Training Programme in Radiology

Faculty of Radiologists

Training Programme in Radiology

Training Programme in Radiology

Commencing xth July xxxx

APPLICATION FORM

Closing Date: xxxxx

Please read the enclosed guidelines carefully prior to completing the application form.

This application must be submitted unbound and stapled but in the correct order as per
page numbers

APPLICANTS NAME:________________________________

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 Training Programme in Radiology
GUIDELINES (read carefully)
General:
Administration Fees: €50.00 (Non-refundable)
Commencement Date: xxxx
Title of Post: Specialist Registrar (SpR) in Radiology
Duration of Programme: Five Years (subject to satisfactory continuous assessments)
Curriculum: [Link]

Approved Hospitals:
 Beaumont Hospital, Dublin  St. Vincent’s University  St. James Hospital, Dublin
Hospital, Dublin
 Adelaide / Meath Hospital,  Mater Misericordiae University  Galway University Hospital
Tallaght Hospital, Dublin
 Cork University Hospital, Cork  Mercy University Hospital,  Waterford University Hospital
Cork

Additional hospitals throughout Ireland may be accredited during the course of your training. Successful candidates may
be required to rotate between training hospitals.

Entry Requirements:
 For Radiology, all applicants must have, as a minimum, at least 2 years clinical experience.
o One year as an intern and 1 year as an SHO is the minimum acceptable pre-Radiology training.
 All candidates must be registered or eligible for registration with the Irish Medical Council
([Link])
 Candiates must meet the English Language requirements as detailed our on website before applying for the
training scheme ([Link]
[Link])

Salary:
In accordance with approved Department of Health scales ([Link]/publications)

Application Conditions & Procedures:

A complete application consists of the following: 1 credit card form submitted in a sealed envelope, 3 sealed
references, 2 passport photos, 4 application packs each including an application form, applicant declaration
form and all supporting documentation and a full curriculum vitae.

Applications must include all of the following together by post:

 4 copies of completed application form (unbound and stapled in correct order as per page numbers)
 4 copies of applicant declaration form
 4 copies of your full curriculum vitae
 Two passport size photographs
 Original Structured reference forms X 3 (form attached)
 4 copies of Transcripts of Medical School Results
 4 copies of Verification of your decile /centile place within graduating class
 4 copies of Verification of other relevant Degree(s) / Diplomas / Professional Examinations
 4 copies of Verification of Publications, Reviews, Case Reports, Book Chapters to include PubMed reference
page and copy of front page of published work. Publications accepted for publication but not published require
a letter from the editor confirming acceptance for publication of the piece. The acceptable letter should
reference the author’s position on the paper and title of work. Work in progress is not accepted.
 4 copies of Verification of presentations and research prizes.
 Please provide evidence of your eligibility to be on the Trainee Specialist Division of the Irish Medical Council
(Please refer to guideline documents on our website). Evidence includes:
o Certificiate of experience from Irish Medical Council
o Registration certificate
o Email from Irish Medical Council attesting your eligibilty for Trainee Specialist Division
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 Training Programme in Radiology
o If you were previously registered for Trainee Specialist Division then a copy of that registration
certificate is acceptable.
 English Language Competency
All applicants are required at the time of application to demonstrate their English language competency either
by means of submitting the required IELTS Certificate or by declaring themselves exempt under one of the
exemptions outlined in the guidance document and providing the required documentary evidence of same
(Please refer to guidelines on our website).
 All applicants will be required at the time of application to submit a colour scanned copy of their passport and,
as appropriate, a colour scanned copy of the current immigration stamp held by the applicant from the Irish
Naturalisation and Immigration Service and / or a scanned copy of the applicant’s current Certificate of
Registration from the Garda National Immigration Bureau (GNIB card). (See statement by INIS outlining recent
changes to immigration arrangements for doctors working in the public hospitals on our website)
 €50.00 administration fee in separate sealed envelope (payable to Faculty of Radiologists by cheque, bank draft
or credit card - authorisation form enclosed). Please note this fee is non-refundable. Applications will not be
accepted without payment.

Structured Reference Forms: It is the responsibility of the candidate to ensure that the structured reference
forms(x3) are submitted to the Faculty of Radiologists on or before the closing date:

Verification of the above items are required for awarding points for the selection process. Failure to submit these items
with your application form will result in you losing out on points you may be entitled to otherwise. Under no
circumstances will marks be given after the shortlisting.

