https://www.ouh.nhs.uk/working-for-us/default.

aspx

Oxford International Neonatal Paediatric Fellowship Scheme

Application Form 2020
Please complete this form, in full, and return to Deborah Henwood, Deputy Service Unit Manager (NeonatalPaedFellowshi

5/22/2023 8:52
Section A:
Personal
Details
Title
*Surname/ *Title
Family Name
Wickremasinghe Dr
*First Names
Indumini Kaushalya Mohotti
Other names
used e.g. for
registration
official
with
bodies (if
different)

*Address Date of Birth dd/mm/yyyy 11/27/1985

(Please Type)

23-B Wekunagoda Road Galle

Sri Lanka
Postcode
*Country
Home Mobile
Telephone Telephone

Work Do you have

Telephone access to
*Email video-
Address conference
(N.B: most
facilities?
communicatio
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Please provideB:
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email. which
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other leave to
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05/22/2023
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of the
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*Speaking
component
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component

Fitness to Practice and Criminal Investigations

It is vitally
important that
you read,
understand and
answer the
questions asked
in this
We aim section
to
by indicating
promote
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equality or “no”
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Please read the
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notes carefully
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completing this to
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applicantsIf youyou for
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International
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Paediatric
Fellowship
Scheme, I will
provide full
05/22/2023
details within 5 666889352.xlsx 3
working days
to Dr Amit
Place Photo here Place Signature here

You must
provide
contact
The reference
details,
process is
including
designed toe-
mail
check the
addresses,
accuracy of of
Section
two
your referees
D: References
previous
who have
employment
Your clinical
supervised
and training
referees
your
historyclinical
and to
should be
training
provide
contacted by
during
assurance theof
you in advance
last
your two years
to confirm that
of your
qualifications,
they are willing
employment
integrity and
to provide a
or
track record.
reference and
undergraduat
Please ensure
are available
e training.
these details
and able to do
Onecorrect
are referee
so in the time
must
and be your
if required
period
current
possible or
for selection
most
provide recent
us
and
consultant
with more or
appointment.
educational
than one
You are
Referee 1
supervisor
email address
responsible
(must be for
your
familiar
as you with
will
ensuring or
present thatbe
yourbe
not clinical
offered
the references
most recent
development.
GMC or Tier 5
are delivered
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by your
*Name
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sponsorshipof or
referees
Consultant
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of the
without
timely manner.
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*Job title of
appropriate
Ref 1
Consultant
references. or
Supervisor
*What
Ref 1 was
their role in
relation to
*Your
you (e.g.
specialty at
consultant)?
time
Ref 1in post
*Your
Ref 1 job title
at time in
post Ref 1
*Referee
contact e-
mail address
*Referee
Ref 1 email
second
*Address
address RefRef1
1

*Start date
(dd/mm/yyyy)
of this post
*End
Ref 1 date
(dd/mm/yyyy)
of this post
Ref 1 2
Referee
*Name of
Consultant or
Supervisor
*Job title of
Ref 2
Consultant or
Supervisor
*What was
Ref 2role in
their
relation to
you (e.g.
consultant)?
Ref 2
05/22/2023 666889352.xlsx 4
*Your
specialty at
time
*Yourinjob
post
title
Reftime
at 2 in
*Referee
post Ref 2
contact e-
mail address
*Referee
Ref 2 email
second
*Address
address RefRef2
2

*Start date
(dd/mm/yyyy)
of this post
*End date
Ref 2
(dd/mm/yyyy)
of this post
Ref 2 E:
Section
Professional
Primary
qualifications
Medical
Qualification
Qualification Date of
Type (e.g. Qualification
MBBS.MBCh (dd/mm/yyyy
B etc.) PMQ )

Medical Country
School/Unive
rsity

Other
degrees done
Degree Other
as part of the Awarding Date of
1
medical Body and Qualificat
course (eg Country ion
BSc, MD). Other 1 (dd/mm/y
State class of yyy)
degree Other 1
awarded

Please enter the title of any dissertations carried out as part of such degrees:

Postgraduate
Qualifications
Qualification / Awarding Date of
Degree PG 1 Body and Qualificat
Country PG ion
1 (dd/mm/y
yyy) PG 1

MRCPCH (if applicable)

MRCPCH Part 1A Date of
Passed
MRCPCH Part 2B Date of
(dd/mm/yyyy
Passed
)Date
MRCPCH
MRCPCH Part 2 Written of
(dd/mm/yyyy
P1A
Passed
) MRCPCH
MRCPCH Part 2 Clinical Date of
(dd/mm/yyyy
P2B
Passed
) MRCPCH
(dd/mm/yyyy
P2W
) MRCPCH
P2C
05/22/2023 666889352.xlsx 5
Prizes,
awards and
Prize
other (include Awarding Date of
speciality and
distinctions Body 1 Passed
qualifying (mm/yyyy
distinction) 1 )1

