical &
Dental Education
THE LONDON DEANERY




         Adenike Adebanjo, Recruit5@londondeanery.ac.uk Tel: 0207 866 3195 Fax: 0207 866 3276.
           Reference number :           029/36
           Closing date and time:       12.00PM GMT + 1 on 20 August 2010
           Interviews will be held in : September 2010
           For further information about this training programme and visiting arrangements (shortlisted
            candidates only), please contact: Mr V Tsang or Mr M Kostolny at Great Ormond Street
            Hospital on telephone number 0207 813 8159 or by email: tsangV@gosh.nhs.uk
           Please let your referees know that you are applying for this post, so that if you are shortlisted,
            they will be prepared to respond to our reference request.
           Successful applicants need to be aware that changes could occur during the progression of the
            training programme. The principal aim will always be to deliver the best quality training
            experience.
           Applicants need to be aware that although trainees’ preferences are considered when making
            decisions on placements, final decisions take into account the service needs of all sites within
            our training programmes.
  Thank you for applying to this training programme. Good luck with your application.
  Yours sincerely
  Adenike Adebanjo
 MedicalRecruitmentAdministrator




Dr Fiona Moss
Acting Dean Director of Postgraduate Medical &
Dental Education
THE LONDON DEANERY




                                  ***Important information***
                      It is essential that all applicants read this page.
  Dear Applicant
  Thank you for your interest in this training programme. The application form is enclosed.
  It is essential that you give careful thought to your answers and complete each section accurately. Please note
  that you may be asked to provide evidence to support the statements you have made in any part of your form.
  Please pay particular attention to the following and complete the corresponding sections in the application form
  as appropriate.
  Visa status – International Medical Graduates
  On 7 March 2006 the Home Office announced changes to the immigration rules which have an effect on
  Postgraduate Doctors and Dentists and which we must take into account during our recruitment activity.
  From 7 March 2006 we have to recruit doctors and dentists from the UK and the EEA (including those doctors
  and dentists who have been accepted onto the Highly skilled Migrant Programme / Tier 1 who are not prohibited
  from taking employment as a Doctor in Training) before we recruit migrant doctors from outside EEA countries.
  However, if there are posts available on any of the London Deanery training programmes and no doctor or
  dentists with permanent residence or HSMP / Tier 1 (as described above) status in this country is able to take up
  the post, fully trained international medical graduates with the appropriate qualifications may also be considered
  for appointment. (Please see A Points-based System : Making Migration Work for Britain, pages 1 & 8).
  The above statements represent our current understanding of the effects of the changes. For further information
  regarding the new immigration strategy please contact the Home Office’s Border Agency Enquiry Bureau on
  telephone 0870 606 7766 or by email: UKBApublicenquiries@ukba.gsi.gov.uk
  Fitness to Practise
  When completing that part of the application form headed “Fitness to Practise and Criminal Investigations”, you
  should note that all doctors are exempt from the Rehabilitation of Offenders Act and you are therefore required to
  complete the section of the application form which related to your Fitness to Practise status.
  If you have any queries about any of the statements in this section please do not hesitate to contact the Medical
  Workforce Department at the London Deanery as stated in the Fitness to Practise section. Any query you may
  have will be treated confidentially.
  Criminal Records Bureau checks (CRB)
  CRB checks are carried out by the employing Trust in accordance with the guidelines set out by NHS Employers
  (http://www.nhsemployers.org).
  All offers of appointment are subject to CRB checks. The London Deanery will inform you first employing Trust of
  your offer of appointment, however on receiving your offer you should make contact with the Medical Staffing
  Department at your Trust to arrange for a CRB check
  The London Deanery would like to wish you good luck with your application and your future career.




Dr Fiona Moss
Acting Dean Director of Postgraduate Medical &
Dental Education
THE LONDON DEANERY




                                 THE LONDON DEANERY
                                 General Statement of Policy
 General Statement of Policy regarding fitness to practise proceedings by a licensing/regulatory
                            body and relating to criminal records.
Registration with a professional body, such as the General Medical Council or General Dental
Council, imposes a duty on health care professionals to provide a good standard of medical care for,
and behave appropriately towards, patients. NHS employers also have a duty to ensure that patients
receive a good standard of medical care and to take all practicable steps to ensure the safety of patients
and staff.
In order to assess job related risks, the London Deanery needs to establish if applicants who may be
offered a placement on a Specialty training programme have a criminal record in the UK or in another
country that they can lawfully be required to disclose.
Applicants for Specialty training posts are exempted from the Rehabilitation of Offenders Act 1974,
and can therefore be asked to disclose “spent” convictions that they would otherwise not have to
declare.
Applicants for Specialty training posts will also be asked if they are “bound over”, have received a
police caution, warning or reprimand and whether they have been charged with a criminal offence that
is not yet disposed of.
Prior to making an appointment, the London Deanery also needs to establish if applicants for
Specialty training posts have ever been disqualified from the practice of a profession or required to
practise it subject to specified limitations following fitness to practise proceedings by a regulatory
body in the UK or in another country, and whether they are currently the subject of any investigation
or proceedings by any body having regulatory functions in relation to health/social care professionals,
including such a regulatory body in another country.
Where such a position involves regular care, training, supervision or sole charge of persons aged
under 18 or vulnerable adults (as defined by The Police Act 1997 (Enhanced Criminal Record
Certificates)(Protection of Vulnerable Adults) Regulations 2000), applicants will also be asked
whether they are currently the subject of any police investigation in the UK or any other country of
which they are aware.
Where the position is a “regulated position” under the terms of the Protection of Children Act 1999
(as amended by the Criminal Justice and Court Services Act 2000), checks will be carried out in
accordance with the Protection of Children Act 1999. Anyone whose name is on the list is legally
barred from working with children. It is an offence for such a person to knowingly apply for, offer to
do, accept or to do such work. If you are appointed to a Specialist Registrar post, you will be subject
to a Criminal Records Bureau (CRB) check.



