Oxford International Neonatal Paediatric Fellowship Scheme

2024 Application Form

Please complete this form, in full, and return to Dawn Watts OINPFS Administrator ([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
Working in the UK
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