Applications or parts of applications are not accepted by email or fax. Any such documents received by this method will
be discarded.

Shortlisted applicants will be required to bring their offical logbook and certificates along to the interview.

Please be aware that all references and verifications documentation will be made available to interview panel.

It is the responsibility of the applicant to ensure that all documentation is provided at the time of submission.

Selection Process:
Applicants shortlisted for interview will be notified in writing and any additional information required will be requested at
that time. Please ensure accurate and full completion of the application form as scoring will be based solely on this.
Your Curriculum Vitae will only be reviewed at the interview stage.

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 Training Programme in Radiology

Dates for your diary:

Closing Date: xxxxx
Provisional Interview Date: xxxxx

Completed applications to:

Faculty of Radiologists Queries to:
Royal College of Surgeons in Ireland
123 St. Stephens Green Email: radiology2@[Link]
Dublin 2 Phone: 01-4022476
Ireland

Hospital Coordinators

Applicants are encouraged to visit the above hospitals and to discuss the training programme with the Hospital
Coordinators.

Adelaide/ Meath Hospital, Tallaght (Dr. Emily Ward) Ph: +353-1- 4143752
Beaumont Hospital (Dr. Mark Given) Ph: +353-1-8093001
Cork University Hospital (Dr. Sean McSweeney) Ph: +353-21-4922256
Mercy University Hospital (Dr. Marie Staunton) Ph: +353-21-4271971
Galway University Hospital (Dr. AnnaMarie O’Connell) Ph: +353-91-544491
Mater Misericordiae University Hospital (Dr. Michelle McNicholas) Ph: +353-1-8032274
St. James's Hospital (Dr. Susannah Harte) Ph: +353-1-4537941
St. Vincent’s University Hospital (Dr. Jeffrey McCann) Ph: +353-1-2213895
Waterford University Hospital (Dr Lorna Hanlon) Ph: +353-51 848 000

National Training Coordinator (Dr. Ian Murphy, Tallaght Hospital)

Should you be successful in obtaining a position on the Faculty of Radiologists Training Programme, you will
be required to fomally write to both the Faculty and your employing hospital (Human Resources Department or
Medical Manpower) within one month of the offer to confirm that you are accepting the training post. If you
have not notified both the the Faculty and to your employing hospital (Human Resources Department or
Medical Manpower) within the month, the offer will be withdrawn.

Any attempt to provide misleading or false information to improve your score in shortlisting or interview will
result in automatic disqualification.

SECTION N - SIGNATURE

I declare that to the best of my knowledge and belief that all the particulars furnished in connection with this application
are true and accurate. I understand that I may be required to submit documentary evidence in support of any particulars
given by me on my Application Form. I understand that any false or misleading information submitted by me may render
any offer of a training position and associated employment offers as null and void.
Signature Date

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 Training Programme in Radiology

Section One: Personal Details

APPLICANT DETAILS
Name
Title:

First Name:

Surname:

Personal Details
Date Of Birth:

Age:

Place Of Birth:

Nationality:

Contact Details (Telephone & Email)

Home:

Work:

Mobile:

Email:

Current Mailing Address

REGISTRATION (VERIFICATION REQUIRED)

(PLEASE REFER TO WEBSITE FOR GUIDELINES ON ELIGIBILITY FOR TRAINEE SPECIALIST DIVISION)
Registration General Trainee Registration Number
Specialist

Irish Registration (IMC):

UK Registration (GMC):

Other (please specify):

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 Training Programme in Radiology

ENGLISH LANGUAGE COMPETENCY (PLEASE REFER TO GUIDELINES ON OUR WEBSITE)

All applicants are required at the time of application to demonstrate their English language competency either
by means of submitting the required IELTS Certificate or by declaring themselves exempt under one of the
exemptions outlined in the guidance document and providing the required documentary evidence of same
(Please refer to guidelines on our website)

Do you qualify under any of the exemption grounds – YES or NO

If Yes, which ground?

Tick appropriate box

Country of Graduation
Registered with Medical Council prior to 1st January 2015

Have you attached documentary evidence of the above ground ?– YES or NO

If you do not qualify for exemption have you attached the required IELTS results?