Dr Fiona Moss
Acting Dean Director of Postgraduate Medical &
Dental Education
THE LONDON DEANERY




Applicants are encouraged to declare criminal conviction information and any other matters that are,
or that might be, relevant to the position for which they are applying at an early stage in the
appointment process. All applicants are also expect to inform the London Deanery if, before taking up
any position offered to them, they are charged with a criminal offence in the UK or another country.
The London Deanery is an equal opportunities recruiter, and all applications will be decided fairly
and on merit. Information declared will be used to consider the applicant’s suitability for the position.
Information supplied will be treated in confidence and will not be used as the sole criterion to decide
an applicant’s fitness for the position.
Unless an appointment is prohibited by law, a criminal conviction will not automatically debar the
applicant from appointment. Applicants will be given an opportunity to discuss any information
supplied before a final decision is taken regarding their appointment.
However, an applicant may not be selected if the selection panel considers that the information
declared renders that person unsuitable for the position for which they have applied. In reaching such
a decision the London Deanery will consider the nature of the record/action, its relevance to the
position applied for, and any other information the applicant wishes to provide.
The information declared will be treated in compliance with the Data Protection Act 1998.
NOTE: Failure by an applicant to provide accurate and truthful information is considered to be
a serious matter.
Where it is found that a person has intentionally or recklessly provided inaccurate information
or withheld information relevant to his/her position, this may disqualify them from an
appointment, or if appointed, dismissal and referral to the appropriate professional regulatory
body.
If you would like to discuss what effect any criminal record or fitness to practise proceedings might
have on your application, you may telephone Jane Appleyard, telephone 0207 866 3105, in the
Medical Workforce department, in confidence or email fitnesstopractise@londondeanery.ac.uk .
Any information you provide regarding criminal investigations, convictions or fitness to practise
proceedings will be kept confidential. If the Deanery considers that the information provided may
have a bearing on your appointment and that the information needs to be considered by the selection
panel, we will discuss this with you in advance. If we do not raise this information with you, this is
because we do not believe that it should be taken into account. In that event, you still remain free,
should you wish, to discuss the matter with the interviewing panel.
Prior to making a final decision concerning your application, we shall discuss with you any
information declared by you that we believe has a bearing on your suitability for the position.
The London Deanery aims to promote equality of opportunity and is committed to treating all
applicants for positions fairly and on merit regardless of race, gender, marital status, religion,


Dr Fiona Moss
Acting Dean Director of Postgraduate Medical &
Dental Education
THE LONDON DEANERY




disability, sexual orientation or age. We undertake not to discriminate unfairly against applicants on
the basis of criminal conviction or other information declared.
The Data Protection Act 1998 requires us to provide you with certain information and to obtain your
consent before processing sensitive data about you. Processing includes: obtaining, recording,
holding, disclosing, destruction and retaining information. Sensitive personal data includes any of the
following information: criminal offences, criminal convictions, criminal proceedings, disposal or
sentence.
The information that you provide on the Declaration Form in the application form will be processed in
accordance with the Data Protection Act 1998, and will only be used for the purpose of determining
your application for this position. Once a decision has been made concerning your appointment, we
will not retain this Declaration Form longer than is necessary (i.e. until you leave your
post/programme or the recruitment episode is closed).
The Declaration Form will be kept in securely and in confidence, and access to it will be restricted to
designated persons within the Medical Workforce Department of the London Deanery and other
persons who need to see it as part of the selection process and who are authorised to do so. The
information may be passed to your employing trusts.




Dr Fiona Moss
Acting Dean Director of Postgraduate Medical &
Dental Education
   To applicants: you should complete your application form after carefully reading this person
   specification which is based on the GMC’s “Good Medical Practice”

                        THE LONDON DEANERY
          PAEDIATRIC CARDIOTHORACIC SURGICAL FELLOWSHIPS
                        PERSON SPECIFICATION
                   ESSENTIAL                        WHEN        DESIRABLE                       WHEN
                                                    EVALUATED                                   EVALUATED
QUALIFICATIONS      Eligible for registration      AF             Other degrees /             AF
                     with the GMC                                   qualifications eg BSc,
                    MB BS or equivalent            AF              MSc, MD (except those
                                                                    which are a primary
                    MRCS / FRCS or                 AF
                                                                    qualification, PhD, MS
                     equivalent
CLINICAL            2 years Basic Surgical         AF           Experience in other related   AF
EXPERIENCE           Training or equivalent                       specialties eg Cardiology,
                    Junior appointment – At        AF            ITU, Paediatrics,
                     least 2 years at SpR level                   Respiratory Medicine,
                     (or equivalent) in                           Anaesthetics
                     Cardiothoracic Surgery                      Additional experience in      AF
                                                                  Cardiothoracic Surgery
                                                                 Successful completion of      AF
                                                                  ATLS / APLS / ALS
                                                    AF
CLINICAL SKILLS     Specific clinical procedures   AF, I/V      Defined procedures            AF
                    Understanding of clinical      I/V          Operative skills course       AF, I/V
                     risk management
                    Competent to work without      I/V, Ref
                     direct supervision where
                     appropriate
                    Clear, logical thinking        AF, I/V
                     showing an
                     analytical/scientific
                     approach
                    Good manual dexterity and      Ref
                     hand / eye co-ordination
KNOWLEDGE           Appropriate level of           Ref          Demonstrates breadth of       AF, I/V
                     clinical knowledge                           experience and awareness
                    Shows knowledge of             I/V           in and outside specialty /
                     evidence-informed practice                   medicine
                    Shows awareness of own         I/V, Ref     Demonstrates use of           I/V
                     limitations                                  evidence-informed practice
   To applicants: you should complete your application form after carefully reading this person
   specification which is based on the GMC’s “Good Medical Practice”


