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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 12 OCTOBER 2011 ( ED)
I 3or ! 3o"! / o !o $ &$ or$ +o 3,$ "!g $ $!+,o/$% 33,"+ "o!
or
a) Entries in this form MUST be either in BLOC* LETTERS or T4PE
RITTEN5
b) This form must be submitted together with the FULL SET OF
6H*ICBSCASSESSMENT FORM FOR BASIC SURGICAL TRAINING7 covering your
entirebasic surgical training (except those indicated in point (f)
below). Failure to providefull set of the assessment forms will
lead to incomplete scoring to your disadvantage.
c) The number of available HST posts in various surgical
specialties will be posted at theH website
!http"##www.ha.org.h$#ho#resident.htm% in early &ct ' . The
numbersare sub*ect to changes. +lease visit the website for the
latest update before finali,ingyour priorities. -oth priorities
will carry weight in the selection exercise.
d) +lease ensure completion of the Staff evelopment /eview (S /)
reports sincecommencement of your -ST appointment till the latest S
/ cycle. They will beobtained from the Human /esources department
of your hospital.
e) +lease ensure the referees have agreed to and are available
to complete and return astandardi,ed referee assessment form to the
selection panel in &ctober ' . Thereferees should have wor$ed
with you in the same wor$place within the last 01months of basic
surgical training.
f) The panel will normally not incorporate H234-S4 and S /
assessments made in "5
(i) those periods preceding a clear brea$ of service and
employment from the H(for H 5employees)6
(ii) those periods preceding non5H234-S45approved interrupted
training unless theperiods are assessed by the H234-S4 as being
fully contributory to the currentbasic surgical training or
(iii) those discrete assessment periods with ma*or parts
containing prolongedabsence 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$ing daysupon receipt of your application. 3f you do
not receive the ac$nowledgement7 pleaseinform 8r 9incent 4HE:;<
of the H H& 4luster Services ivision at '0 =>? .
I) LATE SUBMISSION ILL NOT BE ACCEPTED5
File" ' ?> [email protected]
For official use:
pplication recAd on";ame of pplicant"/emar$s7 if any"
http://www.ha.org.hk/ho/resident.htmhttp://www.ha.org.hk/ho/resident.htm
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15 FULL NAME (English)
(4hinese)
25 EMAIL ADDRESS (+lease ensure reliability of this address for
the purpose of receiving email and attachments for this
exercise.)
CORRESPONDENCE ADDRESS
MOBILE TEL NO
OR*PLACE TEL NO
85 BASIC MEDICAL 9UALIFICATIONS ITH 4EARS AND INSTITUTIONS
>. OTHER 9UALIFICATIONS ITH 4EARS AND INSTITUTIONS (excluding
those under items =5@) "
:5 SPECIALT4 APPLIED FOR ( MH*ICBSC
H234-S4 8embership Exam +art 0 (new) "
Doint 8/4S 3ntercollegiate (Surgery) Exam +art 0 "
8/4S (Final ssessment) Exam (old style) "
(+lease specify place in which the examination is ta$en for
overseas e uivalent examinations7 and note that theirrecognition
rests with the decision of individual colleges.)
File" ' ?> [email protected] '
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?5 DATE PASSED MRCS > MH*ICBSC EXAM
105 NUMBER OF PAST ATTEMPTS IN HST SELECTION EXERCISE
. ROTATIONS SINCE REGISTRATION AS BST (in chronological order)
"
S3$+" , ' > Ho/3" , S r D $ E!% D $ R$+og!"/$% BST r "!"!g (
o! /)
'. PUBLISHED ARTICLES (local and non5peer reviewed articles to
be included as well and presented in standard citation format
listingall authors with your name underlined)
0. PAPERS PRESENTED IN LOCAL>INTERNATIONAL MEETINGS (local
and non5peer reviewed presentations with you as the presenter to be
included as well6 list allinvestigators#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 andcompletion dates of
pro*ects7 any associated ualifications#degree and duration of
pro*ect)
N $
File" ' ?> [email protected] 0
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G. SPECIAL S*ILLS > INTERESTS > HOBBIES (including
achievements you have in areas outside medicine)
1. NAME AND CORRESPONDENCES OF THREE REFEREES (+lease nominate
those having wor$ed with you in the same wor$place in the last 01
months of basicsurgical training7 not more than one from each
recognised training rotation7 and exclude supervisors fillingin
your S /s7 i.e. B8anagerC shown in the S /. BSecond 8anagerC and
B4ountersigning 8anagerC in theS / can be invited. +lease ensure
accuracy of the refereesA email address as communication will
normallybe 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
withinstitutions or individuals as part of the selection and
matching process.
NAME
SIGNATURE DATE
File" ' ?> [email protected] >
P,$ /$ r$ .r! $ +o 3,$ $% or @" F.,, S$ O 6H*ICBSC A//$// $! For
For B /"+ S.rg"+ ,Tr "!"!g7 o Mr V"!+$! CHEUNG o $ HAHO C,./ $r S$r
"+$/ D" "/"o! o! or &$ or$ 12 O+ o&$r2011 ( $%) " !' o $
o,,o@"!g $ !/
Po/ R :2=N Ho/3" , A. or" ' B.",%"!g 1