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PLEASE SPECIFY ANY POSTGRADUATE QUALIFICATIONS / MEMBERSHIP YOU HAVE OBTAINED

(VERIFICATION REQUIRED)
Qualification Date College

EMPLOYMENT HISTORY (PLEASE PLACE IN CHRONOLOGICAL ORDER AND ENTER ANY PERIODS OF TIME NOT
EMPLOYED)

Hospital: Specialty Interest Consultants: Duties undertaken Dates:

and Grade (From – To)

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 Training Programme in Radiology

Section Two:
A.1 Educational & Academic Achievements
MEDICAL SCHOOL ACHIEVEMENTS (*EVIDENCE REQUIRED TO BE SUBMITTED)

Date College Course

Honours Degree*

Please specify 1st or 2nd Class

Direct or Graduate Entry
(Mandatory Field)
Are you a CAO/HEA graduate Yes No
of an Irish Medical School?
A CAO/HEA graduate is defined as a trainee who
was entitled to free fees in an Irish Medical
School and accessed the programme through the
CAO process. Any student who was required to
pay fees to access their degree is not considered
a CAO/HEA graduate.

Decile / Centile Place within

Graduating class*
(Evidence required)

Honours in Clinical Subjects* Subject Yes No

Medicine

Surgery

Paediatrics

Obstetrics & Gynaecology

Honours in Pre-Clinical
Subjects*

Please list subjects

Undergraduate Prizes*

POSTGRADUATE ACHIEVEMENTS (*EVIDENCE REQUIRED TO BE SUBMITTED)

Qualification Yes/No Level Achieved Date College

MRCPI*

AFRCSI*

BSc*

USMLE*

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 Training Programme in Radiology
Qualification Yes/No Level Achieved Date College
MSc/PDip in
Multidisciplinary Radiology

Other*

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PLEASE INDICATE IF YOU HAVE COMPLETED A BST PROGRAMME (OR WILL COMPLETE IF APPOINTED)
Speciality

Commencement date
Completion (expected completion) date

Where

PLEASE SPECIFY ANY OTHER RELEVANT DEGREE/S YOU HAVE OBTAINED (EVIDENCE REQUIRED TO BE SUBMITTED)

Qualification Date from: Date to: College

PLEASE SPECIFY ANY RELEVANT DIPLOMA/S YOU HAVE OBTAINED (EVIDENCE REQUIRED TO BE SUBMITTED)

Qualification Date from: Date to: College

Skill Courses e.g. ACLS, ATLS, BLS etc

Name of Course Location & Provider of Course Date

Academic Distinctions
Please give details i.e. name and brief description, of any prizes, medals or scholarships received

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A.2 RESEARCH / EXTRACURRICULAR

1. PUBLICATIONS / PRESENTATIONS / RESEARCH

PUBLICATIONS
ORIGINAL PUBLISHED PEER-REVIEWED SCIENTIFIC PAPERS
(EVIDENCE REQUIRED TO BE SUBMITTED, IF THE ARTICLE IS NOT IN PRINT THEN A LETTER OF FINAL ACCEPTANCE FROM THE JOURNAL IS REQUIRED, OTHERWISE DO NOT
ENTER REFERENCE)

Name of Journal (International) Impact Title of Paper Reference PMID Number Author Status (i.e. 1st,
Factor Senior, 2nd )

Name of Journal (National) Impact Title of Paper Reference PMID Number Author Status (i.e. 1st,
Factor Senior, 2nd )

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ORIGINAL PUBLISHED NON PEER-REVIEWED SCIENTIFIC PAPERS

(EVIDENCE REQUIRED TO BE SUBMITTED, IF THE ARTICLE IS NOT IN PRINT THEN A LETTER OF FINAL ACCEPTANCE FROM THE JOURNAL IS REQUIRED, OTHERWISE DO NOT
ENTER REFERENCE)

Name of Journal (International/National) Impact Title of Paper Reference PMID Number Author Status (i.e. 1st,
Factor Senior, 2nd )

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BOOK CHAPTERS (EVIDENCE REQUIRED TO BE SUBMITTED. NO LEAFLETS OR HOSPITAL AND PATIENT INFORMATION IS ACCEPTED)