                   ESSENTIAL                          WHEN           DESIRABLE                         WHEN
                                                      EVALUATED                                        EVALUATED
ORGANISATION &      Ability to prioritise clinical   I/V, Ref        Understanding of NHS,           AF, I/V
PLANNING             need                                              clinical governance &
                    Ability to organise oneself      I/V, Ref         resource constraints;
                     & own work                                        management / financial
                                                                       awareness; experience of
                    Evidence of participation in     AF
                                                                       committee work
                     audit
                                                                      Active involvement in           AF, I/V
                    Experience and ability to        AF, I/V, Ref
                                                                       audit
                     work in multi-professional
                     teams
TEACHING SKILLS     Evidence of teaching             AF              Enthusiasm for teaching;        AF, I/V
                     experience                                        exposure to different
                                                                       groups / teaching methods
ACADEMIC/                                                             Research experience,            AF, I/V
RESEARCH                                                               presentations, publications,
                                                                       prizes and honours
                                                                      Publications in                 AF, I/V
                                                                       Cardiothoracic journals
CAREER                                                                  Progression of career         AF
PROGRESSION                                                              consistent with personal
                                                                         circumstances
START DATE                                                              [available to start on post   AF, I/V
                                                                         start date]
PERSONAL SKILLS       COMMUNICATION &                AF, I/V, Ref
                       LANGUAGE SKILLS
                       (the ability to
                       communicate with clarity
                       and intelligibility in
                       written and spoken
                       English; ability to build
                       rapport, listen, persuade,
                       negotiate)
                    DECISIVENESS/                    I/V, Ref
                     ACCOUNTABILITY
                     (ability to take
                     responsibility, show
                     leadership, make decisions,
                     exert appropriate authority)
                    INTERPERSONAL                    AF, I/V, Ref
                     SKILLS (see patients as
                     people, empathise, work
                     co-operatively with others,
                     open and non-defensive,
                     sense of humour)
   To applicants: you should complete your application form after carefully reading this person
   specification which is based on the GMC’s “Good Medical Practice”
                    USES A NON-                      Ref
                     JUDGMENTAL
                     APPROACH TO
                     PATIENTS AND
                     COLLEAGUES regardless
                     of their sexuality, ethnicity,
                     disability, religious beliefs
                     or financial status
                    FLEXIBILITY (able to             I/V, Ref
                     change and adapt, respond
                     to rapidly changing
                     circumstances)
                    RESILIENCE (able to              I/V, Ref
                     operate under pressure,
                     cope with setbacks, self-
                     aware)
                    THOROUGHNESS (is                 I/V, Ref
                     well prepared, shows self-
                     discipline/commitment, is
                     punctual and meets
                     deadlines)
                    SHOWS INITIATIVE/                AF, I/V, Ref
                     DRIVE/ENTHUSIASM
                     (self-starter, motivated,
                     shows curiosity, initiative)
                    PROBITY (displays                I/V, Ref
                     honesty, integrity, aware of
                     ethical dilemmas, respects
                     confidentiality)
PHYSICAL            Meets professional health        pre-employment
REQUIREMENTS         requirements                     health screening
Template 2010 – last amended 10th February 2010   Candidate Number : ________________________
Please complete this application form carefully. CVs and additional pages will not be accepted.
                                         THE LONDON DEANERY
                                              APPLICATION FORM
          PAEDIATRIC CARDIOTHORACIC JUNIOR SURGICAL FELLOWSHIP

                                                   Ref: 029/36
                                                  PART ONE
Section A – Personal Details
Surname :                                                     Forenames :

Title :                                                       If previously known by another name, please specify :



Home Address :                                                Address for correspondence :




Home telephone number :                                       Work telephone number :
Home Fax number :                                             Work fax number :
Email address :
Mobile phone number :


Date available to start if offered the post

Section B – General Medical Council Registration
Do you have, or are you        GMC Number                     Renewal date                   Name in which you are
eligible for, FULL GMC                                                                       registered
registration?



If not registered with the GMC at time of application, will you be eligible for FULL registration by the time of
appointment? Please give details below.
Template 2010 – last amended 10th February 2010       Candidate Number : ________________________


Section C – Equal Opportunities Monitoring Form
We are committed to eliminating unlawful discrimination from employment and selection practices. We will take steps to
ensure that employees are recruited, trained and promoted on the basis of ability, the requirements of the job and the need to
maintain an efficient and effective service. To monitor this policy, we require the following information which will only be
used for this purpose. It will form no part of the interviewing process, and will be treated in strict confidence. This sheet will
be detached from your application form on receipt. If you are appointed, it will be kept on your training record, otherwise it will
be destroyed 6 months after the appointments committee.
   IF YOU DO NOT COMPLETE THIS SECTION OF THE APPLICATION FORM, YOUR APPLICATION WILL NOT BE
                  CONSIDERED COMPLETE AND WILL NOT BE PUT FORWARD FOR SHORTLISTING

DATE OF BIRTH:                                                     AGE:

                                          Male                                            Female
GENDER:
                                          Transgender Male                                Transgender Female
please select
                                          I do not wish to disclose my gender


Race Relations (Amendment) Act 2000
I would describe my ethnic origin as: (please select)
Asian or Asian British                      Mixed                                        Other Ethnic Group
       Bangladeshi                                  White & Asian                                Chinese
       Indian                                       White & Black African                        Any other ethnic group
       Pakistani                                    White & Black Caribbean                      Please specify below:
       Any other Asian background                   Any other mixed background
Black or Black British                      White                                        Undisclosed
       African                                      British                                      I do not want to disclose my
       Caribbean                                    Irish                                Ethnic origin
       Any other Black background                   Any other white background

Employment Equality Regulations 2003
Please select the option which best describes your sexuality
        Lesbian / Gay woman                                               Heterosexual
        Gay Man                                                           I do not wish to disclose my sexual orientation
        Bisexual
Please indicate your religious belief
       Atheism                                      Jainism                                      Judaism
       Buddhism                                     Sikhism                                      Hinduism
       Christianity                                 Other
       Islam                                        I do not wish to disclose by religion / belief
Template 2010 – last amended 10th February 2010    Candidate Number : ________________________

Disability Discrimination Act 1995
The Disability Discrimination Act protects disabled people. This includes people with long-term health conditions. If you
tell us that you have a disability we can make reasonable adjustments to where you work and your work arrangements or
at interview.
Do you consider yourself to have a disability?             Yes                I do not wish to disclose this information
                                                           No
Please state the type of impairment which applies to you. People may experience more than one type of impairment, in
which case you may indicate more than one. If none of the categories apply, please mark “other”.
      Physical impairment                        Learning Disability / Difficulty            Mental Health Condition
      Sensory impairment                         Long-standing illness                       Other
If you have a disability, do you require any specific arrangements to enable you to attend
                                                                                                 ---Please Select---
for interview?
If YES, (I have a disability which I consider relevant to my application) please describe any adaptation or
adjustment you consider an employer should make to accommodate you if you are shortlisted for interview /
appointed on a separate piece of paper and place in a sealed envelope addressed to Jane Appleyard, Medical
Workforce, London Deanery, Stewart House, 32 Russell Square, London WC1B 5DN. Please mark the envelope
“CONFIDENTIAL”. Alternatively, you may send an email to 2009confidentialenquiries@londondeanery.ac.uk ,
Please also let us know if you need any special arrangements to enable you to attend for interview.
If you have a disability, provided you meet the minimum criteria as specified in the
Person Specification, do you wish to be considered under the Guaranteed Interview
Scheme? Pleas see the Disability Discrimination Act for more details
If you tick Yes you must email 2009ConfidentialEnquiries@londondeanery.ac.uk to                  ---Please Select---
ensure your eligible for the guaranteed interview scheme. Failure to do so may result
in you not being granted a guaranteed interview. Emails to this address are managed
in strict confidence and will not be shared with the interview panel. Please see the
Disability Discrimination Act for more details.

