1. During the time of your primary medical degree, were you awarded prizes, awards or distinctions? Were you involved in research or quality improvement projects that are otherwise not credited anywhere else on this form (i.e. publications or presentations). Prizes, awards, distinctions, research and quality improvement projects AFTER the end of your primary medical degree will not count for this section. * (Option list (choose one))

   Maximum score: 5

   Notes: National means that participation is routinely extended to, and accepted by, anyone in the country; as implied, international means participation extends beyond this. For national neurosurgery selection, all of the UK nations are considered to be nations for scoring purposes.

   Evidence to upload: Full dates about undergraduate medical degree. EVIDENCE OF PRIZES, AWARDS: through either certificates or official letters awarding prizes EVIDENCE OF DISTINCTIONS/HONOURS: shown through either certificates or official letters awarding these distinctions/honours. EVIDENCE OF RESEARCH: This should be presented as an abstract of the research work. The following must be included - • Title of project • Background – why was this important • Methodology • Results • Discussion of importance of findings • Your involvement in this project. This document should be signed off by your research supervisor. EVIDENCE OF AUDITS AND QUALITY IMPROVEMENT PROJECTS: The following must be reported - • Title of project• Background – why was this important• Aim • Method of baseline data collection• Method of subsequent data collection after change implemented. • Method of planning and implementing changes • Stakeholder engagement • Evaluation of results and plan for maintaining changes • Reflection on learning. This document should also be signed off by the Consultant Supervisor. A copy of the audit form can be found on the National Neurosurgery ST1 & ST2 Webpage.

   • Awarded NATIONAL or INTERNATIONAL prize in full competition at undergraduate level : 5
   • Two or more local prizes OR Distinction in more than one area OR Led a research project OR Led an audit/quality improvement project : 2
   • One local prize OR Distinction awarded in one single area. OR Involved in a research project (that is not listed anywhere else on this form (e.g. a publication or presentation) OR Involvement in a quality improvement project (e.g. to collect data) : 1
   • No prizes, awards or distinctions No research No audit/quality improvement : 0

2. During the time of your primary medical degree, what experience of Neurosurgery did you obtain? * (Option list (choose one))

   Maximum score: 5

   Notes: Clinical neurosciences include: • NEUROSURGERY • NEUROLOGY • PSYCHIATRY• NEUROPHYSIOLOGY Allied specialities include: • TRAUMA • PAEDIATRICS

   Evidence to upload: Must upload evidence of completing these electives as well as the dates/duration.

   • Two or more separate electives or clinical attachments in the clinical neurosciences or allied fields in non-home institution of at least 4 week duration each : 5
   • Two or more separate electives or clinical attachments in the clinical neurosciences or allied fields in own institution of more than 2 weeks each : 3
   • One elective or clinical attachment in the clinical neurosciences or allied fields in non-home institution of at least 4-week duration : 2
   • One elective or clinical attachment in the clinical neurosciences or allied fields in non-home institution of at least 2 weeks duration : 1
   • One elective or clinical attachment in the clinical neurosciences or allied fields in own institution of more than 2 weeks : 1
   • Electives or clinical attachments in the clinical neurosciences or allied fields in own institution of 2 weeks or less or no electives or attachments : 0

3. FROM the end of your primary medical degree, what experience of neurosurgery did you obtain? * (Option list (choose one))

   Maximum score: 2

   Notes: You may count any FY2 neurosurgery post that you are due to undertake before the end of Foundation Training. For Non-UK applicants any posts that are equivalent to the UK Foundation Programme can be counted.