Section F:
Employment
Current
History Post

Hospital Substantive
Current Post or Locum
Current Post

Job Title From

Current Post (dd/mm/yyyy
) Current
Speciality To
Post
Current Post (dd/mm/yyyy
Approved for ) Currentin
Months
training Post (w.t.e)
Current Post Current Post
Previous
Posts
Please list
your previous
posts
(whether in
paediatrics or
not)
Poststarting
1
with the most
recent. You
Hospital PP1 Substantive
are required or Locum
to provide a PP1
full
employment
Job Title PP1 From
history in
(dd/mm/yyyy
chronological
) PP1
order from
your
Speciality To
internship to
PP1 (dd/mm/yyyy
the present
Was this a ) PP1 in
Months
day. Should
training post? post PP1
If
youYes please
need more
provide
space for your
documentary Country PP1
previous posts,
evidence to
please
confirm
continue
employment using
Post
this 2PP1 on
format
dates.
additional
Hospital
paper. PP2 Substantive
or Locum
PP2
Job Title PP2 From
(dd/mm/yyyy
) PP2
Speciality To
PP2 (dd/mm/yyyy
) PP2

Was this a Months in

training post? post PP2
If Yes please
provide Country PP2
documentary
evidence to
confirm
employment
Post 3
dates.PP2

05/22/2023 666889352.xlsx 6
Hospital PP3 Substantive
or Locum
PP3
Job Title PP3 From
(dd/mm/yyyy
) PP3
Speciality To
PP3 (dd/mm/yyyy
) PP3
Was this a Months in
training post? post PP3
If Yes please Country PP3
provide
documentary
evidence to
confirm
employment
Post
dates.4PP3
Hospital PP4 Substantive
or Locum
PP4
Job Title PP4 From
(dd/mm/yyyy
Speciality ) PP4
To
PP4 (dd/mm/yyyy
Was this a Months
) PP4 in
training post? post PP4PP4
If Yes please Country
provide
documentary
evidence to
confirm
employment
dates.
Post 5PP4
Hospital PP5 Substantive
or Locum
PP5
Job Title PP5 From
(dd/mm/yyyy
Speciality ) PP5
To
PP5 (dd/mm/yyyy
Was this a Months
) PP5 in
training post? post PP5PP5
If Yes please Country
provide
documentary
evidence to
confirm
employment
dates. PP5
Post 6
Hospital PP6 Substantive
or Locum
PP6
Job Title PP6 From
(dd/mm/yyyy
Speciality )To
PP6
PP6 (dd/mm/yyyy
Was this a Months
) PP6 in
training post? post PP6PP6
If Yes please Country
provide
documentary
evidence to
confirm
employment
dates.7PP6
Post
Hospital PP7 Substantive
or Locum
PP7
Job Title PP7 From
(dd/mm/yyyy
) PP7
Speciality To
PP7 (dd/mm/yyyy
Was this a Months
) PP7 in
training post? post (w.t.e)
If Yes please Country PP7
PP7
provide
documentary
evidence to
confirm
employment
dates.8PP7
Post

05/22/2023 666889352.xlsx 7
Hospital PP8 Substantive
or Locum
PP8
Job Title PP8 From
(dd/mm/yyyy
Speciality To
) PP8
PP8 (dd/mm/yyyy
Was this a Months
) PP8 in
training post? post PP8
If Yes please Country
provide
documentary
evidence to
confirm
employment
dates. PP8
Post 9
Hospital PP9 Substantive
or Locum
PP9
Job Title PP9 From
(dd/mm/yyyy
Speciality To
) PP9
PP9 (dd/mm/yyyy
)Months
PP9 in
Was this a
training post? post PP9PP9
If Yes please Country
provide
documentary
evidence to
confirm
Do you have
employment
any gaps in
dates. PP9
your
Employment
employment
Gaps of more
history
than 4 weeks
duration? This
will be strictly
If Yes, please
scrutinised – if
explain
you havethe any
gap
gapsand give
longer
relevant dates
than 28 days
(max
your 150
words)
application
might be
rejected.

05/22/2023 666889352.xlsx 8
Section G:
Please give
Clinical
details of your
Experience
clinical
experience as
it relates to
Neonatal
Medicine.
Neonatal experience
Please include
details on the
total amount of
months you
have spent
working in this
area, and to
what level.
Please also
state when this
experience
was gained.
(Max 250
words)

05/22/2023 666889352.xlsx 9
Please give
details of your
clinical
experience
and level of
competence
Other
and howclinical
they experience
link directly or
indirectly to
your suitability
for an MTI post
(including
specific
important
competences
such as
neonatal
intubation).
(Max 250
words)

Please
indicate any
areas of
interest or
clinical
experience
within
Other Sub-Speciality
paediatric sub- interests and experience
specialties
(e.g. oncology,
hepatology
etc) and how
this links with
your suitability
for the MTI
scheme and
the steps you
have taken to
broaden this
05/22/2023 666889352.xlsx 10
experience to
date. (Max 250
words)
Please give
details of any
relevant
courses which
you have
attended
including the
dates.