Chapter Title Book Title Publisher Author/s Date & Pages ISBN
(In order)

INVITED REVIEW ARTICLES IN PEER REVIEW JOURNALS (EVIDENCE REQUIRED TO BE SUBMITTED)

Review Title Journal Reference Impact Factor PMID No. Author Status

CASE REPORTS (EVIDENCE REQUIRED TO BE SUBMITTED)

Title Journal Reference Impact Factor PMID No. Author Status

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 Training Programme in Radiology
PRESENTATIONS - POSTER

INTERNATIONAL (EVIDENCE REQUIRED TO BE SUBMITTED)

Name of Meeting Date Venue Title of Presentation

PRESENTATIONS – POSTER

NATIONAL (EVIDENCE REQUIRED TO BE SUBMITTED)

Name of Meeting Date Venue Title of Presentation

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PRESENTATIONS – ORAL

INTERNATIONAL (EVIDENCE REQUIRED TO BE SUBMITTED)

Name of Meeting Date Venue Title of Presentation Did you
present the
paper or
presentation?

PRESENTATIONS – ORAL

NATIONAL (EVIDENCE REQUIRED TO BE SUBMITTED)

Name of Meeting Date Venue Title of Presentation Did you
present the
paper or
presentation?

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 Training Programme in Radiology
PRIZES AND RESEARCH GRANTS
INTERNATIONAL (EVIDENCE REQUIRED TO BE SUBMITTED)
International Research Prizes / Grants Date Amount

PRIZES AND RESEARCH GRANTS

NATIONAL (EVIDENCE REQUIRED TO BE SUBMITTED)
National Research Prizes / Grants Date Amount

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 Training Programme in Radiology
ADDITIONAL INFORMATION (EVIDENCE REQUIRED TO BE SUBMITTED)
If you wish to include any additional information relating to your application please use the space provided below
(i.e. teaching experience, membership of societies, audit experience, management experience, IT experience)

EXTRA-CURRICULAR INTERESTS, HOBBIES

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STRUCTURED REFERENCES

Applicants are required to submit three structured referee assessement forms (attached) with their application. Reference
forms must relate to recent appointments (i.e. no more than three years old).

REFEREES
Please give the name, job title and address of the three referees who will provide you with a reference. One of
these referees must be your present or most recent supervising consultant.

Please note that all referees must use the standard reference template provided by the training body. All
references must be supplied in an enclosed envelope which the referee has signed across the seal.
Referee Number One Referee Number Two
Name: Name:
Title: Title:
Clinical Site: Clinical Site:

Phone: Phone:
Fax: Fax:
E-mail:
E-mail:

Referee Number Three

Name:
Title:
Clinical Site:

Phone:
Fax:
E-mail:

Any attempt to provide misleading or false information to improve your score in shortlisting or interview will result
in automatic disqualification.

I certify that all information provided in this application is, to the best of my knowledge true and accurate.

Signature: Date:

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NOTES
Please read the following notes carefully and confirm your understanding of each and every one.
Please confirm that you understand that if your application is successful, that this
application form in its entirety and your appraisal / reference forms will be made available
to the relevant employers / clinical sites who facilitate the delivery of this specialist training  Yes  No
programme.

Please confirm that you understand that if your application is successful, that in addition to
meeting the requirements of the training body, participation in this programme throughout
its duration is dependent on you meeting the relevant employers’ requirements. Such
requirements include formal Garda and Police clearance as required, induction,
satisfactory completion of occupational health assessments and provision in a timely
manner of the relevant documentation required by employers for employment purposes.  Yes  No
Failure to meet the requirements of any relevant employer may result in your removal from
the programme as you will be unable to assume training slots required for participation in
this programme.

Please confirm that you understand that any information supplied by you in this form may
be held on computer.  Yes  No

DECLARATIONS
Please read the following three declarations carefully and sign and date your agreement with the text of each of the
declarations.

Declaration One - Garda/Police

• I declare that I have not at any time been convicted (i.e. probation, fine, sentence, penalty) of a criminal offence (e.g.
assault, public order, sexual assault) in the Republic of Ireland and/or in any other jurisdiction nor are there any charges
relating to criminal offences outstanding or pending. I have never been the subject of a Caution or Bound over order. I accept
that making a false or misleading declaration may render any offer of a training position and associated employment offers as
null and void.

