Prof. Gian Battista Parigi
EBPS Secretary
Chirurgia Pediatrica
IRCCS Policlinico "S.Matteo"
27100 Pavia
Italy
UNION OF EUROPEAN MEDICAL SPECIALISTS
UNION EUROPEENNE DES MEDECINS SPECIALISTES
SECTION OF PAEDIATRIC SURGERY
APPLICATION FORM
FOR RECOGNITION OF TRAINING PROGRAMME AT:
NAME OF CENTRE: __________________________________________________
This form should be returned to:
SPECIALIST TRAINING PROGRAMME IN PAEDIATRIC SURGERY
This form should be completed by any Paediatric Surgical Centre (hospital or group of hospitals) seeking recognition for a training programme.
The information requested on the form must be given as fully as possible. When completed the form is sent to the National Member Association of the U.E.M.S. for final approval and the last page of the form is completed before returning it to the Certification Secretary of the E.B.P.S.
The Executive Committee will consider the application. When this has been completed the Centre may be visited by representatives of the E.B.P.S. The Executive will recommend to the U.E.M.S. (Paediatric Section) whether recognition will be granted and to what extent.
Name and address of Hospitals included in the Training Programme:
University affiliation:
________________________
STAFFING:
(a) Consultants directly responsible for the training programme
(i) NAME:
QUALIFICATIONS, including names of awarding body e.g. University or College:
YEAR OF APPOINTMENT AS CONSULTANT,.
NO. OF PAEDIATRIC SURGICAL SESSIONS (1 session = 3 hours) or total number of Paediatric Surgical Hours per week.
SPECIAL INTERESTS:
STAFFING (a) Continued:
(ii) Continue details as for (i)
________________________
STAFFING (b)
Other consultant staff contributing to training programme (e.g. Anhaestesia, Radiology, Urology (non-paediatric surgeon9 Haematology/Oncology, Histopathology, Clinical Microbiology / Biochemistry, Genetics, Paediatrics)
NAME
SPECIALTY
No of Paediatric Sessions (1 session = 3 hours) / or total number of Paediatric hours
________________________
Current non-consultant staff (Training Grades) in paediatric surgery in Hospital or Group:
(Qualifications should be given
(lf your grading is different to outline below please specify)
Pre-registration House officers (Intern):
________________________
Senior House Officers:
Registrars:
Senior Registrars:
Please addend the weekly time table for each trainee to the back of this form (Appendix 1).
________________________
OTHERS :
Training Grade Staff in Anaesthesia working in the Unit:
________________________
CLINICAL FACILITIES
Total number of children's beds: .............................
Paediatric Surgical:
Other surgical Paediatric:
Medical:
Patient Statistics: (most recent full year)
Total General Surgical Paediatric ADMISSIONS (excluding Day Cases):
Paediatric Surgical Day Cases: ..............................
Index Cases:
a) Neonatal admissions under surgical care: ...............
(Please give diagnostic breakdown:)
b) Non-neonatal: .................. ..........
Acute non-specific abdominal pain
Acute appendicitis (Appendectomy)
Bladder augmentation
Bronco-oesophagoscopy
Central line insertion (Non-percutaneous)
C.S.F. shunt insertion/revision
Fundoplication
Hypospadias
Intussusception (all cases)
Intussusception (Surgery)
Malignant disease
Resection Wilm's
Resection Neuroblastoma
Orchidopexy
Pelvi-ureteric junction obstruction
Pull through operation:
ureteric re-implant
c) Other major surgery (please specify)
________________________
State what facilities exist for training in the following:
Burns:
Cardio/thoracic Surgery:
Ear, Nose & Throat Surgery:
lnjuries (excluding burns and orthopaedics):
Neurological Surgery:
Orthopaedics:
Plastic Surgery:
Urology:
________________________
TEACHING PROGRAMME FOR TRAINEES IN PAEDIATRIC SURGERY:
Please indicate titles/frequency of meetings:
SURGICAL AUDIT,
Please give details of your surgical audit:
LIBRARY
What library facilities are available?
Give details including library staff:
What commitments have the trainees in paediatric surgery f or the teaching of:
a) Nurses
b) Under Graduates
c) Post Graduates
What opportunities exist for clinical or laboratory research?
________________________
Please addend paediatric surgical publications from the centre for the past 3 years:
Appendix (ii)
________________________
The hospital authority agree to pay reasonable expenses for the visiting consultants who will make the site visit to assess the unit?
Signed on behalf of the Hospital by the Surgeon/Surgeons in Administrative Charge of Training Programme
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
and by the appropriate district or regional administrator or hospital secretary
___________________________________________________________________
Date- ____________________________
Form to be filled in by the National Body responsible for UEMS affairs:
We have reviewed the application form for _________________________________
___________________________________________________________________
and believe this to be a true reflection of the current situation at
___________________________________________________________________
and that it is a suitable centre for consideration for Paediatric Surgical Training.