Please Venue
include any Date and
Course 1 life
paediatric attended 1 Organiser
support, 1
neonatal life
support and
child
protection
courses.

Describe your
involvement
with audits,
providing
evidence from
2 or 3 audit
projects you
have been
involved in
during
Section your
H:
paediatric
Supporting
training.
Information
Indicate your
specific level
of involvement
at each stage
of the audit
cycle; what
have been the
consequences
of the audit for
the
department(s)
05/22/2023
and what have 666889352.xlsx 11
you learnt
about the audit
 Title and
Other
level of
Audits/Guidel
involvement
ine - Date 1
1

Management

Describe any
leadership,
administrative
and
managerial
contributions
you have
made in your
professional
life i.e.
undergraduate
or
postgraduate.
Please do not
include
educational/te
aching
experience in
this section;
this
information
should go into
the teaching
section. (Max
200 words)

Academic
Achievement
s

05/22/2023 666889352.xlsx 12
Outline up to 3
areas of
research in
which you
have been
directly
involved in.
What were the
key findings?
What was your
part in the
activity and at
what level did
your research
achieve
recognition?
Do not include
publications or
presentations
in this section
(see below). If
you have been
awarded a
higher degree
as a result of
research
please detail
this in the
qualifications
section. (Max
200 words)

Publications

Provide details
of Publications
in peer
reviewed
journals with
full citations
and PubMed
number
(excluding
your own
name) and any
other
publications
(books, letters,
abstracts,
electronic).
Please also
state
authorship
(e.g. first
author, co-
author etc).
Although you
may list for
interest
publications
that have been
submitted,
please note
that only
05/22/2023
published 666889352.xlsx 13
articles will
receive points
05/22/2023 666889352.xlsx 14
Presentation /
Posters
In this section
please provide
details of
presentations/
posters detail
Please at a
conferences,
maximum of 5
congresses or
presentations/
other you
posters
local/national/i
have given
nternational
locally
meetings,
followed by
including of 5
maximum
author details.
presentations/
posters made
at a higher
level.

Teaching

Describe your
experience of
teaching /
education
delivery and
different
teaching
methods. Detail
any
contributions to
the design and
leadership of
teaching you
have been
involved with.
Include here if
you have had
any formal
training in
teaching,
examples may
include ‘teach
the teachers’,
Generic
Instructor
Course (GIC),
diploma,
certificate, MA,
PhD in
education. You
should have
listed if you
have achieved
a formal
qualification in
the
qualifications
section of the
application form
but if you hold a
specific
Further
educational
information
qualification
please
to also
support
include it here.
your
(Max 200
application
words)
05/22/2023 666889352.xlsx 15
Please outline
your eventual
career aims
and any
additional
information
you would like
to provide to
support your
Oxford
International
Neonatal and
Paediatric
Fellowship
Scheme
application;
particularly
demonstrating
your
commitment to
Paediatrics
and Child
Health and
how you feel
that you and
your patients
will benefit
upon your
return home.

Documents
to support
your
In addition to
application.
completing this
application
form, you are Letter
required to from
Required Primary
provide clear Dean/Prin
Medical
documents
scanned/elect cipal of
Qualificat
Certificat
ronic copies Medical
ion
e of(e.g.
of the 1 Passport
School
MBBS)
completio
documents (this must
certificate
n of
listed below. include
in
internshithe of
Please2note dates
original
p OR a
attendanc
that Oxford language
letter of
University e,
and
experienc
Hospitals NHS confirmati
Certificat
translated
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Foundation on
e of
3 if of Good
relevant
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Trust will not Standing
necessary
hospital/U
accept hard n from
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of each
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copies unless Letter
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INTERVIEW COMMENTS

05/22/2023 666889352.xlsx 18
 Oxford International Neonatal Paediatric Fellowship Scheme
Application Form 2020
Please complete this form, in full, and return to Deborah Henwood, Deputy Service Unit Manager ([email protected] )
Section A: Personal Details
*Title
*Surname/Family Name

*First Names
Other names used e.g. for
registration with official
bodies (if different)

Date of Birth (dd/mm/yyyy)

*Address

Postcode

*Country

Home Telephone

Work Telephone
Mobile Telephone
Do you have access to
video-conference
facilities?

*Email Address (N.B: most

communication will be via email.
Please provide an active email Section B: Right to work in the UK and English Language Skills
address which you check
regularly. You must inform
Working in the UK
[email protected]
hs.uk of any changes)
In accordance with the principles of the GAE route, Oxford International Neonatal and Paediatric Fellowship is only available to doctors from outside of the UK/EU/EEA/Switzerland who have no current
leave to remain in the United Kingdom.

