Intern-Training-Verification-Form

MEDICAL COUNCIL OF IRELAND REFERENCE NUMBER (IF KNOWN):

INTERN TRAINING VERIFICATION FORM
VERIFICATION OF INTERN TRAINING BENCHMARKED AGAINST THE MEDICAL COUNCIL OF IRELAND CRITERIA FOR AWARDING A CERTIFICATE OF EXPERIENCE To be completed by a person responsible for intern training at the training site/hospital.

Name of Intern: Date of Birth: Name of training site (eg. hospital): Number of Intern trainees at the training site : Address of training site:
Line 1: Line 2: Line 3: Line 4: City/State/County/Country:

PLEASE USE BLOCK CAPITALS DD / MM / YYYY PLEASE USE BLOCK CAPITALS

Contact Details of Signatory: Phone: Fax:

(PLEASE INCLUDE INTERNATIONAL CODES)

E-mail address: Type of rotation(s) How many months’ internship training were completed at the training site and in which specialty/ies? SPECIALTY ROTATION ROTATION ENDED TOTAL DURATION OF COMMENCED ROTATION (MONTHS) M M Y Y Y Y M M Y Y Y Y M M M M M M M M M M M M M M M M M M Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y M M M M M M M M M M M M M M M M M M Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Language/s through which internship was completed:

INTERN TRAINING VERIFICATION FORM – MEDICAL COUNCIL OF IRELAND

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MEDICAL COUNCIL OF IRELAND REFERENCE NUMBER (IF KNOWN):

I, the undersigned declare and confirm the following:

(Please tick only if applicable)

The training site where the person named on page 1 of this form (hereinafter called “the intern”) completed the internship training rotation(s) outlined on page 1 of this form is affiliated with a recognised medical school and / or a postgraduate training network which is accredited by the relevant authorities in this country. The intern’s training comprised a combination of, and integration between, formal and informal training, practical and theoretical learning, and training and service delivery. The intern’s training comprised the following:  Practice-based training involving personal participation, at an appropriate level, in the services and responsibilities of patient-care activity in the training institution;  Personal participation at an appropriate level in all medical activities relevant to the training, including oncall duties;  The opportunity to exercise the degree of responsibility and clinical decision-making appropriate to the intern’s growing competency, skills, knowledge and experience  The opportunity to work as part of a team composed of a variety of disciplinary backgrounds. The intern participated in regular, pre-arranged formal education and training sessions, with learning opportunities including lectures, small group tutorials, case presentations and discussions, the opportunity to participate in clinical audit, and external courses. The intern completed his/her internship training under the supervision of the following clinician(s) who is/are of an appropriately senior level and is/are recognised as a specialist by the regulatory authority of the host country:
SUPERVISING CONSULTANT(S)

The training site(s) emphasised professionalism and the development and maintenance of the relevant knowledge, skills, attitude and behaviour. The intern was made aware of and complied with any ethical guidance provided by the relevant competent authority in this jurisdiction and / or the ethical guidance provided by the Medical Council in Ireland (insert hyperlink) The intern received regular and constructive feedback and assessment by his/her trainer / supervisor. This / these training site(s) provided the intern with access to a sufficient number of patients and an appropriate case mix that gave him/her exposure to a broad range of appropriate clinical cases. The intern was afforded the space and opportunity for private study and access to adequate professional literature, including on-line access. The above-named training site has sufficient resources for the number of interns on site The intern had access to counselling and advice on ethical issues in the event of work-related or personal problems. I confirm that the intern made satisfactory progress during his/her internship training and passed all relevant examinations (where applicable). Signed: ______________________________________ Date: _____________________

Name of Signatory: ______________________________________________________________
(Block Capitals)

Authority of Signatory: __________________________________________________________

INTERN TRAINING VERIFICATION FORM – MEDICAL COUNCIL OF IRELAND

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