Do you wish to apply for a deferred start date because you are registered for a higher degree (eg PhD, MD)?
---Please Select---
Date available to start post – please give reasons




Do you wish to be considered for less than full-time training?
If you select “Yes” as you wish to be considered for less than full-time training, this information will not be made
known to the selection panel but you will need to formally apply for less than full-time training via the deanery
Flexible Training Team. Further guidance and details on how to apply can be found on the deanery website
---Please Select---
Template 2010 – last amended 10th February 2010   Candidate Number : ________________________

D: Language Skills
You are required to demonstrate skills in written and spoken English that are adequate to enable effective
communication about medical and/or health topics with patients, colleagues and the public.
Evidence of English language proficiency – If you select „No‟ to both boxes then you must complete the
„Other‟ Section.
Country of Primary Medical Qualification (See list within Appendix A)

Was your undergraduate training taught in English?                                  ---Please Select---

Have your language skills been tested through the IELTS (International              ---Please Select---
English Language Testing System) to the minimum overall score required as
                            1
per the person specification ?                                                      Overall Score

                                                                                    Speaking Score



                                                                                    Listening Score



                                                                                    Reading Score


Date IELTS taken (dd/mm/yyyy)
                                                                                    Writing Score
Have all components of the IELTS been completed in one sitting?                     ---Please Select---
Other – Please provide details below – provide evidence of your English Language proficiency (max 50 words)




Where did you see this post advertised?
BMJ                                     London Deanery                         NHS Jobs
                                        website




1
 The Applicant must have achieved as a minimum the following scores in the academic International English
Language Testing System (IELTS) in a single sitting within 24 months at time of application – Overall 7, Speaking
7, Listening 7, Reading 7, Writing 7
Template 2010 – last amended 10th February 2010       Candidate Number : ________________________

E: Right To Work in the United Kingdom
Some applicants may be considered before others on the basis of immigration status, in accordance with
guidance from the UK Border Agency. If you require Tier 2 sponsorship in order to take up the offer of a
place on this training programme and you are subject to the Resident Labour Market Test, your application
will not be considered in this round of recruitment. Applicants in this category should consider re-applying
to any further rounds of recruitment in this speciality.
1a     Are you a United Kingdom (UK) national                                                        ---Please Select---
                                                                                              2
1b     Are you a European Community (EC) or European Economic Area (EEA) national?                   ---Please Select---
1c     Are you a Bulgarian or Romanian national
                                                                                                     ---Please Select---
       *Please complete the immigration status applicable
2      If not, do you have evidence of entitlement to enter and work permanently in the United
       Kingdom without restriction i.e Indefinite Leave to remain – free from immigration            ---Please Select---
       control?
If you have selected no to both of the above please mark with a cross the boxes below in the Personal
Status section which define your immigration status and complete start and expiry date of your permit,
unless you also tick yes to the question below, in which case you need to go to the Partner/Civil
Partner/Spouse Status section.
3      Are you on a dependents visa*
       *If you have answered YES please complete the Partner/Civil Partner/Spouse status             ---Please Select---
       section
Nationality (Choose country           pertaining to your nationality - see country list –
Appendix A)

Personal Status
Select     Status                                                                             Start Date     Expiry
                                                                                                             Date
           Bulgarian or Romanian National with Blue registration certificate

           Highly Skilled Migrant Programme (dates of endorsement stamp in passport)

           Points based system – with endorsement “no employment as a doctor in training”

           Points based system – no endorsement regarding “employment as a doctor in
           training”
           Permit Free Training / Postgraduate doctor or dentist

           Refugee in the UK

           Work Permit / Tier 2

           Tier 4 – UK Graduate

           Tier 4 – Not a UK Graduate

           Tier 4 – Studying for a Masters/PHD

           UK ancestry

           Student visa holder

           Other immigration categories i.e. Overseas government employees, Innovators etc.




2
    For the purposes of this form Switzerland has been included within the EEA national category
Template 2010 – last amended 10th February 2010       Candidate Number : ________________________
If Other than above – Please specify the immigration category (Max 50 words – 455 Characters)




Partner / civil partner / spouse status
Please complete this section if you have answered YES to question 3 above.
Select      Status                                                                                  Start Date   Expiry
                                                                                                                 Date
                                                        3
            Partner / civil partner or spouse of UK / EEA citizen
                                                                     4
            Non EEA national partner / civil partner or spouse of EEA citizen exercising a treaty
            right
            Partner / civil partner or spouse of HSMP holder

            Partner / civil partner or spouse under the Points based system – with endorsement
            “no employment as a doctor in training”
            Partner / civil partner or spouse under the Points based system – no endorsement
            regarding “employment as a doctor in training”
            Partner / civil partner or spouse of student visa holder – student visa holder must
            have 12 months or more leave to remain
            Partner / civil partner or spouse of other immigration categories i.e. refugees, work
            permit holders, Overseas government employees, Innovators etc.
If Other than above – Please specify the immigration category (Max 50 words – 455 Characters)




    If you are shortlisted, you will be required to produce the original documents (passports, page
                 with the stamp and letter from the Home Office) on the interview day.