Signed: __________________________ Date:_______________

OR

• I declare that I have been convicted (i.e. probation, fine, sentence, penalty) of a criminal offence (e.g. assault, public order,
sexual assault) in the Republic of Ireland and/or in any other jurisdiction. I have been the subject of a Caution or Bound over
order. Please provide the details of same in the table below. I accept that making a false or misleading declaration may render
any offer of a training position and associated employment offers as null and void.

Date Court Country Offence Court Outcome

Signed: __________________________ Date:_______________

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Declaration Two - Training Organisation / Programme

• I declare that I currently am not nor was I the subject of an investigation by any professional medical training body or its
equivalent in the Republic of Ireland and/or in any other jurisdiction. I accept that making a false or misleading declaration
may render any offer of a training position and associated employment offers as null and void.

Signed: __________________________ Date:_______________

OR

• I declare that I currently am or was the subject of an investigation by a professional medical training body or its
equivalent in the Republic of Ireland and/or in any other jurisdiction. Please provide the details of same in the table below.
I accept that making a false or misleading declaration may render any offer of a training position and associated employment
offers as null and void.

Date Organisation Offence Status/Outcome

Signed: __________________________ Date:_______________

Declaration Three - Medical Council/Licensing Body

• I declare that I am not nor have I been the subject of any investigation by a medical registration or licensing body or
authority in any jurisdiction with regard to my medical practice or conduct as a practitioner. I have not been suspended
from registration, nor had any restrictions on practice nor had my registration or licence cancelled or revoked by any
medical registration or licensing body or authority in any jurisdiction nor am I the subject of any current suspension or
any restrictions on practice. I accept that making a false or misleading declaration may render any offer of a training
position and associated employment offers as null and void.

Signed: __________________________ Date:_______________

OR

• I declare that I am or was the subject of an investigation by a medical registration or licensing body or authority in any
jurisdiction with regard to my medical practice or conduct as a practitioner. I am or have been suspended from
registration, have/had restrictions on practice and/or my registration or licence cancelled or revoked by a medical
registration or licensing body or authority in any jurisdiction and/or am the subject of any current suspension and/or have
any restrictions on practice. Please provide the details of same in the table below. I accept that making a false or
misleading declaration may render any offer of a training position and associated employment offers as null and void.

Date Country Medical Council/ Offence Status/ Outcome

Licensing Body

Signed: __________________________ Date:_______________

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 Training Programme in Radiology
NOTES TO ASSIST IN THE COMPLETION OF STRUCTURED REFERENCE REPORT
Faculty of Radiologists
The Royal College of Surgeons in Ireland

1. The Assessment Form is CONFIDENTIAL once completed, and must be handled accordingly.

2. The following guidelines are for referees completing the form:

A. Complete as fully as possible the candidate’s details in the first section, circling the appropriate period of assessment.
B. Where more than one supervisor was involved with candidate a consensus opinion should be expressed on the form.
C. Complete the main assessment by placing an ‘X’ in one box against each criterion. The following guidelines should to
be used when assessing each category.
D. Please note that, if requested by the candidate, a copy of this reference may be given to the candidate.

