SUB-SPECIALITY CERTIFICATION
 
APPLICATION FORM
 
Contact Details
Name Institute
Address
Postal Code
City
Country
Telephone
Fax
E-mail
Type Institute
 
Date
Name head of department
Name director of sub-specialty programme
 
A. General Information
1. Statistics Hospital Department of Urology
Number of beds Total
  Adult
  Paediatric
  Day care
Number of admissions per year
Number of outpatients per year Total N/A
  Adult N/A
  Paediatric N/A
 
2. Department of Urology
Number of qualified urologists  
Number of qualified in other specialties  
Number of residents  
Number of Fellows  
 
3. Diagnostic Facilities (tick when appropriate)
Ultrasound
Endoscopic unit
Urodynamic unit
Interventional radiology
CT
MRI
Angiography
Nuclear Medicine
Other  
 
B. SUB-SPECIALTY INFORMATION
4. Type of sub-specialty you are applying for
5. Is the centre a referral hospital? Yes  No
6. Number of population serving in the sub-specialty
7. Number of patients investigated per year
8. Number of patients treated per year
 
9. List sub-specialised consultants
# Name Specialty


10. List and describe the equipment used specifically for the sub-specialty
11. List and describe the treatment modalities
12. List the number of patients treated with different treatment modalities
# Year Treatment Modality Number of Patients


13. List and describe the collaboration with the supporting specialties
14. Treatment Conferences
14.1 Are there regular conferences within your own department or
with collaborating departments?		 Yes  No
14.2 Describe how the optimal treatment modality is selected in each individual case
14.3 Who is invited to participate?
14.4 How often are the conferences held?
15. Protocols & Registration
15.1 Are follow-up protocols for different treatment modalities available?
When available, provide copy. 		Yes No
15.2 Are follow-up protocols available for failures or complication?
When available, provide copy.		 Yes No
16. Are results of the different treatment modalities registered in databases? Yes No
17. List the treatment results for each treatment modality performed in the last 3 years.
Note: This overview cannot be replaced by copies of posters or publications.
In case the results are published, indicate the reference in the publication list.



18. Post-graduate Fellowship Programme
18.1 Is there a post-graduate Fellowship programme? Yes No
18.2 How many Fellows have been trained in the last two years?
18.3 Are there currently any Fellows in training? Yes No
18.4 Is surgical training or other practical training included in the Fellowship? Yes No
18.5 What kind of certificate is required to perform hands-on training?
18.6 How would the applicant obtain this certificate?
18.7 How is the Fellowship programme financed?
18.8 Do Fellows take part in activities other than related to the sub-specialty? Yes No
18.10 What kind of language skills are required?
18.11 Are there possibilities to be accommodated in/nearby the institute? Yes No
18.12 Number of Fellowship positions offered at the same time
18.13 Number of Fellows present at the same time
18.14 Number of supervision consultants
18.15 Could you provide us with the contact details of Fellows
who completed the Fellowship programme over the last three years?		 Yes No
19. Do you train residents at the same time? Yes No
20.1 Is there any financial connection to industry? Yes No
 

FELLOWSHIP PROGRAMME DESCRIPTION
PLEASE READ THE INSTRUCTIONS BEFORE COMPLETING THE FORM!
 
General
Name Programme
Target Group
Previous Knowledge Required
Previous Knowledge Preferred
Length of Programme (in months)
GENERAL AIM
GOALS - What are the specific goals of the programme?
To archieve these goals, the following objectives will be met
List what the Fellow should be able to know or do after participating in the programme
WAYS OF WORKING - List how work will be done to achieve the specific goals
ASSESSMENT - How is the Fellow assessed at the end of the programme?