CONFIDENTIAL

INTERCOLLEGIATE MRCS EXAMINATION

Application to become an Examiner

Personal Details

Name: ______________________________________________________________________________________________________
Surname Initials Preferred first name

Title: ___________________________________ Date of Birth: ___________________________________________________

Mr/Mrs/Miss/Ms/Dr/Prof/Other

______________________________________________________________________________________________________
Specialty Sub-speciality interest GMC / IMC Number (if applicable)

Home Address: _____________________________________________________________________________________________________

______________________________________________________________________________________________________
Post Code

_______________________________________________________________________________________________________
Home phone Home e-mail

Name of Hospital (if applicable): _____________________________________________________________________________________

Work Address (rooms or hospital): _____________________________________________________________________________________

_______________________________________________________________________________________________________
Post Code

______________________________________________________________________________________________________
Hospital/rooms telephone number Hospital/rooms fax number

______________________________________________________________________________________________________
Mobile/bleep number Work e-mail address

Education
Qualifications Obtained (including degrees, diplomas, professional examinations). Evidence may be requested:
Exam/Qualification Grade Year Exam/Qualification Grade Year

V8. 1
CONFIDENTIAL
Hospital and Medical Appointments (current appointment first and then those relevant to the application)

Name and Address Position held Dates Specialty

From To

Training/teaching/examining/education experience: (continue on a Dates

separate sheet if necessary)

V8. 2
CONFIDENTIAL

Personal Statement
Please explain why you are interested in examining and what qualities you would bring to the position of examiner. Where
possible, please cite evidence of your commitment.

Examiner Type
I am applying as a (please tick as appropriate):

Clinician anatomy
pathology
physiology

Examiner of the basic sciences: anatomy

pathology
physiology

V8. 3
CONFIDENTIAL

Referees:
References may be sought from applicants. Please supply the names, addresses and telephone numbers of two
referees who can provide an independent view on how you meet the eligibility criteria and the person
specification (see page 6).
1st Referee 2nd Referee
Contact Name: Contact Name:

Employing Organisation: Employing Organisation:

Address: Address:

Telephone Number: Telephone Number:

Fax Number: Fax Number:

E-mail address: E-mail address:

Data Protection Act of 1998 and Freedom of Information Act 1998:

I understand that, if I am appointed, personal information about me will be computerised for
personnel/administrative purposes and statutory returns

Notification of Chief Executive / Medical Director:

Given the time spent away from the employing authority when examining, it is expected that a potential examiner
will inform his/her Chief Executive / Medical Director of his/her application to become an Intercollegiate MRCS
examiner, and list this commitment in his/her job plan.

I confirm that I have informed my Chief Executive/Medical Director of my application to become an

Intercollegiate examiner

Name of Chief Executive / Medical Director:

Signature of Chief Executive / Medical Director: _______________________________________________________

I confirm that I will, if appointed, honour examining commitments faithfully. I certify that I conform to the
eligibility criteria and that the information I have given above is to the best of my knowledge correct.

Signed:___________________________________________ Date:________________________________

For official use:

Date Received Date Acknowledged Criteria Met

/ / / / Yes / No

V8. 4
CONFIDENTIAL

EQUAL OPPORTUNITIES MONITORING (OPTIONAL)

In line with UK legislation and good practice guidelines, we are asking everyone to complete this section. You are not
obliged to provide any of the information in this section, but if you do so, it will enable us to monitor our business
processes and ensure that we provide equality of opportunity to all. This form will be detached from your application.

Gender
 Female Ethnicity
 Male Choose one selection from the list below to
indicate your cultural background.
Nationality……………………….
a) White
Do you consider your first language to be
English?
 British
 Yes  Irish
 No  Any other White background

Do you have a disability under the terms of b) Mixed

the Disability Discrimination Act 1995 (a  White and Black Caribbean
person with a physical or mental impairment  White and Black African
that affects you ability to carry out normal day  White and Asian
to day activities which are substantial, adverse  Any other mixed background
and long term)?
c) Asian or Asian British
 Yes  Indian
 No  Pakistani
 Bangladeshi
What is your sexual orientation?  Any other Asian background

 Bisexual d) Black or Black British

 Heterosexual  Caribbean
 Lesbian or Gay  African
 Any other Black background

What is your religion or belief? e) Chinese or other ethnic group

 Chinese
 Buddhist  Any other background
 Christian
 Hindu f) Middle Eastern/Arabic
 Jewish  Arabic
 Muslim  Any other Middle Eastern Background
 Sikh
 Other religion/belief Indicate a more specific category here:

Indicate a more specific category here:

______________________________

This information will be recorded electronically with your other data in accordance with the Data Protection
Act 1998, but used only for monitoring our business practices.

V8. 5
CONFIDENTIAL
APPOINTMENT TO INTERCOLLEGIATE MRCS PANEL OF EXAMINERS

1. ELIGIBILITY CRITERIA

 Fellow (including Fellow ad eundem) of one of the four Royal Surgical Colleges
or
 Fellow (including Fellow ad eundem) of the Royal College of Anaesthetists
or
 Holder of equivalent basic science qualification

 Hold or have held full consultant status (clinicians only) (not a locum post) for at least 2 years post
CCST or equivalent

 Engaged in active clinical/academic practice (clinical practice essential for clinical examination)

 (Clinical examiners only) able to complete one term of office before retirement i.e one full term (6
years including probationary year)

 Active in postgraduate surgical training/education/teaching

 In good standing with the College / Professional Organisation.

 In good standing with the GMC / IMC or equivalent body and not under investigation by an NHS
Trust / employing body.

 Able to provide the names and contact details of two referees

2. PERSON SPECIFICATION

In addition to meeting the eligibility criteria, examiners must show commitment to

 High professional standards as an examiner, including understanding of appropriate techniques and

a policy of courtesy, fairness and non-discrimination towards all candidates
 High professional standards in teaching, including an ability and positive attitude towards teaching
 Competence in and loyalty to the surgical profession
 Commitment to the examination process, i.e. honouring commitments to write questions and attend
examinations, except in exceptional circumstances
 Commitment to ongoing assessment, training and development as an examiner

3. LIST OF POSSIBLE REFEREES

 Postgraduate Tutor in your Trust

 Medical Director
 Postgraduate Dean
 Programme Director
 Regional Specialty Advisor or Regional Advisor
 Head of any academic Department of Surgery