*Do you currently have a

visa or other leave to
remain in the UK?
English Language Skills
You are required to demonstrate skills in written and spoken English that are adequate to enable effective communication about medical and / or health topics with patients, colleagues and the public.

Evidence of English Language proficiency is an essential criterion for entry to the Oxford International Neonatal and Paediatric Fellowship scheme. You are required to provide evidence that your
written and spoken English language is adequate to enable effective communication about medical topics with patients and colleagues.

For this we require you to have obtained an overall IELTS (International English Language Testing System) score of at least 7.5 (All the component scores must be at least 7, all taken at the same
time, within 2 years of the application closing date). The achievement of these scores is also required for GMC registration.

PLEASE NOTE: Passing PLAB I or II is NOT considered a satisfactory alternative to IELTS.

*Have you previously
attempted the PLAB test?

*Please provide the date

you passed IELTS/OET
(dd/mm/yyyy)

*Overall IELTS score/OET

*Speaking component
*Listening component
*Reading component
*Writing component

Fitness to Practice and Criminal Investigations

It is vitally important that you read, understand and answer the questions asked in this section by indicating “yes” or “no” Please read the notes carefully before completing this part of the form. If you require further
information please contact [email protected] . All enquiries will be treated in strict confidence.

We aim to promote equality of opportunity and are committed to treating all applicants for positions fairly and on merit regardless of race, age, disability, gender, religion or belief, sexual orientation,
gender reassignment, marriage and civil partnership or pregnancy and maternity. We undertake not to discriminate unfairly against applicants on the basis of criminal conviction or other information
declared.
This post you have applied for has been identified as "regulated activity" within the terms of the Safeguarding Vulnerable Groups Act 2006. as amended by the Protection of Freedoms Act (2012) and
is eligible for an enhanced Disclosure & Barring Service check (Access NI in Northern Ireland & Disclosure Scotland in Scotland) under provisions of the Police Act (1997) (Criminal Records)
Regulations (as amended). The enhanced Disclosure & Barring Service check will, where appropriate to the role, also include any information which may be held against the barred lists for working
with children and/or adults.
Before you can be considered for appointment in a position of trust as trainee in this scheme we need to be satisfied about your character and suitability.
The position you have applied for is exempt from the Rehabilitation of Offenders Act 1974. This means that you must declare all criminal convictions, including those that would otherwise be considered "spent".

Answering "YES" to any of the questions below will not necessarily bar you from appointment. This will depend on the nature of the position for which you are applying and the particular circumstances.

Prior to making a final decision concerning your application, we shall discuss with you any information declared by you that we believe may have a bearing on your suitability for the position. If we do
not raise this information with you, this is because we do not believe that it should be taken into account. In that event, you remain free to discuss the matter with the interviewing panel, should you wish
to. As part of assessing your application, we will only take into account relevant criminal record and other information declared.

The Data Protection Act 1998 requires us to provide you with certain information and to obtain your consent before processing sensitive data about you. Processing includes: obtaining, recording,
holding, disclosing, destruction and retaining information. Sensitive personal data includes any of the following information: criminal offences, criminal convictions, criminal proceedings, disposal or
sentence.

The information that you provide in this Declaration Form will be processed in accordance with the Data Protection Act 1998. It will be used for the purpose of determining your application for this
position. It will also be used for purposes of enquiries in relation to the prevention and detection of fraud.

This Declaration Form and any information provided relating to a positive declaration will be kept securely and in confidence, and access to it will be restricted to designated persons within the
recruiting organisation and other persons who need to see it as part of the selection process and who are authorised to do so. If successfully appointed to a training post, this information may be
passed to designated persons in your first or lead employing organisation and any organisations through which you rotate.

Please answer the following questions. If you answer “yes” to any of the questions please provide full written details, including dates and outcomes by email to [email protected].
Please mark the email “CONFIDENTIAL” and provide clear indication of which question(s) you are answering.

Section C: Fitness to Practice and Criminal Investigations

It is vitally important that you read, understand and answer the questions asked in this section

Please answer all of the following questions. If you answer “YES” to any of the questions, please provide full details to [email protected] Please mark the email “CONFIDENTIAL”
and provide clear indication of which question(s) you are answering.

If you would like to discuss what effect any previous convictions, police investigations or fitness to practise proceedings taken or being taken either in the UK or by an overseas licensing or regulatory
body might have on your application, you may contact Dr Amit Gupta by telephone in confidence.

Please indicate Yes or No to the following questions

FP1. *Are you currently bound over or have you ever been convicted of any offence by a Court or Court-Martial in the United Kingdom or in any other country? You do NOT need to tell us about
parking offences but other driving offences must be declared (excluding fixed penalty notices).

FP2. *Have you ever received a police caution, reprimand or final warning that has yet to be investigated by the GMC?

FP3. *Have you been charged with any offence in the United Kingdom or in any other country that has not yet been disposed of ?