   Evidence to upload: List of continuous employment history from end of medical school to date of interview. Specialty must be specified for each post. Evidence of completion of training posts. For non-training posts please provide a copy of the front page of your contract of employment which includes dates. For locum positions, specify dates and specialty for each post. If the front page of your contract does not include both start and finish dates other evidence will be required to confirm duration of post e.g. Letter from HR/Head of Service/Supervising Consultant

   • 4 month FY2/FY1 post in neurosurgery (you can count any posts that you are due to undertake before the end of Foundation Training) : 2
   • A ‘taster’ week/observership in neurosurgery : 2
   • No postgraduate experience of a neurosurgical post : 0

4. What is your highest postgraduate qualification? * (Option list (choose one))

   Maximum score: 5 points

   Notes: EXCLUSIONS: MD (as a basic medical degree, equivalent to MB BS) and MS (where not requiring completion of a thesis, or where thesis contributes < 50% marks). Non-UK higher degrees should be stand-alone qualifications, not integral to primary medical qualification, with regulations equivalent to the relevant UK qualifications. Intercalated degrees (BSc or masters level) do not count, but MB PhD programme will.

   Evidence to upload: Copies of degree certificates / thesis & submission

   • PhD or MD by research (can include non-medical related qualifications) NOTES: You undertook research involving original work, usually of at least two to three years’ duration, and ideally resulting in one or more peer-reviewed publication. A majority of the time during the period should have been dedicated to research rather than clinical training. To score yourself for an MD it should meet the UK definition of an MD: A supervised research degree for students already registered with the General Medical Council, is studied full time over 2 years or 4 years part time awarded a doctorate if your thesis is judged to represent an original contribution to knowledge in your chosen area : 5
   • Masters level degree eg MSc, MA, MRes, MPhil, MCh, etc. (can include non-medical qualifications). NOTES: This must be a specific course that usually lasts for three university terms (or equivalent) and is eight months’ or more duration (full time equivalent); it must not be claimed for upgrading a bachelor’s degree without further study as is offered in some universities. Please do not include Masters in Education in this section. This is credited in question 12. You cannot claim this option for qualifications which are gained as part of a programme where a substantial amount of time was spent in clinical training. Peer reviewed PhD/MD theses (as above) which have been submitted, but not yet awarded, will be counted in this category. : 3
   • Other relevant postgraduate diploma or postgraduate certificate. Qualifications unrelated to medicine cannot be claimed for in this option. NOTES: You can claim this option for an MD or masters degree (by teaching, usually including a dissertation), where a substantial amount of time was spent in clinical training and being taught; the dissertation is a smaller part of the programme, not usually involving new research. These qualifications typically last between one and ten months (whole-time equivalent). Any part of the MRCS could be claimed in this section. Please do not include PGCert or PGDip in Education in this section. This is credited in station 12. It is not permissible to claim points for partially completed qualifications - eg 1 year of a three-year degree. For a qualification to count, the eligibility criteria must specify that only graduate entrants can apply. : 1
   • None/other : 0

5. Have you any experience of postgraduate research? This has to be AFTER THE END OF PRIMARY MEDICAL DEGREE. * (Option list (choose one))

   Maximum score: 5 points

   Evidence to upload: Evidence from certificate or official grant award letter/email. This must include funding body, evidence that you have been awarded this grant (i.e. not as a co-applicant) and the amount of the grant.

   • Recipient of a research grant as principal grant holder with a total of £25,000 or more : 5
   • Recipient of a research grant as principal grant holder with a total of £10,000 - £25,000 OR NIHR Associate PI for a clinical study. : 3
   • Recipient of a research grant as principal grant holder with a total of £2,000 - £10,000 OR Evidence of local PI for a multicentre study from NANSIG or BNTRC : 2
   • Substantive role in a completed research project or recruitment to a major portfolio study (Not recognised elsewhere in application i.e. not yet presented or published) OR Recipient of a research grant as a co-applicant. OR Recipient of a research grant as principal grant holder with a total of less than £2,000 : 1
   • No or Limited involvement in research e.g. data collection only : 0

6. Have you any postgraduate prizes or awards? This has to be AFTER THE END OF PRIMARY MEDICAL DEGREE. * (Option list (choose one))

   Maximum score: 5 points

   Notes: National means that participation is routinely extended to, and accepted by, anyone in the country; as implied, international means participation extends beyond this. For national neurosurgery selection, all of the UK nations are considered to be nations for scoring purposes.