A. Clinical Skills Poor / Deficient Satisfactory Above Average / Excellent

History taking Incomplete, Inaccurate, Usually complete, orderly Precise, perceptive, ‘can spot
Poorly recorded. and systematic the rarity’
Physical Lacks basic skills Can elicit correct signs. Thorough, accurate. Knows and
Examination Recognises most elicits specialist signs
significant findings
Diagnostic Haphazard or inappropriate Orders laboratory and Very good awareness of most
Investigations ordering of diagnostic tests. imaging investigations appropriate and efficient
Unaware of significance of appropriately. diagnostic pathway.
appropriate testing.
Diagnostic Skills Fails to interpret and Competent clinician. Good Outstanding diagnostician.
synthesise symptoms, knowledge with an orderly Excellent clinical memory.
signs and investigations logical approach to
differential diagnosis.
Clinical Judgement Deficient assessments of Sound patient Outstanding clinician who is
patient status. Does not assessments. Recognises aware of his / her limits. Always
recognise own limitations. the sick patient. knows when to call for help.
Does not call for help.
Operative Skills Clumsy, rough with tissues. Competent. Handles Promises to develop into an
Totally lacking in self- tissues well excellent technical surgeon
confidence technically
Postoperative Uninterested. Fails to Conscientious. Good Excellent on wards. Notices
Management notice complications and awareness for problems early
act appropriately. Only complications. Knows
follows up patients when patients well.
pressed to do so.
B. Professional Poor / Deficient Satisfactory Above Average / Excellent
Development
Teaching Activities Uninterested and avoids Competent and Excellent enthusiastic teacher
teaching. Contributes little conscientious in teaching who inspires others.
to the education of others.
students or interns.
Clinical Audit Little interest in auditing Participates actively in Very good understanding of role
clinical activity. Poor regular audit. of audit. Plays active role in
knowledge of audit collection and storage of audit
process. data.
Presentations No interest in giving papers Keen to give presentations Fully researched original ideas.
or making presentations which are well illustrated Enthusiastic presenter. Answers
within the hospital or at and well delivered. questions lucidly.
clinical meetings.
Research Has neither inclination nor Keen to do research but Flare for original research and
ideas. Unable to carry out needs direction. ability to carry it out
“directed” projects. independently. Good grasp of
statistics and research methods.
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C. Personal Skills Poor / Deficient Satisfactory Above Average / Excellent

Communication Does not communicate Good communicator. Pays great attention to

satisfactorily with patients, importance of good
relatives or other team communications skills. Regularly
members. seeks feedback that his / her
message has been understood.
Teamwork Poor team player. Works Good team player. Good understanding of team
alone. Does not contribute Understands importance roles of his / her role on team.
to team performance. of teamwork. Works harmoniously with all
other team members.
Leadership Very limited. ‘Switches Competent but lacks Outstanding team leader with
people off’. Colleagues and inspiration. Gives clear exceptional ability to motivate
other staff confused by his / instructions. others
her instructions
Self Awareness and Little or no understanding Aware of his / her Very secure person. Recognises
Insight of own limitations or strengths and own deficiencies and prepared
deficiencies. weaknesses. to make appropriate changes.
Motivation and Drive No inclination to organise Able to organise working Constantly pro-active, always
work. Needs to be ‘pushed’ routine without prepared to accept additional
constantly supervision. Looks for opportunities to advance.
opportunities to learn
Disposition and Sloppy in appearance and Good overall attitude. Highly motivated enthusiastic
Appearance work manner. Does not Presents himself / herself and ambitious.
inspire confidence in well.
others.
Management of Constantly disorganised. Manages priorities well in Very good handling of stress
Stress and Workload Does not identify priorities. face of excessive and workload. Prioritises
Always behind in workload. workloads. appropriately. Delegates or
seeks help when necessary.
Management of Falls apart at times of Remains calm and Handles crises situations very
Crises crises. Unable to deal organised at time of well. Calm demeanour. Inspires
satisfactorily with crises. other team members.
emergencies.
Reliability Unreliable, scatterbrained. Dependable. Does not Highly conscientious. Anticipates
Forgets to do things to the need reminding. problems.
possible detriment of Conscientious in patient
patients care
D. Relationships Poor / Deficient Satisfactory Above Average / Excellent

Medical Colleagues Fails to get on with seniors, Good rapport with Always willing to help even if
contemporaries or juniors. colleagues. Usually willing personally inconvenient. Able to
May even undermine them. to help in a crisis. Trusted, diffuse problems in the surgical
Refuses to help them out easy to work with. team. ‘An excellent colleague’.
Nursing & Treats them with disdain. Sound and professional Inspires enthusiasm.
Paramedical Staff Generates as opposed to yet approachable. Treats Exceptional communication
solving problems. Rude others with respect and is skills.
respected in return
Patients and Increases patient’s and Sound caring attitude. Can Inspires confidence. Establishes
Relatives. relatives anxieties. Rude. allay fears of patients and excellent rapport. Excellent
Patients do not want him / relatives. Takes time. communicator. Patients
her as their doctor. Bad Listens well. Explains well. delighted to be looked after by
listener & communicator Trusted by the patients him / her
and relatives.