FP4. *Are you aware of any current NHS Counter Fraud and Security Management Service (CFSMS) investigation following allegations made against you?
FP5. *Have you ever been investigated by the Police, NHS CFSMS or any other Investigatory Body resulting in a current conviction or dismissal from your employment?

FP6. *Have you ever been dismissed by reason of misconduct from any employment, office, or other position previously held by you?

FP7.*Have you ever been disqualified from the practice of a profession or required to practise subject to specified limitations/conditions/warnings following fitness to practise proceedings by a
regulatory or licensing body in the United Kingdom or in any other country?

FP8. *Are you currently the subject of any investigation, or fitness to practise proceeding by any licensing or regulatory body in the United Kingdom or any other country?

FP9.*Are you subject to any other prohibition, limitation or restriction that means we are unable to consider you for the post to which you are applying?

FP10. *Do you know of any other matters in your background which might cause your reliability or suitability for employment to be called into question?

DECLARATION
I hereby declare that the information given here is true. I further declare that should the situation change with regard to police investigations, criminal convictions or fitness to practise while applying for/
appointed to the Oxford International Neonatal and Paediatric Fellowship Scheme, I will provide full details within 5 working days to Dr Amit Gupta (OXFORD UNIVERSITY HOSPITALS NHS
FOUNDATION TRUST [email protected])

Signed Declaration

Date Declaration
Name Declaration
Place Photo here

Section D: References
The reference process is designed to check the accuracy of your previous employment and training history and to provide assurance of your qualifications, integrity and track record.

You must provide contact details, including e-mail addresses, of two referees who have supervised your clinical training during the last two years of your employment or undergraduate
training. One referee must be your current or most recent consultant or educational supervisor familiar with your clinical development.

Your clinical referees should be contacted by you in advance to confirm that they are willing to provide a reference and are available and able to do so in the time period required for selection and
appointment. You are responsible for ensuring that the references are delivered by your referees in a timely manner.

Please ensure these details are correct and if possible provide us with more than one email address as you will be not be offered GMC or Tier 5 Visa sponsorship without the appropriate
references.

Referee 1 (must be your present or most recent supervising Consultant or Head of Department)
*Name of Consultant or
Supervisor Ref 1
*Job title of Consultant or
Supervisor Ref 1

*What was their role in

relation to you (e.g.
consultant)? Ref 1
*Your specialty at time in
post Ref 1
*Your job title at time in
post Ref 1
*Referee contact e-mail
address Ref 1
*Referee second email
address Ref 1
*Address Ref 1

*Start date (dd/mm/yyyy)

of this post Ref 1

*End date (dd/mm/yyyy) of

this post Ref 1

Referee 2
*Name of Consultant or
Supervisor Ref 2
*Job title of Consultant or
Supervisor Ref 2
*What was their role in
relation to you (e.g.
consultant)? Ref 2

*Your specialty at time in

post Ref 2
*Your job title at time in
post Ref 2
*Referee contact e-mail
address Ref 2
*Referee second email
address Ref 2
*Address Ref 2
*Start date (dd/mm/yyyy)
of this post Ref 2

*End date (dd/mm/yyyy) of

this post Ref 2

Section E: Professional qualifications

Primary Medical Qualification
Qualification Type (e.g.
MBBS.MBChB etc.) PMQ

Date of Qualification
(dd/mm/yyyy)
Medical School/University
Country

Other degrees done as part of the medical course (eg BSc, MD). State class of degree awarded

Degree Other 1
Awarding Body and
Country Other 1
Date of Qualification
(dd/mm/yyyy) Other 1
Degree Other 2
Awarding Body and
Country Other 2
Date of Qualification
(dd/mm/yyyy) Other 2
Degree Other 3
Awarding Body and
Country Other 3
Date of Qualification
(dd/mm/yyyy) Other 3
Please enter the title of
any dissertations carried
out as part of such
degrees:

Postgraduate Qualifications

Qualification / Degree PG 1

Awarding Body and

Country PG 1
Date of Qualification
(dd/mm/yyyy) PG 1
Qualification / Degree PG 2

Awarding Body and

Country PG 2
Date of Qualification
(dd/mm/yyyy) PG 2
Qualification / Degree PG 3

Awarding Body and

Country PG 3
Date of Qualification
(dd/mm/yyyy) PG 3
MRCPCH (if applicable)
MRCPCH Part 1A

Date of Passed
(dd/mm/yyyy) MRCPCH
P1A

MRCPCH Part 2B

Date of Passed
(dd/mm/yyyy) MRCPCH
P2B

MRCPCH Part 2 Written

Date of Passed
(dd/mm/yyyy) MRCPCH
P2W

MRCPCH Part 2 Clinical

Date of Passed
(dd/mm/yyyy) MRCPCH
P2C

Prizes, awards and other distinctions

Prize (include speciality
and qualifying distinction)
1

Awarding Body 1
Date of Passed (mm/yyyy)
1
Prize (include speciality
and qualifying distinction)
2