3
    For the purposes of this form Switzerland has been included within the EEA national category
Template 2010 – last amended 10th February 2010   Candidate Number : ________________________


F: Fitness to Practise and Criminal Investigations
We aim to promote equality of opportunity and are committed to treating all applicants for positions fairly and on
merit regardless of race, gender, marital status, religion, disability, sexual orientation or age. We undertake not to
discriminate unfairly against applicants on the basis of criminal conviction or other information declared.
Prior to making a final decision concerning your application, we shall discuss with you any information declared by
you that we believe may have a bearing on your suitability for the position. If we do not raise this information with
you, this is because we do not believe that it should be taken into account. In that event, you still remain free, should
you wish to discuss the matter with the interviewing panel. As part of assessing your application, we will only take
into account relevant criminal record and other information declared. However, please be advised that any failure to
declare relevant information relating to your fitness to practice may well lead to your application being withdrawn,
and/or any employment or training programme placement terminated.
The Data Protection Act 1998 requires us to provide you with certain information and to obtain your consent before
processing sensitive data about you. Processing includes: obtaining, recording, holding, disclosing, destruction and
retaining information. Sensitive personal data includes but is not limited to any of the following information: criminal
offences, criminal convictions, criminal proceedings, disposal or sentence.
The information that you provide in this Declaration Form will be processed in accordance with the Data Protection
Act 1998. It will be used for the purpose of determining your application for this position. It will also be used for
purposes of enquiries in relation to the prevention and detection of fraud. Once a decision has been made
concerning your appointment, we will not retain this Declaration Form longer than is necessary (ie until you leave the
post you are applying for / programme or the recruitment episode is closed).
This Declaration Form and any information provided relating to a positive declaration will be kept securely and in
confidence, and access to it will be restricted to designated persons within the Recruitment Department and other
persons who need to see it as part of the selection process and who are authorized to do so. If successfully
appointed to a training post, this information may be passed to your employing trusts.
Rehabilitation of Offenders Act 1974
Before you can be considered for appointment in a position of trust as a Specialty Trainee on a Deanery
programme, we need to be satisfied about your character and suitability.
This post is considered a “regulated activity” within the terms of the Safeguarding Vulnerable Groups Act
2006, and appointments made after 26 July 2010 will be subject to registration with the Independent
Safeguarding Authority (ISA). This will become a mandated requirement from 1st November 2010. Only
successfully registered employees will be permitted to continue their training and employment after that
date.
It is vitally important that you read, understand and answer the questions asked in this section by selecting
each box – please read the accompanying notes carefully before completing this part of the form.
Please answer all of the following questions. If you answer “YES” to any of the questions, please ensure you provide
full details via email to fitnesstopractise@londondeanery.ac.uk by the closing date if application. Failure to do so
may result in your application being withdrawn. In this email please indicate clearly the programme for which you
are applying, the question(s) to which you have provided a positive response .

The position for which you have applied is exempted from the Rehabilitation of Offenders Act 1974. This
means that you must declare all criminal convictions, including those that would otherwise be considered
“spent”. Answering “YES” to any of the questions below will not necessarily bar you from appointment.
This will depend on the nature of the position for which you are applying and the particular circumstances.
Template 2010 – last amended 10th February 2010   Candidate Number : ________________________


If you would like to discuss what effect any previous convictions, police investigations or fitness to practice
proceedings taken or being taken either in the UK or by an overseas licensing or regulatory body might have on
your application, you may telephone: Jane Appleyard at the Deanery on 020 7 866 3105 in confidence.
1      Are you currently bound over or have you ever been convicted of any offence by a
       Court or Court-Martial in the United Kingdom or in any other country? NB You do not       ---Please Select---
       need to tell us about parking offences.
2      Have you ever received a police caution, reprimand or final warning?                      ---Please Select---
3      Have you been charged with any offence in the United Kingdom or in any other country
       that has not yet been disposed of?
       Please note: you must inform us immediately if you are charged with any                   ---Please Select---
       offence in the United Kingdom or in any other country after you complete this
       form and before taking up any position offered to you. You do not need to tell us
       if you are charged with a parking offence.
4      Are you aware of any current police investigation in the United Kingdom or in any other
                                                                                                 ---Please Select---
       country following allegations made against you?
5      Are you aware of any current NHS Counter Fraud and Security Management Service
                                                                                                 ---Please Select---
       investigation following allegations made against you?
6      Have you ever been investigated by the Police, CFSMS or any other Investigatory
       Body resulting in a caution, conviction or dismissal from your employment?
       (Investigatory bodies include Local Authorities, Customs & Excise, Immigration,
                                                                                                 ---Please Select---
       Passport Agency, Inland Revenue, Department of Trade & Industry, Banks and
       Building Societies, General Life Insurance Companies – this list is not exhaustive, and
       you must declare any investigation conducted by an Investigatory Body).
7      Have you ever been dismissed by reason of misconduct from any employment, office
                                                                                                 ---Please Select---
       or other position previously held by you?
8      Have you ever been disqualified from the practice of a profession or required to
       practice subject to specified limitations / conditions / warnings following fitness to
                                                                                                 ---Please Select---
       practice proceedings by a regulatory or licensing body in the United Kingdom or in any
       other country?
9      Are you currently the subject of any investigation or fitness to practice proceeding by
       any employer, any licensing or regulatory body in the United Kingdom or any other         ---Please Select---
       country?
10     Are you subject to any other prohibition, limitation, or restriction that means we are
                                                                                                 ---Please Select---
       unable to consider you for the position for which you are applying?
If you have answered “YES” to any of the questions, please provide full details on a separate sheet and place in a
sealed envelope addressed to Jane Appleyard, Medical Workforce, London Deanery, Stewart House, 32 Russell
Square, London, WC1B 5DN. Alternatively, you can email the details to fitnesstopractise@londondeanery.ac.uk .
Please indicate clearly the number(s) of the question (s) that you are answering. Please mark the envelope
“CONFIDENTIAL”
     You are reminded that if you are appointed to a training post or programme, you will have a continuing
     responsibility to inform your employer(s) and the Postgraduate Dean of any new criminal convictions,
                 police investigations or fitness to practice proceedings that arise in the future.
Note: if you wish to withdraw your consent at any time after completing this Declaration Form, please
contact Jane Appleyard at the Deanery (see above).
Template 2010 – last amended 10th February 2010   Candidate Number : ________________________