   Evidence to upload: Evidence from certificate or official letter.

   • Major national or international award reflecting outstanding achievement : 5
   • Two awards or prizes awarded on a local or regional basis. Prizes should be for different pieces of work and in different areas : 3
   • Second or third place in a major national or international award reflecting outstanding achievement. : 2
   • Two awards or prizes awarded on a local or regional basis. Prizes should be for different pieces of work and in different areas. : 2
   • One awards or prizes awarded on a local or regional basis : 1
   • No awards and prizes : 0

7. Do you have any publications? * (Option list (choose one))

   Total score: 5 points

   Notes: Publications will only be accepted if a full citation (including PMID number) is provided. The panel will only consider publications in Pub — Med cited journals (hence need for the PMID). Please state clearly where you are on the author list. Failure to do so will assume you are a co-author. Published abstracts and letters will be excluded. ‘Formally accepted’ papers will be counted. Books must have an ISBN number (books related to exam revision or interview preparation courses will not count). Recognised Pub — Med journals can be found here: https://www.nlm.nih.gov/bsd/serfile_addedinfo.html

   Evidence to upload: Publication citation that includes all the authors, title, year, full reference and the PMID as found on PubMed. Please Citations must be in ANSI/NISO Z39. 29-2005 (R2010) Bibliographic References standard (used in PubMed). (Acceptance letters for ‘formally accepted’ publications.)

   • First-named author in 3 or more papers relevant to the clinical neurosciences and neurosurgery (excluding case reports). NOTES: Can include joint first author : 5
   • First-named author in 2 papers relevant to the clinical neurosciences and neurosurgery (excluding case reports). NOTES: Can include joint first author : 3
   • First-named author in a peer- reviewed paper (not a case report). This paper doesn’t have to be relevant to the clinical neurosciences and neurosurgery. OR Named author in three or more peer reviewed journal articles (only including 1 case report paper in this total). NOTES: Can include joint first author : 2
   • First author of a chapter in a book related to medicine in its broadest sense (this does not include self-published books). NOTES: This refers to medicine in its broadest sense and not just hospital medicine. Books must be published by an independent publishing house, ie not self-published. : 2
   • Named co-author in 1 or 2 peer-reviewed papers. OR Named first author of a case report paper. OR Co-author of a book chapter relevant to neurosurgery. NOTES: Does not include publications where the author is listed as a contributor, only those where they are named. Books must be published by an independent publishing house, ie not self-published. : 1
   • No publications OR Letter to editor OR Published Abstracts OR E-comments OR Pay to publish journal articles OR Pre-publication archives. OR Publications where the author is listed as a contributor, but not named in the author list. : 0

8. Have you any presentations? Include mode of presentation (oral/poster), meeting title and type (International/National/Regional). Maximum 150 words per summary. * (Option list (choose one))

   Total score: 5

   Notes: Each presentation should be on different project. National means that participation is routinely extended to, and accepted by, anyone in the country; as implied, international means participation extends beyond this. For national neurosurgery selection, all of the UK nations are considered to be nations for scoring purposes. Examples of International / National meetings SBNS, BNRG, any of the subspeciality group meetings. Please note that local or regional meetings that occur abroad will not be recognised as an international meeting. Regional means that participation is confined to, for example, a county, medical training region, health authority, extending beyond a city. Local means participation is confined to a local hospital (or a recognised cluster of hospitals) or university setting. Accepted presentations / posters that have not yet been given will not be counted. Presentations must be original work (e.g. teaching presentations will not be accepted) Online Meetings / Conferences will not be accepted. Collaborative work will only be considered as a presentation if there is clear evidence that you had a significant role in the project such as in the design of the study, data analysis or delivery of the presentation, and you presented this. Each project will only be counted once even if presented at more than one meeting.

