CONJOINT SELECTION EXERCISE (NOVEMBER 2011) FOR ADMISSION TO HIGHER SURGICAL TRAINING PROGRAM

(Co-org !"#$% &' ()$ H* I!($r+o,,$g" ($ Bo r% o- S.rg"+ , Co,,$g$/ !% HA)

APPLICATION AND STRUCTURED CV FORM SUBMISSION DEADLINE 0 12 OCTOBER 2011 (1ED)

I23or( !( 3o"!(/ (o !o($ &$-or$ +o23,$("!g ()$ $!+,o/$% 33,"+ ("o! -or2 0 a) b) Entries in this form MUST be either in BLOC* LETTERS or T4PE1RITTEN5 This form must be submitted together with the FULL SET OF 6H*ICBSC ASSESSMENT FORM FOR BASIC SURGICAL TRAINING7 covering your entire basic surgical training (except those indicated in point (f) below). Failure to provide full set of the assessment forms will lead to incomplete scoring to your disadvantage. The number of available HST posts in various surgical specialties will be posted at the H website !http"##www.ha.org.h$#ho#resident.htm% in early &ct '()). The numbers are sub*ect to changes. +lease visit the website for the latest update before finali,ing your priorities. -oth priorities will carry weight in the selection exercise. +lease ensure completion of the Staff .evelopment /eview (S./) reports since commencement of your -ST appointment till the latest S./ cycle. They will be obtained from the Human /esources department of your hospital. +lease ensure the referees have agreed to and are available to complete and return a standardi,ed referee assessment form to the selection panel in &ctober '()). The referees should have wor$ed with you in the same wor$place within the last 01 months of basic surgical training. The panel will normally not incorporate H234-S4 and S./ assessments made in "5 (i) those periods preceding a clear brea$ of service and employment from the H (for H 5employees)6 (ii) those periods preceding non5H234-S45approved interrupted training unless the periods are assessed by the H234-S4 as being fully contributory to the current basic surgical training or (iii) those discrete assessment periods with ma*or parts containing prolonged absence from training wor$place or mainstream duties due to reasons such as maternity leave or long overseas training. g) +lease use additional sheet as needed. h) n ac$nowledgement will be issued to you via email normally within 0 wor$ing days upon receipt of your application. 3f you do not receive the ac$nowledgement7 please inform 8r 9incent 4HE:;< of the H H& 4luster Services .ivision at '0(( =>?(.

c)

d)

e)

f)

I) LATE SUBMISSION 1ILL NOT BE ACCEPTED5

For official use: pplication recAd on" ;ame of pplicant" /emar$s7 if any"

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15 FULL NAME 0

(English) (4hinese)

25 EMAIL ADDRESS 0
(+lease ensure reliability of this address for the purpose of receiving email and attachments for this exercise.)

CORRESPONDENCE ADDRESS 0

MOBILE TEL NO 0 1OR*PLACE TEL NO 0 85 BASIC MEDICAL 9UALIFICATIONS 1ITH 4EARS AND INSTITUTIONS 0

>. OTHER 9UALIFICATIONS 1ITH 4EARS AND INSTITUTIONS (excluding those under items =5@) "

:5 SPECIALT4 APPLIED FOR 0

(<eneral Surgery7 :rology7 ;eurosurgery7 4ardiothoracic Surgery7 +lastic Surgery7 +aediatric Surgery7 &torhinolaryngology7 &rthopaedic Surgery and Emergency 8edicine)

)st priority 'nd priority

(+lease leave B'nd priorityC blan$ if there is none apart from the )st priority.)

;5 DATE OF COMPLETION OF THE RE9UIRED ROTATIONS IN BST 0 <5 NUMBER OF ATTEMPTS AT 0 H234-S4 8embership Exam +art ) (new) " H234-S4 8embership Exam +art ' (new) " Doint 8/4S 3ntercollegiate (Surgery) Exam +art ) " Doint 8/4S 3ntercollegiate (Surgery) Exam +art ' " 84E ) (old style) " 84E ' (old style) " =5 NUMBER OF ATTEMPTS FOR MRCS > MH*ICBSC 0 H234-S4 8embership Exam +art 0 (new) " Doint 8/4S 3ntercollegiate (Surgery) Exam +art 0 " 8/4S (Final ssessment) Exam (old style) "
(+lease specify place in which the examination is ta$en for overseas eFuivalent examinations7 and note that their recognition rests with the decision of individual colleges.)

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?5 DATE PASSED MRCS > MH*ICBSC EXAM 0 105 NUMBER OF PAST ATTEMPTS IN HST SELECTION EXERCISE 0

)). ROTATIONS SINCE REGISTRATION AS BST (in chronological order) "

S3$+" ,(' > Ho/3"( , S( r( D ($ E!% D ($ R$+og!"/$% BST (r "!"!g (2o!()/)

)'. PUBLISHED ARTICLES 0

(local and non5peer reviewed articles to be included as well and presented in standard citation format listing all authors with your name underlined)

)0. PAPERS PRESENTED IN LOCAL>INTERNATIONAL MEETINGS 0

(local and non5peer reviewed presentations with you as the presenter to be included as well6 list all investigators#authors with your name underlined)

)>. RESEARCH PROJECTS (if not covered under items )' and )0) "
(details of your involvement7 sub*ect7 institution7 full time#part time7 name of supervisor7 commencement and completion dates of pro*ects7 any associated Fualifications#degree and duration of pro*ect)

N 2$0

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)G. SPECIAL S*ILLS > INTERESTS > HOBBIES 0

(including achievements you have in areas outside medicine)

)1. NAME AND CORRESPONDENCES OF THREE REFEREES 0

(+lease nominate those having wor$ed with you in the same wor$place in the last 01 months of basic surgical training7 not more than one from each recognised training rotation7 and exclude supervisors filling in your S./s7 i.e. B8anagerC shown in the S./. BSecond 8anagerC and B4ountersigning 8anagerC in the S./ can be invited. +lease ensure accuracy of the refereesA email address as communication will normally be made via electronic means.)

())

Tel " Fax " Email "

(')

Tel " Fax " Email "

(0)

Tel " Fax " Email "

I certify that the information supplied in this application is true, complete and correct. I agree to the access of my SDRs and enquiries being undertaken to verify this information with institutions or individuals as part of the selection and matching process.

NAME 0 SIGNATURE 0 DATE 0

P,$ /$ r$(.r! ()$ +o23,$($% -or2 @"() F.,, S$( O- 6H*ICBSC A//$//2$!( For2 For B /"+ S.rg"+ , Tr "!"!g7 (o Mr V"!+$!( CHEUNG o- ()$ HAHO C,./($r S$rA"+$/ D"A"/"o! o! or &$-or$ 12 O+(o&$r 2011 (1$%) A" !' o- ()$ -o,,o@"!g 2$ !/ 0 Po/( 0 R2 :2=NB Ho/3"( , A.()or"(' B.",%"!gB 1C<B Arg',$ S(r$$(B *o@,oo!B H*D or F E 0 21?C ;0C?D or E2 ", 0 +@FC:?G) 5org5)F T)$ /$,$+("o! "!($rA"$@ @",, &$ )$,% "! , ($-NoA 2011 ($!( ("A$,'5 1$ /) ,, !o("-' 'o. o- ()$ % ($>("2$ o!+$ +o!-"r2$%5

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