Section G – Referees
Reference reports are not used for scoring purposes during shortlisting or interview, but will be reviewed during the
selection process and again prior to confirmation of appointment for successful applicants. The reference process
is designed to check the accuracy of your previous employment and training history and to provide assurance of
your qualifications, integrity and track record.
You must provide contact details, including email addresses of three referees who have supervised your clinical
training during the last three years of your employment or undergraduate training. One referee must be your
current or most recent Consultant / Educational supervisor familiar with your clinical development. Please
provide NHS email addresses where possible.
Your clinical and academic referees should be contacted by you in advance to confirm that they are willing to
provide a reference and are available to do so in the time period required for selection and appointment.
Please ensure these details are correct as you will be unable to begin in post until references are supplied and
checked.
Reference 1                                       Post Details (post held by applicant)
(Present or
most recent        Specialty                                        Start Date
Consultant /       Level                                            End Date
Educational
Supervisor)                                       Consultant / Educational Supervisor
                   Name
                   Job title

Please give full   Address
address


                   Town
                   County
                   Post code
                   Country
                   Telephone number
                   Fax Number
                   Email address
Template 2010 – last amended 10th February 2010   Candidate Number : ________________________

Reference 2                                       Post Details (post held by applicant)
                   Specialty                                        Start Date
                   Level                                            End Date
                                                  Consultant / Educational Supervisor
                   Name
                   Job title

Please give full   Address
address


                   Town
                   County
                   Post code
                   Country
                   Telephone number
                   Fax Number
                   Email address
Reference 3                                       Post Details (post held by applicant)
                   Specialty                                        Start Date
                   Level                                            End Date
                                                  Consultant / Educational Supervisor
                   Name
Please give full
address            Job title
                   Address




                   Town
                   County
                   Post code
                   Country
                   Telephone number
                   Fax Number
                   Email address
Template 2010 – last amended 10th February 2010   Candidate Number : ________________________

Entry Criteria checklist
You should select the following checklist to indicate that you have completed this application form in conjunction
with the entry criteria set out in the relevant Specialty / entry level Person Specification for the post applied for.
Entry Criteria
I meet the entry qualifications                                                               ---Please Select---
I have the right to work in the UK                                                            ---Please Select---
I have no fitness to practice restrictions, or any other prohibition, limitation or           ---Please Select---
restriction which would prevent me from applying for this post
I am proficient in English Language Skills at the required level                              ---Please Select---




The Deanery is currently seeking advice on whether it is classified as an Employment Agency for the
purposes of the Employment Agencies Act 1973 (“the Act”) and associated regulations. In the meantime,
you are notified of the following terms and conditions that will apply to the provision of services by the
Deanery in connection with the recruitment of junior doctors to training programmes.

       1. The services provided include a work-finding service for which the Act prohibits the Deanery
       from charging a fee.
       2. The services provided by the Deanery will be provided without any charge to either junior
       doctors or the NHS employers that engage them.
       3. If it is determined that the Act applies to the Deanery, the Deanery will operate as an
       employment agency in providing the services.
       4. The Deanery is authorised to act for NHS employers that are offering training posts as part of
       the junior doctor training programme and is not authorised to enter into contracts with junior
       doctors on behalf of those employers.
By proceeding with the application process you are deemed to accept these terms and conditions.
 Please note, PART ONE of this form is for office use only and will not be seen by the shortlisting panel
                      and will not form any part of the interviewing process.
Template 2010 – last amended 10th February 2010            Candidate number : _______________________
APPENDIX A
Country of Origin
Afghanistan                   Egypt                           Macedonia                     Saudi Arabia
Albania                       El Salvador                     Madagascar                    Senegal
Algeria                       Equatorial Guinea               Malawi                        Seychelles
American Samoa                Eritrea                         Malaysia                      Sierra Leone
Andorra                       Estonia                         Maldives                      Singapore
Angola                        Ethiopia                        Mali                          Slovakia             (Slovak
Anguila                       Falkland           Islands      Malta                         Republic)
Antarctica                    (Malvinas)                      Marshall Islands              Slovenia
Antigua and Barbuda           Faroe Islands                   Martinique                    Solomon Islands
Argentina                     Fiji                            Mauritania                    Somalia
Armenia                       Finland                         Mauritius                     South Africa
Aruba                         France                          Mayotte                       South Georgia and South
Australia                     French Guiana                   Mexico                        Sandwich Islands
Austria                       French           Southern       Micronesia      (Federated    South Korea
Azerbaijan                    Territories                     States of)                    Spain
Bahamas                       Gabon                           Moldova                       Sri Lanka
Bahran                        Gambia                          Monaco                        St Helena
Bangladesh                    Georgia                         Mongolia                      St Pierre and Miquelon
Barbados                      Germany                         Montserrat                    Sudan
Belarus                       Ghana                           Morocco                       Suriname
Belgium                       Gibraltar                       Mozambique                    Svalbard and Jan Mayen
Belize                        Greece                          Myanmar                       Islands
Berin                         Greenland                       Namibia                       Swaziland
Bermuda                       Grenada                         Nauru                         Sweden
Bhutan                        Guadeloupe                      Nepal                         Switzerland
Bolivia                       Guam                            Netherland Antilles           Syrian Arab Republic
Bosnia & Herzegovina          Guatemala                       Netherlands                   Taiwan
Botswana                      Guinea                          New Caledonia                 Tajikistan
Bouvet Island                 Guinea Bissau                   New Zealand                   Tanzania
Brazil                        Guyana                          Nicaragua                     Thailand
British    Indian   Ocean     Haiti                           Niger                         Togo
Territory                     Heard and McDonald              Nigeria                       Tokelau
Brunei Darussalam             Islands                         Niue                          Tonga
Bulgaria                      Honduras                        Norfolk Islands               Trinidad and Tobago
Burkina Faso                  Hong Kong                       North Korea                   Tunisia
Burundi                       Hungary                         Northern Mariana Islands      Turkey
Cambodia                      Iceland                         Norway                        Turkmenistan
Cameroon                      India                           Oman                          Turks and Caicos Islands
Canada                        Indonesia                       Pakistan                      Tuvalu
Cape Verde                    Iran (Islamic Republic)         Palau                         Uganda
Cayman Islands                Iraq                            Palestinian       Territory   Ukraine
Central African Republic      Ireland                         (Occupied)                    United Arab Emirates
Chad                          Israel                          Panama                        United Kingdom
Chile                         Italy                           Papua New Guinea              United States of America
China                         Jamaica                         Paraguay                      United     States      Minor
Christmas Island              Japan                           Peru                          Outlying Islands
Cocos (Keeling) Islands       Jordan                          Philippines                   Uruguay
Colombia                      Kazakhstan                      Pitcairn                      Uzbekistan
Comoros                       Kenya                           Poland                        Vanuatu
Congo (Republic of)           Kiribati                        Portugal                      Vatican City State (Holy
Cook Islands                  Kuwait                          Puerto Rico                   See)
Costa Rica                    Kyrgyzstan                      Qatar                         Venezuela
Côte d'Ivoire                 Lao Peoples Democratic          Reunion                       Vietnam
Croatia                       Republic                        Romania                       Virgin Islands (British)
Cuba                          Latvia                          Russian Federation            Virgin Islands (U.S.)
Cyprus                        Lebanon                         Rwanda                        Wallis and Futuna Islands
Czech Republic                Lesotho                         Saint Kitts and Nevis         Western Sahara
Denmark                       Liberia                         Saint Lucia                   Yemen
Djibouti                      Libyan Arab Jamahiriya          Saint Vincent and the         Yugoslavia
Dominica                      Liechtenstein                   Grenadines                    Zambia
Dominican Republic            Lithuania                       Samoa                         Zimbabwe
East Timor                    Luxembourg                      San Marino
Ecuador                       Macau                           San Torne and Principe
 Template 2010 – last amended 10th February 2010       Candidate number : _______________________

