ENTRY INTO SPECIALTY TRAINING USING THE CESR (CP) ROUTE DETAILS OF PREVIOUS POSTS IN OBSTETRICS & GYNAECOLOGY PRIOR TO APPOINTMENT TO NTN

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1 ENTRY INTO SPECIALTY TRAINING USING THE CESR (CP) ROUTE DETAILS OF PREVIOUS POSTS IN OBSTETRICS & GYNAECOLOGY PRIOR TO APPOINTMENT TO NTN PERSONAL DETAILS Trainee name Surname Forename(s) NTN Details NTN Date commenced In programme ST level on entry to programme Provisional CESR (CP) date Please include details of ALL POSTS that have been agreed as counting towards specialist registration via the CESR (CP) route, at the time of appointment to the specialty training programme Type of Appointment (for example FTSTA, LAT, FTTA, LAS, Clinical Fellowship, SHO, overseas SHO or registrar, Staff Grade, etc) For EACH post, confirm if PMETBrecognised Hospital Location Date from Date to Number of months recognised towards training & specialist registration For each GMC-recognised training post, please circle RITA or ARCP to confirm satisfactory progress OR For each non-gmc approved post, HOS (or delegated representative) to sign & confirm that the time which is to counting towards training has been assessed and is appropriate

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3 CONFIRMATION BY THE TRAINEE A. I confirm that the details above are correct B. I am aware that I am following the CESR (CP) route to Specialist Registration in the UK Signed (Trainee signature) Date CONFIRMATION BY THE HEAD OF SCHOOL A. I confirm that the non-gmc approved posts included in the list above, were assessed as being suitable to count towards Specialist Registration at or near the time of appointment to the Deanery Specialty Training programme in Obstetrics and Gynaecology Signed Date Name Position

4 THE CESR (CP) ROUTE - CONFIRMATION OF COMPETENCES This first page reviews the applicant s progress relative to the competences required to enter training at ST3 level or above For those entering at ST2 level, there should be appropriate progression towards attainment of these specific competences This form must be completed by the Trainer/Educational Supervisor in the unit from which the applicant applied to enter specialty training GENERAL REQUIREMENTS & PRACTICAL SKILLS GENERAL REQUIREMENTS Date Name of Trainer/Educational Supervisor Signature of Trainer/Educational Supervisor Attainment of Part 1 of the MRCOG examination Completion of RCOG BPS (Basic Practical Give details of course (include name of course, venue, country, date): Skills) course or equivalent PLEASE CONFIRM IF THE APPLICANT CAN UNDERTAKE EACH OF THE FOLLOWING PROCEDURES INDEPENDENTLY (ALL SHOULD BE ACHIEVED FOR ENTRY AT ST3 LEVEL) Procedure Opening and closing the abdomen Insert tick () to confirm competence achieved & independent practice - otherwise leave blank Name of Trainer/Educational Supervisor Signature of Trainer/Educational Supervisor Uncomplicated acute and elective caesarean section Non-rotational operative vacuum delivery Manual removal of placenta CTG Interpretation (intrapartum electronic fetal monitoring) Management of shoulder dystocia Management of cord prolapse Perineal repair Fetal blood scalp sampling Uncomplicated surgical uterine evacuation Non-rotational forceps delivery

5 REVIEW OF RCOG LOGBOOK COMPETENCES 1. Applicants & trainers must review each logbook module: see RCOG website 2. The unshaded boxes in the RCOG logbook are basic competences and all of these should be achieved for entry at ST3 level or above 3. For each logbook module, confirm that appropriate progression has been made for the planned level of application to specialty training RCOG LOGBOOK MODULES - CONFIRMATION OF APPROPRIATE PROGRESSION FOR LEVEL OF APPLICATION Logbook Module Appropriate progression (tick ) Name of Trainer/Educational Supervisor Signature of Trainer/Educational Supervisor 1 Basic Clinical Skills 2 Teaching Appraisal and Assessment 3 Information Technology, Clinical Governance and Research 4 Ethics and Legal Issues 5 Core Surgical Skills 6 Postoperative Care 7 Surgical Procedures 8 Antenatal Care 9 Maternal Medicine 10 Management of Labour 11 Management of Delivery 12 Postpartum Problems (the puerperium) 13 Gynaecological Problems 14 Subfertility 15 Women s Sexual and Reproductive Health 16 Early Pregnancy Care 17 Gynaecological Oncology 18 Urogynaecology and Pelvic Floor Problems 19 Professional Development

6 FINAL CONFIRMATION OF APPROPRIATE PROGRESS AND ACHIEVEMENT OF COMPETENCES We confirm that there has been an assessment of each competence listed on page 1 of this form We confirm that the applicant is competent in the individual procedures that have been ticked and signed up on page 1 of this form We confirm that direct reference has been made to each logbook module referred to on page 2 of this form (see RCOG website - ) We confirm that the applicant has made appropriate progress towards achieving the logbook modules as signed up on page 2 of this form We are aware that the information in this document will be used to ensure that the applicant is placed at the correct training level on appointment to the Specialty Training programme using the CESR (CP) route to specialist registration Date Name of Applicant Signature of Applicant Date Name of Trainer/Educational Supervisor Signature of Trainer/Educational Supervisor Position of Trainer/Educational Supervisor Name of Trainer s Hospital (include City and Country)