   Evidence to upload: For each presentation, include mode of presentation (oral/poster), meeting title and type (International/National/Regional). Maximum 150 words per summary. Please provide a copy of the relevant page of the meeting programme(s). Please provide certificate of presentation. If not available a supervisor should sign and date with registration number stating, you presented the work. The Selection Design Group Station Leads will be the final arbitrators regarding legitimate conferences and duplicate presentations Any probity issues will be reported to the GMC

   • I presented THREE OR MORE oral presentations in which I was a first author at a national or international medical meeting on 2 or more different subjects/ areas of research within the last 4 years. : 5
   • I presented TWO oral presentations in which I was a first author at a national/ international medical meeting within the last 4 years : 3
   • I presented ONE oral presentation in which I was a first author at a national/ international medical meeting within the last 4 years : 2
   • Oral presentations to regional meetings or societies. : 1
   • Poster presentations at national/ international meetings within the last 4 years : 1
   • None or Departmental presentations only : 0

What are your two best audits or quality improvement projects?

9. Audit 1 * (Option list (choose one))

   Max score: 3

   Notes: Audits will not be considered without a supporting, completed audit form for each audit. A copy of the audit form can be found on the National Neurosurgery ST1 & ST2 Webpage https://www.yorksandhumberdeanery.nhs.uk/recruitment/national_recruitment/national_neurosurgery_st1__st3_recruitment/ Evidence:Audit form 1 - You need to complete one audit form per audit. If you have been involved in a long-running multi-cycle project, you can only claim points based on the cycles in which you were directly involved. The following audits will score 0 points, regardless of involvement: VTE, notes/handwriting, WHO checklist, pre/post teaching or course.

   • Involvement in all aspects of a cycle of an original QI project where you can demonstrate a leadership capacity by supervising other members of the team. NOTES: In addition to the requirements for the option immediately below, you should be able to demonstrate that you undertook a significant leadership role within the project. This should include designing the project, playing a leading role in the project delivery and supervision of other members of the team. : 3
   • Involvement in all aspects of a cycle of a QI project. NOTES: For example, you participated in all stages of a PDSA cycle (or similar) or were involved in planning, data collection, data analysis and change, as well as a further cycle. It is likely that this involved working as part of a team but you must evidence your own role within the QI activity for all stages : 2
   • Participating in QI activity - this requires involvement in one aspect of a completed, multi-cycle QI project OR involvement in two or more aspects of a single cycle QI project. NOTES: For example, you were only involved in data collection in a multi-cycle project OR you were involved in data collection and analysis in a single cycle project. You cannot choose this option if you were only involved in a single aspect of a single cycle project; for example you only collected data in a single cycle of a project. : 1
   • None/other NOTES: This includes VTE, notes/handwriting, WHO checklist, pre/post teaching or course : 0

10. Audit 2 * (Option list (choose one))

Max score: 3

Notes: Audits will not be considered without a supporting, completed audit form for each audit. A copy of the audit form can be found on the National Neurosurgery ST1 & ST2 Webpage https://www.yorksandhumberdeanery.nhs.uk/recruitment/national_recruitment/national_neurosurgery_st1__st3_recruitment/ Evidence: Audit form 2 - You need to complete one audit form per audit. If you have been involved in a long-running multi-cycle project, you can only claim points based on the cycles in which you were directly involved. The following audits will score 0 points, regardless of involvement: VTE, notes/handwriting, WHO checklist, pre/post teaching or course.