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TRAINING PROGRAMME IN DIAGNOSTIC RADIOLOGY
xxxx Intake
Structured Reference Report
Faculty of Radiologists
The Royal College of Surgeons in Ireland

This is an important and official document, which will be used as part of the selection process for the training programme in
Diagnostic Radiology. Following completion you should forward it to the Faculty of Radiologists, Royal College of
Surgeons, RCSI House 123 St. Stephens Green Dublin 2.

Candidate name:

Referee Name

Hospital / Specialty:

Rotation Start Date: End Date:

Notes:
 Complete the form by placing an ‘X’ in one box against each assessment. A “satisfactory” grade indicates that the candidate
performed according to reasonable expectations but was no better and no worse than average. The majority of candidates
would be expected to score “satisfactory”
 Supervisors who award a “Poor” or “Excellent” grade should clarify why this grade is being awarded in the overall
comments section below
 This form is accompanied by a list of grading descriptors to assist supervisors in grading the candidates.
 When assessing candidates the supervisor should consider the candidate’s performance in all of the domains in which he or
she works, i.e. elective work on the wards, emergency work (on-call) in the Emergency Medicine department, and work in
the out-patients clinic, operating theatre, and specialist areas.

A. Clinical Skills
Above
Poor Deficient Satisfactory Excellent
Average
History Taking

Physical Examination

Diagnostic Investigations (Lab / Imaging)

Diagnostic Skills

Clinical Judgement

Operative Skills

Post-operative Management

B. Professional Development
Above
Poor Deficient Satisfactory Excellent
Average
Teaching Activities

Clinical Audit

Presentations

Research

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Above
C. Personal Skills Poor Deficient Satisfactory Excellent
Average
Communication

Teamwork

Leadership

Self Awareness and Insight

Motivation and Drive

Disposition and Appearance

Management of Stress and Workload

Management of Crises

Reliability

Above
D. Relationships
Poor Deficient Satisfactory Excellent
Average
Medical Colleagues

Nursing and Paramedical Staff

Patients and Relatives

Comments

Did this doctor perform well in his / her post with you? _____________________________________

Do you think he / she is suitable for a career in Radiology? ___________________________________

Has he / she any outstanding characteristics? ___________________________________________

Overall Comments:

________________________________________________________________________________

________________________________________________________________________________

______________________________________________________________________________

Final Assessment

Please indicate on scale of 1-5 your overall assessment of this trainee’s

suitability for Training Programme in Diagnostic Radiology
(5 = strongest possible support; 1 = very little support)

Signature: ______________________________________________________

Date: ____________________________________________

Please return completed form with Application by xxxxx

Faculty of Radiologists, Royal College of Surgeons in Ireland,

RCSI House, 123 St. Stephen’s Green, Dublin 2

Any attempt to provide misleading or false information to improve your score in shortlisting or interview will result
in automatic disqualification.

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 Training Programme in Radiology
TRAINING PROGRAMME IN DIAGNOSTIC RADIOLOGY
xxxxx Intake
Structured Reference Report
Faculty of Radiologists
The Royal College of Surgeons in Ireland

This is an important and official document, which will be used as part of the selection process for the training programme in
Diagnostic Radiology. Following completion you should forward it to the Faculty of Radiologists, Royal College of
Surgeons, RCSI House 123 St. Stephens Green Dublin 2.

Candidate name:

Referee Name

Hospital / Specialty:

Rotation Start Date: End Date:

Notes:
 Complete the form by placing an ‘X’ in one box against each assessment. A “satisfactory” grade indicates that the candidate
performed according to reasonable expectations but was no better and no worse than average. The majority of candidates
would be expected to score “satisfactory”
 Supervisors who award a “Poor” or “Excellent” grade should clarify why this grade is being awarded in the overall
comments section below
 This form is accompanied by a list of grading descriptors to assist supervisors in grading the candidates.
 When assessing candidates the supervisor should consider the candidate’s performance in all of the domains in which he or
she works, i.e. elective work on the wards, emergency work (on-call) in the Emergency Medicine department, and work in
the out-patients clinic, operating theatre, and specialist areas.