Awarding Body 2
Date of Passed (mm/yyyy)
2
Prize (include speciality
and qualifying distinction)
3

Awarding Body 3
Date of Passed (mm/yyyy)
3
Prize (include speciality
and qualifying distinction)
4

Awarding Body 4
Date of Passed (mm/yyyy)
4
Prize (include speciality
and qualifying distinction)
5
Awarding Body 5
Date of Passed (mm/yyyy)
5
Section F: Employment History

Current Post
Hospital Current Post
Job Title Current Post
Speciality Current Post

Approved for training

Current Post
Substantive or Locum
Current Post
From (dd/mm/yyyy)
Current Post
To (dd/mm/yyyy) Current
Post
Months in Post (w.t.e)
Current Post
Previous Posts
Please list your previous posts (whether in paediatrics or not) starting with the most recent. You are required to provide a full employment history in chronological order from your
internship to the present day. Should you need more space for your previous posts, please continue using this format on additional paper.

Post 1
Hospital PP1
Job Title PP1
Speciality PP1
Was this a training post? If
Yes please provide
documentary evidence to
confirm employment dates.
PP1

Substantive or Locum PP1

From (dd/mm/yyyy) PP1

To (dd/mm/yyyy) PP1
Months in post PP1
Country PP1
 Post 2
Hospital PP2
Job Title PP2
Speciality PP2
Was this a training post? If
Yes please provide
documentary evidence to
confirm employment
dates.PP2

Substantive or Locum PP2

From (dd/mm/yyyy) PP2

To (dd/mm/yyyy) PP2
Months in post PP2
Country PP2
Post 3
Hospital PP3
Job Title PP3
Speciality PP3
Was this a training post? If
Yes please provide
documentary evidence to
confirm employment dates.
PP3

Substantive or Locum PP3

From (dd/mm/yyyy) PP3

To (dd/mm/yyyy) PP3
Months in post PP3
Country PP3
Post 4
Hospital PP4
Job Title PP4
Speciality PP4
Was this a training post? If
Yes please provide
documentary evidence to
confirm employment dates.
PP4

Substantive or Locum PP4

From (dd/mm/yyyy) PP4

To (dd/mm/yyyy) PP4
Months in post PP4
Country PP4
Post 5
Hospital PP5
Job Title PP5
Speciality PP5
Was this a training post? If
Yes please provide
documentary evidence to
confirm employment dates.
PP5

Substantive or Locum PP5

From (dd/mm/yyyy) PP5

To (dd/mm/yyyy) PP5
Months in post PP5
Country PP5
Post 6
Hospital PP6
Job Title PP6
Speciality PP6
Was this a training post? If
Yes please provide
documentary evidence to
confirm employment dates.
PP6

Substantive or Locum PP6

From (dd/mm/yyyy) PP6

To (dd/mm/yyyy) PP6
Months in post PP6
Country PP6
Post 7
Hospital PP7
Job Title PP7
Speciality PP7
Was this a training post? If
Yes please provide
documentary evidence to
confirm employment dates.
PP7

Substantive or Locum PP7

From (dd/mm/yyyy) PP7

To (dd/mm/yyyy) PP7
Months in post (w.t.e) PP7

Country PP7
Post 8
Hospital PP8
Job Title PP8
Speciality PP8
Was this a training post? If
Yes please provide
documentary evidence to
confirm employment dates.
PP8

Substantive or Locum PP8

From (dd/mm/yyyy) PP8

To (dd/mm/yyyy) PP8
Months in post PP8
Country
Post 9
Hospital PP9
Job Title PP9
Speciality PP9
Was this a training post? If
Yes please provide
documentary evidence to
confirm employment dates.
PP9

Substantive or Locum PP9

From (dd/mm/yyyy) PP9

To (dd/mm/yyyy) PP9
Months in post PP9
Country PP9

Employment Gaps
Do you have any gaps in
your employment history of
more than 4 weeks duration?
This will be strictly
scrutinised – if you have any
gaps longer than 28 days
your application might be
rejected.

If Yes, please explain the

gap and give relevant
dates (max 150 words)

Section G: Clinical Experience

 Please give details of your clinical experience as it relates to Neonatal Medicine. Please include details on the total amount of months you have spent working in this area, and to what level. Please
also state when this experience was gained. (Max 250 words)

Neonatal experience

Please give details of your clinical experience and level of competence and how they link directly or indirectly to your suitability for an MTI post (including specific important competences such as
neonatal intubation). (Max 250 words)

Other clinical experience

Please indicate any areas of interest or clinical experience within paediatric sub-specialties (e.g. oncology, hepatology etc) and how this links with your suitability for the MTI scheme and the steps you
have taken to broaden this experience to date. (Max 250 words)
Other Sub-Speciality
interests and experience

Please give details of any relevant courses which you have attended including the dates. Please include any paediatric life support, neonatal life support and child protection courses.