• Involvement in all aspects of a cycle of an original QI project where you can demonstrate a leadership capacity by supervising other members of the team. NOTES: In addition to the requirements for the option immediately below, you should be able to demonstrate that you undertook a significant leadership role within the project. This should include designing the project, playing a leading role in the project delivery and supervision of other members of the team. : 3
• Involvement in all aspects of a cycle of a QI project. NOTES: For example, you participated in all stages of a PDSA cycle (or similar) or were involved in planning, data collection, data analysis and change, as well as a further cycle. It is likely that this involved working as part of a team but you must evidence your own role within the QI activity for all stages : 2
• Participating in QI activity - this requires involvement in one aspect of a completed, multi-cycle QI project OR involvement in two or more aspects of a single cycle QI project. NOTES: For example, you were only involved in data collection in a multi-cycle project OR you were involved in data collection and analysis in a single cycle project. You cannot choose this option if you were only involved in a single aspect of a single cycle project; for example you only collected data in a single cycle of a project. : 1
• None/other. NOTES: This includes VTE, notes/handwriting, WHO checklist, pre/post teaching or course. : 0

11. Have you been involved in medical teaching / training delivery? * (Option list (choose one))

Maximum score: 4

Notes: Online courses will not be considered. Involvement in, or organisation of, medical student teaching programmes will score a maximum of 2 points. Definition of a “course” (for application purposes): A “course” is defined as a structured, educational or professional development event that: • Runs for one full day or multiple consecutive days• Has at least 15 delegates in attendance• Centres on a clear, defined topic or subject area, and • Incorporates both pre-course and post-course feedback to evaluate learning outcomes and participant satisfaction Evidence: Signed letter of support from a consultant supervisor (or equivalent) clearly stating the nature and level of your involvement. Print of the agenda of any courses with the candidate shown as part of the faculty.

• Formal teaching role for 6 months or more. NOTES: Minimum 50% WTE for at least 6 months duration : 4
• Developed and led a course with evidence of a published programme AND formal participant feedback. NOTES: Need to demonstrate the leadership with evidence of being the course organiser. : 3
• Faculty of a course with evidence of a published programme AND formal participant feedback. : 2
• Development of teaching/educational materials e.g. apps, leaflets, course adjuncts : 1
• Talks given to members of the public Evidence of regular teaching commitment to clinical professionals e.g. medical students, nurses etc. NOTES: Minimum frequency of monthly for at least 6 months. : 1
• None or Ad hoc teaching commitment. NOTES: Less than monthly for at least 6 months. : 0

12. Do you have a qualification in medical education? * (Option list (choose one))

Maximum score: 3

Evidence to upload: Copy of certificate.

• Masters in education : 3
• Postgraduate Diploma (PGDip) in education : 2
• Postgraduate Certificate (PGCert) in education : 1
• Associate Fellowship of Advance HE (Higher Education) : 1
• None : 0

13. Have you been involved in leadership? * (Option list (choose one))

Maximum score: 4

Notes: National means that participation is routinely extended to, and accepted by, anyone in the country; as implied, international means participation extends beyond this. For national neurosurgery selection, all of the UK nations are considered to be nations for scoring purposes. Regional means that participation is confined to, for example, a county, medical training region, health authority, extending beyond a city. Local means participation is confined to a local hospital (or a recognised cluster of hospitals) or university setting.

Evidence to upload: Must provide evidence to demonstrate role within societies. This could include letters of appointment or certificates of appointment to a society leadership role. The Selection Design Group Station Leads will be the final arbitrators regarding legitimate conferences and duplicate presentations. Any probity issues will be reported to the GMC.

• Chair of a national or international body. Notes: This may include captain of a national or international team : 4
• Vice Chair, Secretary or Treasurer of a major national or international body. Notes: This may include vice-captain, secretary or treasurer of a national or international sports team : 3
• Chair of a local or regional body. Notes: This may include captain, secretary or treasurer of a sporting or other University Society : 2
• Vice Chair, Secretary, or Treasurer of a local or regional body Notes: This may include vice-captain, secretary or treasurer of a sporting or other University Society : 1
• Evidence of leadership in LOCAL committee work. Notes: This would include ROTA CO-ORDINATOR or JUNIOR DOCTOR REPRESENTATIVE on committees : 1
• No evidence of leadership : 0