 Please complete this application form carefully. CVs and additional pages will not be accepted.

                    THE LONDON DEANERY
                      APPLICATION FORM
         PAEDIATRIC CARDIOTHORACIC JUNIOR SURGICAL
                         FELLOWSHIP
                           Ref: 029/36
                          PART TWO
 Please indicate the level of post for which you are applying (please tick box)
 Senior Fellow – at least 4 years experience             Junior Fellow – at least 2 years experience

 Section H - Professional qualifications
 Medical/Dental School/University                                           Dates




           Shortlisted candidates will be required to bring original certificates to the interviews
Degree/Diploma/Postgraduate            Awarding Body                       Date of Qualification
Qualifications (include BSc, MBBS,
MRCP, MRCS, FRCS, etc) – state
class of degree awarded




Please give details of any research degree (MD, PhD)
currently being undertaken
  Template 2010 – last amended 10th February 2010           Candidate number : _______________________


  Section I - Present employment
  Employer’s/NHS Trust name:
  Address:
  Telephone number:
  Current position please state    Grade             Date            Length       of   Length     of   National
  if locum position                                  appointed       contract          notice          Training
  Specialty                                                                            required        Number




  Section J – Previous Appointments
  Please list posts in chronological order (most recent first) and state if locum/temporary/substantive posts
  Please asterisk those posts in the specialty for which you are currently applying

Specialty, Hospital, Consultant                     Grade                  From         To         Months in post




  Continue overleaf
 Template 2010 – last amended 10th February 2010           Candidate number : _______________________


 Previous Appointments (continued)
Specialty, Hospital, Consultant                    Grade                 From       To         Months in post




 Section K - Clinical Knowledge and Experience
 Name of Procedure                      Please give details of experience and level of competency
 Essential procedures
 Conduct of Adult Cardiopulmonary
 bypass



 Experience as first operator with
 Adult Cardiac Surgery



 Experience as first operator with
 Adult Thoracic Surgery
Template 2010 – last amended 10th February 2010        Candidate number : _______________________



Desirable procedures
Conduct of Paediatric
Cardiopulmonary bypass



Experience with Paediatric
Cardiac Surgery




Section K - (2) – Specific experience and training
                                                    Indicate date and place of training experience
ATLS / APLS / ALS

Operative skills courses attended
(give details, dates, certificates
awarded


Additional experience post BST –
please give details of what you
have done, why you did it and what
it contributed to your personal
development




Section L - Audit and Management
a)    Please describe your experience of clinical audit. Indicate clearly your own level of involvement
Template 2010 – last amended 10th February 2010     Candidate number : _______________________

b)    Please describe any experience of managing people and/or resources or of working in teams. You may
      give examples from both inside and outside medicine




c)    How does clinical governance apply to Cardiothoracic Surgery?




Section M - Other Achievements
A)COMMUNICATION SKILLS. Illustrate what you think are good features of written communications with GPs and
colleagues. (up to 150 words approximately)
Template 2010 – last amended 10th February 2010       Candidate number : _______________________

B)INTERPERSONAL SKILLS.         Comment on your strengths and weaknesses. (up to 150 words approximately)




Section N- Academic Achievements
a)    Prizes or other academic distinctions




b)    Research, whether past or in progress. If you have undertaken or are undertaking a research project,
      please give details and indicate your involvement (Up to 75 words)
Template 2010 – last amended 10th February 2010        Candidate number : _______________________

c)    Publications (shortlisted candidates will be asked to bring copies of all publications to the interview).
      Please list your best 5 publications with full citation and pubmed number. Please asterisk those for which
      you are first author.




d)    Presentations/posters at conferences




e)    Experience of teaching (including outside medicine)
Template 2010 – last amended 10th February 2010   Candidate number : _______________________

Section O – Aims and career objectives




Section P – Interests, other skills and achievements outside medicine




Section Q – Any further information relevant to this application
Please expand upon one aspect of your training and development so far that you would wish the
appointments panel to know about
Template 2010 – last amended 10th February 2010         Candidate number : _______________________

Section R - Notes
  1     Children and Vulnerable Adults
        Where the appointment involves substantial access to children and /or vulnerable adults, the
        appointment is subject to a police check. The Criminal Records Bureau will be asked to verify that you
        have no convictions and cautions or pending prosecutions, convictions, cautions and bind-over orders.
        This will include local police force records in addition to checks with the Police National Computer and
        the government department lists held by the Department of Health and Department for Education and
        Employment, where appropriate.
  2     Declaration
        If you are related to a member or Senior Officer/Manager of the Trusts involved in the training
        programme, you must disclose such a relationship. You are also required to declare any involvement,
        either directly or indirectly, with any firm, company or organisation which has a contract with Trusts
        involved in the training programme. Failure to declare any information on these matters may result in
        your application being rejected or, if it is discovered after appointment that such information has been
        withheld, then this may lead to dismissal. Please note canvassing of a Senior Officer/Manager shall
        disqualify an applicant. Please state any disclosure/declaration related to the above on a separate
        sheet.