Course 1
Date attended 1

Venue and Organiser 1

Course 2
Date attended 2

Venue and Organiser 2

Course 3
Date attended 3

Venue and Organiser 3

Course 4
Date attended 4

Venue and Organiser 4

Section H: Supporting
Information

Describe your involvement

with audits, providing
evidence from 2 or 3 audit
projects you have been
involved in during your
paediatric training. Indicate
your specific level of
involvement at each stage of
the audit cycle; what have
been the consequences of
the audit for the
department(s) and what
have you learnt about the
audit cycle process? (Max
200 words)

Other Audits/Guideline -
Date 1
Title and level of
involvement 1

Other Audits/Guideline -
Date 2

Title and level of

involvement 2

Other Audits/Guideline -
Date 3

Title and level of

involvement 3

Other Audits/Guideline -
Date 4

Title and level of

involvement 4

Other Audits/Guideline -
Date 5

Title and level of

involvement 5

Other Audits/Guideline -
Date 6

Title and level of

involvement 6

Other Audits/Guideline -
Date 7

Title and level of

involvement 7

Other Audits/Guideline -
Date 8

Title and level of

involvement 8
Describe any leadership, administrative and managerial contributions you have made in your professional life i.e. undergraduate or postgraduate. Please do not include
educational/teaching experience in this section; this information should go into the teaching section. (Max 200 words)
Management

Outline up to 3 areas of research in which you have been directly involved in. What were the key findings? What was your part in the activity and at what level did your research achieve recognition?
Do not include publications or presentations in this section (see below). If you have been awarded a higher degree as a result of research please detail this in the qualifications section. (Max 200
words)

Academic Achievements

Provide details of Publications in peer reviewed journals with full citations and PubMed number (excluding your own name) and any other publications (books, letters, abstracts, electronic). Please also
state authorship (e.g. first author, co-author etc). Although you may list for interest publications that have been submitted, please note that only published articles will receive points at shortlisting.

Publications

In this section please provide details of presentations/ posters at conferences, congresses or other local/national/international meetings, including author details.
Please detail a maximum of 5 presentations/posters you have given locally followed by maximum of 5 presentations/posters made at a higher level.
Presentation / Posters

Describe your experience of teaching / education delivery and different teaching methods. Detail any contributions to the design and leadership of teaching you have been involved with. Include here if you have
had any formal training in teaching, examples may include ‘teach the teachers’, Generic Instructor Course (GIC), diploma, certificate, MA, PhD in education. You should have listed if you have achieved a formal
qualification in the qualifications section of the application form but if you hold a specific educational qualification please also include it here. (Max 200 words)

Teaching

Please outline your eventual career aims and any additional information you would like to provide to support your Oxford International Neonatal and Paediatric Fellowship Scheme application;
particularly demonstrating your commitment to Paediatrics and Child Health and how you feel that you and your patients will benefit upon your return home.

Further information to
support your application

Documents to support your application.

In addition to completing this application form, you are required to provide clear scanned/electronic copies of the documents listed below. Please note that Oxford University Hospitals NHS
Foundation Trust will not accept hard copies unless under exceptional circumstances, cleared in advance.
 Required documents
1 Passport
2 Primary Medical Qualification (e.g. MBBS) certificate in the original language and translated if necessary.
Letter from Dean/Principal of Medical School (this must include dates of attendance, confirmation of completion of degree and degree title, satisfactory conduct. Name
3 must match that on PMQ certificate)
Certificate of completion of internship OR a letter of experience from relevant hospital/University (this must confirm attendance dates, any specialties undertaken and that
4 conduct was satisfactory, and be translated if necessary)
Certificate of Good Standing from each country where training has been undertaken. This must include one from the current country of work, granted within the last 3
5 months.
6 Postgraduate medical qualification in the original language and translated if necessary (OR MRCPCH certificate if applicable)
Letter from the Dean/Principal of your Postgraduate Institution (IF NOT MRCPCH) (this must include dates of attendance, confirmation of completion of degree and
7 degree title and satisfactory conduct. (Name must match that on PGQ certificate)
Letter from the relevant medical regulatory authority confirming that your post-graduate qualification and institution was recognised by them at the time of completion (in
8 the case of Indian qualifications check the MCI website too).

9 Letters confirming training (i.e. evidence from the hospital(s) to confirm training undertaken in that/those hospital(s) and was undertaken in approved posts)

British Council or IDP Academic IELTS/OET test.  IELTS - The minimum acceptable score is 7.0 in each section (reading, writing, speaking & listening) and 7.5 overall.
10 The test is valid for 2 years only from the date it was taken. OET – The minimum acceptable score is 350 or above in each section (reading, writing, speaking and
listening)  The test is valid for 2 years only from the date it was taken.
11 Police check (this must have been granted within the last 6 months)

12 In the event of a name change: candidate to submit a statement explaining why and the relevant supporting evidence certificates/documents (e.g. marriage certificate.)