A. Clinical Skills
Above
Poor Deficient Satisfactory Excellent
Average
History Taking

Physical Examination

Diagnostic Investigations (Lab / Imaging)

Diagnostic Skills

Clinical Judgement

Operative Skills

Post-operative Management

B. Professional Development
Above
Poor Deficient Satisfactory Excellent
Average
Teaching Activities

Clinical Audit

Presentations

Research

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 Training Programme in Radiology

Above
C. Personal Skills Poor Deficient Satisfactory Excellent
Average
Communication

Teamwork

Leadership

Self Awareness and Insight

Motivation and Drive

Disposition and Appearance

Management of Stress and Workload

Management of Crises

Reliability

Above
D. Relationships
Poor Deficient Satisfactory Excellent
Average
Medical Colleagues

Nursing and Paramedical Staff

Patients and Relatives

Comments

Did this doctor perform well in his / her post with you? _____________________________________

Do you think he / she is suitable for a career in Radiology? ___________________________________

Has he / she any outstanding characteristics? ___________________________________________

Overall Comments:

________________________________________________________________________________

________________________________________________________________________________

______________________________________________________________________________

Final Assessment

Please indicate on scale of 1-5 your overall assessment of this trainee’s

suitability for Training Programme in Diagnostic Radiology
(5 = strongest possible support; 1 = very little support)

Signature: ______________________________________________________

Date: ____________________________________________

Please return completed form with Application by xxxxx

Faculty of Radiologists, Royal College of Surgeons in Ireland,

RCSI House, 123 St. Stephen’s Green, Dublin 2

Any attempt to provide misleading or false information to improve your score in shortlisting or interview will result
in automatic disqualification.

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 Training Programme in Radiology
TRAINING PROGRAMME IN DIAGNOSTIC RADIOLOGY
xxxxx Intake
Structured Reference Report
Faculty of Radiologists
The Royal College of Surgeons in Ireland

This is an important and official document, which will be used as part of the selection process for the training programme in
Diagnostic Radiology. Following completion you should forward it to the Faculty of Radiologists, Royal College of
Surgeons, RCSI House 123 St. Stephens Green Dublin 2.

Candidate name:

Referee Name

Hospital / Specialty:

Rotation Start Date: End Date:

Notes:
 Complete the form by placing an ‘X’ in one box against each assessment. A “satisfactory” grade indicates that the candidate
performed according to reasonable expectations but was no better and no worse than average. The majority of candidates
would be expected to score “satisfactory”
 Supervisors who award a “Poor” or “Excellent” grade should clarify why this grade is being awarded in the overall
comments section below
 This form is accompanied by a list of grading descriptors to assist supervisors in grading the candidates.
 When assessing candidates the supervisor should consider the candidate’s performance in all of the domains in which he or
she works, i.e. elective work on the wards, emergency work (on-call) in the Emergency Medicine department, and work in
the out-patients clinic, operating theatre, and specialist areas.

A. Clinical Skills
Above
Poor Deficient Satisfactory Excellent
Average
History Taking

Physical Examination

Diagnostic Investigations (Lab / Imaging)

Diagnostic Skills

Clinical Judgement

Operative Skills

Post-operative Management

B. Professional Development
Above
Poor Deficient Satisfactory Excellent
Average
Teaching Activities

Clinical Audit

Presentations

Research

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 Training Programme in Radiology

Above
C. Personal Skills Poor Deficient Satisfactory Excellent
Average
Communication

Teamwork

Leadership

Self Awareness and Insight

Motivation and Drive

Disposition and Appearance

Management of Stress and Workload

Management of Crises

Reliability

Above
D. Relationships
Poor Deficient Satisfactory Excellent
Average
Medical Colleagues

Nursing and Paramedical Staff

Patients and Relatives

Comments

Did this doctor perform well in his / her post with you? _____________________________________

Do you think he / she is suitable for a career in Radiology? ___________________________________

Has he / she any outstanding characteristics? ___________________________________________

Overall Comments:

________________________________________________________________________________

________________________________________________________________________________

______________________________________________________________________________

Final Assessment

Please indicate on scale of 1-5 your overall assessment of this trainee’s

suitability for Training Programme in Diagnostic Radiology
(5 = strongest possible support; 1 = very little support)

Signature: ______________________________________________________

Date: ____________________________________________

Please return completed form with Application by xxxxx

Faculty of Radiologists, Royal College of Surgeons in Ireland,

RCSI House, 123 St. Stephen’s Green, Dublin 2

Any attempt to provide misleading or false information to improve your score in shortlisting or interview will result
in automatic disqualification.

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