Section S - Equal Opportunities
NHS employers are committed to equal opportunities. No applicants will be discriminated against on
the grounds of colour, race, ethnic origin, nationality, age, disability, gender, sexual orientation, marital
status, religion, or politics.

Section T – Accepting an Appointment
You must take up any post, including a locum post, you have formally accepted unless the employer has
adequate time to make other arrangements. (Good Medical Practice published by the General Medical
           rd
Council – 3 edition, May 2001). Failure to comply with this requirement may result in a complaint to the
GMC.

Section U – Declaration
I confirm that I have completed this application by myself, fairly and honestly, without significant help or input
from other sources. I understand that my application form will be checked in accordance with GMC Good
Medical Practice 2006 (paras 63 - 65) If it is subsequently discovered that any statement is false, misleading or
copied from another source, or that I have withheld relevant information, my application may be disqualified
and/or my employment terminated. This may result in a referral to the General Medical Council or other
relevant professional body.
Having been allocated to a training opportunity, any subsequent contract of employment will be subject to
satisfactory pre-employment checks and subject to the information provided on my application form or any
related documents being correct. Pre-employment checks will be carried out to review and confirm the details
of my application.
I understand that the information I have provided may be used by recruiting officers in post graduate deaneries
and employing organisations to progress my application for a training opportunity; however key personal
information, including monitoring data, will not be made available to shortlisting or interview selection panels. I
understand that the data will be recorded and processed on secure information technology systems by
authorised recruiting staff in order to process and monitor appointments as well as to produce aggregated
recruitment statistics.    Postgraduate deaneries may share information with other deaneries and other
organisations involved in the planning, management and delivery of training. I consent to the recording and
processing of personal data in this way in accordance with the Data Protection Act 1998.
Template 2010 – last amended 10th February 2010              Candidate number : _______________________
    I agree to the above declaration.


Signature4

Name




4
 Please do not complete this signature electronically. If you are invited to interview you may be asked to sign a paper
copy at this stage.
                                                                                                                    Candidate number:____________________________
To the applicant : this shows the scoring system to be used for short-listing from the application form. If the short-listing panel agrees that you have
scored “0” in any of the essential criteria this means that you have not provided sufficient evidence to demonstrate the attribute. You therefore
cannot be shortlisted. You are advised to self-assess yourself prior to application and to seek advice from your educational supervisor if necessary.
This should not be returned with your application. It is for your information only.
                                        THE LONDON DEANERY
         SHORT-LISTING SCORE SHEET –PAEDIATRIC CARDIOTHORACIC JUNIOR SURGICAL FELLOWSHIP
ENTRY CRITERIA                                                          Assessed In Section          YES/NO                      ESSENTIAL CRITERIA
Eligible for registration with the GMC                                             B                 To be confirmed             Has this applicant scored a 0 in any of     YES / NO
                                                                                                     by Deanery                  the essential criteria?
MBBS (or equivalent)                                                               H                                             If an applicant scores 0 in any of the essential criteria, the
                                                                                                                                 application must be discussed at the shortlisting committee
MRCS/FRCS (or equivalent)                                                          H
2 years Basic Surgical Training (or equivalent)                                    I&J
Junior appointment – at least 2 years Higher Surgical Training (or                 I&J
equivalent) in Cardiothoracic Surgery



ESSENTIAL CRITERIA                                Maximum Score      Applicant‟s   Assessed in     DESIRABLE CRITERIA                                         Maximum Score          Applicant‟s
                                                  (Range 0 –2)       score         this Section                                                               (Range 0 – 2)          score
                                                                                   of        the
                                                                                   Application
                                                                                   Form

                                                                                         H         BSc                                                                 1
                                                                                         H         MSc, research MD, PhD. MS                                           2
                                                                                         I&J       Experience in related specialties eg Cardiology, ITU                2
                                                                                                   Respiratory Medicine, Paediatrics, Anaesthetics
                                                                                     I, J & K      Additional experience in Cardiothoracic Surgery                     2
                                                                                         I&J       Appropriate progression of career                                   2
Conduct of Adult Cardiopulmonary bypass                 2                                K         Conduct of Paediatric Cardiopulmonary bypass                        2
Experience as first operator with Adult                 2                                K         Successful completion of ATLS / APLS / ALS                          2
Cardiac Surgery
Experience as first operator with Adult                 2                                K         Operative skills courses attended                                   2
Thoracic Surgery
                                                                                                              Candidate number:____________________________
ESSENTIAL CRITERIA                            Maximum Score   Applicant‟s   Assessed in     DESIRABLE CRITERIA                                    Maximum Score   Applicant‟s
                                              (Range 0 –2)    score         this Section                                                          (Range 0 – 2)   score
                                                                            of        the
                                                                            Application
                                                                            Form

Experience of Audit                                 2                          L (a)        Active involvement in Audit                                 2
Experience of working in multi-professional         2                          L (b)
teams
                                                                               L (c)        Management/financial awareness, exp of committee            2
                                                                                            work, understanding of the NHS, clinical governance
                                                                                            and resource constraints
Communication skills                                2                          M (a)
Interpersonal skills                                2                          M (b)
                                                                               N (a)        Prizes, honours                                             2
                                                                               N (b)        Research experience                                         2
                                                                               N (c)        Publications in Cardiothoracic journals                     2
                                                                               N (d)        Presentations                                               2
Experience of teaching                              1                          N (e)        Enthusiasm for teaching, exposure to different              2
                                                                                            groups/teaching methods
Demonstrates analytical/scientific approach         2                           AF          Breadth of awareness                                        2

Total number of points (Maximum - 48) Points scored ______________________ Shortlister:___________________________
                                                                                                       Signature:______________________________
Please note that if an applicant achieves this score he/she will not automatically be short-listed. This is the minimum standard which must be achieved,
but the final shortlist for interview will also reflect the ranking of applicants applying on this occasion. Any attributes which are evaluated on the basis of
the application form alone may be further explored at the interview stage

				
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