Scholarship/Bursary: if funding is being provided by a hospital/organisation we must see an attested (or original) letter confirming amount and duration of funding is
13 required. The funding should be at or above £16,000 per annum for the whole duration of the post.
Confirmation
I confirm that I meet the
essential entry criteria as
set out in the document
check list
Declaration
The Data Protection Act 1998 requires us to advise you that we will be processing your personal data. Processing includes: holding, obtaining, recording, using, sharing and deleting information. The Data Protection Act 1998 defines "sensitive
personal data" as racial or ethnic origin, political opinions, religious or other beliefs, trade union membership, physical or mental health, sexual life, criminal offenses, criminal convictions, criminal proceedings, disposal or sentence. The information
that you provide in this Declaration Form will be processed in accordance with the Data Protection Act 1998. It will be used for the purpose of determining your application for this position. It will also be used for the purposes of enquiries in
relation to the prevention and detection of fraud. Once a decision has been made concerning your appointment, Oxford University Hospitals NHS Foundation Trust will not retain this information for any longer than is necessary This declaration
will be kept securely and in confidence. Access to this information will be restricted to designated persons within the Trust who are authorised to view it as part of their work.

Declaration 1: I declare that the information I have given in support of my application, including information supplied on this form and any attached appendices, is, to the best of my knowledge and belief true and complete. I understand that if it is
subsequently discovered that any statement is false or misleading, or that I have withheld relevant information, particularly on criminal convictions and/or fitness to practise and/or have breached the confidentiality guidance (2009) stipulated by
the General Medical Council, my application may be disqualified or, if I have already been appointed, I may be dismissed and that I may be reported to the General Medical Council.
Declaration 2: I declare that my answers to the questions on this form, any attached appendices and any other application forms required by individual deaneries are my own work and are not copied or reproduced from any other sources. I
understand that if any of my answers are discovered not to be original, my application may be disqualified.

Declaration 3: I understand that information about my application including personal data will be recorded and processed on computer in order to progress and monitor appointments as well as the production of recruitment statistics. Oxford
University Hospitals NHS Foundation Trust shares information with organisations involved in the planning, management and delivery of the Oxford International Neonatal and Paediatric Fellowship Scheme including the Department of Health, the
Academy of medical Royal Colleges and other associated organisations. Oxford International Neonatal and Paediatric Fellowship Scheme commissions and undertakes a programme of research aimed at developing and improving the processes
used for selection into the Oxford International Neonatal and Paediatric Fellowship Scheme. Anonymised recruitment data from all candidates is used in our research and quality assurance programmes. Under no circumstances will those
undertaking such work be able to access candidate identifiable data, without contacting current and past applicants in advance for their permission to do so. I consent to the recording and processing of personal data in this way in accordance with
the Data Protection Act 1998 and as outlined above. I have read and understand the Fair Privacy Notice and understand that my Personal and Sensitive Personal Data will be processed in the manner set out in this Notice.

Declaration 4: I am aware of the GMC Good Medical Practice (paragraph 49) which states that if a post is formally accepted then I must not withdraw unless the employer has time to make other arrangements. I understand that failure to comply
with this requirement may result in a complaint to the GMC.

Declaration 5: Having been allocated to an Oxford International Neonatal and Paediatric Fellowship Scheme post any subsequent contract of employment will be subject to satisfactory pre-employment checks and subject to the information
provided on the application form or any related documents being correct. Pre-employment checks will be carried out to review and confirm the details of my application.

Declaration 6: I understand that employment offered under the Oxford International Neonatal and Paediatric Fellowship Scheme is subject to satisfactory medical clearance which may include a medical examination and/or blood tests. I am aware
that the GMC has published guidelines on fitness to practise where the doctor has contracted a disease that is potentially transmissible.

Declaration 7: Candidates recommended for the Oxford International Neonatal and Paediatric Fellowship Scheme or NTN grid schemes will be subject to the appropriate Disclosure from the Disclosure and Barring Service. A criminal record will not
necessarily be a bar to obtaining a position. All deaneries comply with the Disclosure and Barring Service Code of Practice and undertake to treat all applicants fairly. Further information about the Disclosure and Barring Service can be obtained
from https://www.gov.uk/government/organisations/disclosure-and-barring-service, www.disclosures.co.uk and www.disclosurescotland.co.uk. Candidates are reminded that they should inform the Oxford University Hospitals NHS Foundation
Trust and/or deanery of any new criminal convictions, police investigations or fitness to practise proceedings that arise since the completion of this application form.

Declaration 8: I understand that all candidates offered Tier 5/GMC sponsorship via the Oxford International Neonatal and Paediatric Fellowship Scheme pathway are expected to return home after their maximum
of two years of training in the UK. It is my intention to return home once my training fellowship is completed.

Signature Dec 1-8

Name Dec 1-8

Date Dec 1-8
INTERVIEW COMMENTS