Please select the highest academic achievement you have been awarded

Academic Achievements

Please select the relevant option

• PhD/MD OR first-class honours achievement for additional undergraduate degree
• Undergraduate degree prior to starting medicine OR MSc obtained after qualifying
• No additional undergraduate degree or qualification

Qualifications

• Subject
• Place of study
• Grade/Result
• Undergraduate or Postgraduate
• Date Qualification awarded

Please select the appropriate option and then complete the boxes below where you enter details of any prizes, awards and other distinctions.

Relevant additional achievements and prizes

Please select the most appropriate option

• National prize or award since qualifying
• Undergraduate or Postgraduate academic achievement (e.g. prize, distinction, merit etc)
• Scholarship/Bursary or equivalent
• No additional undergraduate achievements

Name of Prize/Award from selection above

Awarding body

Date awarded

Please select the highest option on the list that applies to you. After you have selected your option please complete the subsequent sections with details of presentations and posters you have delivered at either international, national, regional or local levels.

Where you have multiple presentations/posters within a field, please put the most recent first.

Include: Title of presentation/article/poster, name of meeting delivered, references, details of your contribution eg first author, joint lead, co-author, or contributor.

Presentations, posters or publications

Please select the most appropriate option

• Presentation of research at annual meeting of a national or international medical body OR first author in published paper
• Presentation of research at a regional meeting OR a poster at a national/international meeting OR co-author in a published paper
• Presentation of research or audit at a Trust meeting (not internal teaching) OR co-author in an abstract or paper submitted for publication
• No presentations, posters or publications

Presentations

Presentations at local level (250 words)

Presentations at regional level (250 words)

Presentations at national level (250 words)

Presentations at International level (250 words)

Publications

Publications as first author - Please include title, name of journal, references and date of publication (250 words)

Publications as joint first author- Please include title, name of journal, references and date of publication (250 words)

Publications as co-author - Please include title, name of journal, references and date of publication (250 words)

Publications as named collaborator- Please include title, name of journal, references and date of publication (250 words)

Posters

Posters delivered at local level (250 words)

Posters delivered at regional level (250 words)

Posters delivered at national level (250 words)

Posters delivered at International level (250 words)

In the following section please provide details of any teaching you have provided. For each teaching post give details on the Course title, topic, methodology, target audience, length of time you taught and feedback you have received.

Teaching

Please select the most appropriate option that applies to your teaching experience

• Extensive teaching experience of peers, students, nurses, non-clinicians AND/OR formal training in teaching methodology (eg PGCertEd, MSc in MedEd)
• Designed or led local teaching OR was tutor for medical student group OR has been nominated to be a Life Support Course Instructor
• Taught mainly students
• No experience of delivering teaching

Please provide details of your teaching posts- what level you taught at, how long for and any feedback you have received (250 words)

Research Audit and Quality Improvement

Please select the most appropriate option. Following this please list any audits and/or quality improvement projects (QIP) you have completed and the outcomes in the sections below

• Has completed an audit project / QIP. Has evidence of designing and leading an audit - including re-audit and implementation of recommendations
• Designed or led a completed audit project / QIP
• Currently completing an audit project / QIP
• No evidence of having participated in an audit project / QIP

Research- Include title, outcome and personal role. (250 words)

Audit- Include title, outcome and personal role. (250 words)

Quality Improvement - Include title, outcome and personal role. (250 words)

Please select the relevant option that is most applicable to you.

After this, please give details about your activities and achievements which demonstrate your commitment to the ACCS Emergency Medicine programme.

Please select the most relevant option of your achievements specific to ACCS Emergency Medicine

• Has passed MCEM Part A OR has attended EM specific conferences/training days OR presented at specialist society meetings
• Is sitting MCEM part A OR did a student elective or taster in EM OR Member of specialist society
• No evidence of participation in the EM world

Please provide evidence of activities and achievements which demonstrate your commitment to the EM ACCS programme. How will this programme benefit your career as an Emergency Physician. (250 words)

Outstanding Achievements Outside Medicine

Please select the option that is more applicable to you

• Outstanding personal/sporting/creative/operational/innovative achievement at international level
• Outstanding achievement at national level
• Outstanding achievement at personal level OR student achievement/representation at national level where the extent of the achievement is unclear or limited OR not specific
• No relevant outstanding achievements

List any positions of responsibility you have held outside medicine. (250 words)

Evidence of competencies (workplace based assessments (WBA), multi-source feedback (MSF), educational supervisor reports

Which of the following assessments have you got evidence from based on assessment of your practice in the 12 months prior to completing this form:

• Select all
• Educational supervisor reports
• Multi-source feedback report
• Workplace based assessment 7. Training Courses

Please give details of the relevant training courses you attended.

Please include the course title, organisation body and date for each course. Separate each course you have carried out by starting a new line eg

Course 1 title of course, organising body name, date completed

Course 2 title of course, organising body name, date completed

Course 3 title of course, organising body name, date completed

Please advise how many training courses you have completed

Please provide details for each course. You must include Course name, organisation body and date course completed 8. Do you have any additional skills that can support your application

Please provide details of any skills you feel is relevant towards your career in ACCS EM Please outline any additional skills (250 words)