Centre Application Form – Arrhythmias and CP
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Centre Application Form – Arrhythmias and CP Document Transcript

  • 1. EUROPEAN HEART RHYTHM ASSOCIATION A Registered Branch of the ESC APPLICATION FORM: TRAINING CENTRES TRAINING FELLOWSHIP PROGRAMME FOR CARDIAC PACING WITH EMPHASIS ON ICD/CRT THE EUROPEAN HEART RHYTHM ASSOCIATION (EHRA) A Registered Branch of the ESC To improve the quality of life of the European population by reducing the impact of cardiac arrhythmias. The European Heart House – 2035 route des Colles – Les Templiers – BP 179 – 06903 Sophia Antipolis Cedex – France Web site: www.escardio.org/EHRA - Email contacts: EHRA@escardio..org
  • 2. EUROPEAN HEART RHYTHM ASSOCIATION A Registered Branch of the ESC APPLICATION FOR THE EHRA TRAINING FELLOWSHIP (ICD/CRT) Thanks to educational support from Sorin, the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC), is offering a Training Fellowship Programme available to qualified Medical Doctors and Cardiologists working in the field of Arrhythmias and Cardiac Pacing. Unlike other programmes, we invite separate applications from both, individuals and centres, to be matched exclusively by the EHRA Training Fellowship Committee. The starting period for applications is 15 September 2009. The deadline for applications is 15 December 2009, with a start date within the calendar year 2010. Prior to completing this form, please read the Rules and Regulations for the EHRA Training Fellowship Programme for cardiac pacing with emphasis on ICD/CRT. Application forms are available on the EHRA website: www.escardio.org/EHRA, section: Training Fellowships All parts of the application must be returned by 15 December 2009 in paper (letter) form to: The EHRA c/o ESC Office for Associations 2035 Route des Colles, Les Templiers, B.P. 179 06903 Sophia Antipolis, France Email : EHRA@escardio.org Any application received by fax and/or e-mail only To improve the quality of life of the European population by reducing the impact of cardiac arrhythmias. The European Heart House – 2035 route des Colles – Les Templiers – BP 179 – 06903 Sophia Antipolis Cedex – France Web site: www.escardio.org/EHRA - Email contacts: EHRA@escardio..org
  • 3. EUROPEAN HEART RHYTHM ASSOCIATION A Registered Branch of the ESC or received after the before mentioned deadline will not be acceptable. PART A: 1a Name of Centre: 1b Address of Centre: Phone number * Fax number * Email *These fields are not mandatory ___________________________________________________________________ To improve the quality of life of the European population by reducing the impact of cardiac arrhythmias. The European Heart House – 2035 route des Colles – Les Templiers – BP 179 – 06903 Sophia Antipolis Cedex – France Web site: www.escardio.org/EHRA - Email contacts: EHRA@escardio..org
  • 4. EUROPEAN HEART RHYTHM ASSOCIATION A Registered Branch of the ESC HEAD OF DEPARTMENT APPLYING FOR EHRA TRAINING FELLOWSHIP 2a Name and title: 2b Name and address of Department: Phone number * Fax number * Email *These fields are not mandatory ___________________________________________________________ 3 Name and position of proposed Fellowship Supervisor: Phone number * Fax number * Email *These fields are not mandatory __________________________________________________________ 4 Name and title of Administrator for the Fellowship Programme: Phone number * Fax number * Email *These fields are not mandatory ____________________________________________________ 5 Please state in a few words 5a Why the centre is appropriate for this training and how it will ensure that candidates meet their objectives: To improve the quality of life of the European population by reducing the impact of cardiac arrhythmias. The European Heart House – 2035 route des Colles – Les Templiers – BP 179 – 06903 Sophia Antipolis Cedex – France Web site: www.escardio.org/EHRA - Email contacts: EHRA@escardio..org
  • 5. EUROPEAN HEART RHYTHM ASSOCIATION A Registered Branch of the ESC 5b How many fellows and from which countries, did you train for at least 6 months, over the last 5 years? 5d Could you please give a starting date to welcome the fellow? 5e Could you specify if their activities were orientated more on Basic Science, Clinical research or both ? 5f Short description of the training you provide to training fellows? __________________________________________________________ 6a Please provide information on the how many of the following procedures are carried out in your centre each year: • Implantation: • Pacemaker and ICD: • Bi-Ventricular: • ICD: • Lead extraction: • Catheter Ablation: • Afibrillation: • VT: • LA Tachycardia: • SVT: 6b How many fully recognised EP are working in your centre? 6c Does the Department have access to the following facilities: (Delete as appropriate) To improve the quality of life of the European population by reducing the impact of cardiac arrhythmias. The European Heart House – 2035 route des Colles – Les Templiers – BP 179 – 06903 Sophia Antipolis Cedex – France Web site: www.escardio.org/EHRA - Email contacts: EHRA@escardio..org
  • 6. EUROPEAN HEART RHYTHM ASSOCIATION A Registered Branch of the ESC 1(i) At least one dedicated EP lab YES / NO 2 6d Is a minimum of 1 implantation procedure performed daily? (Delete as appropriate) YES / NO 7 Could you please indicate if you have a fellow to suggest? _________________________ 8 Can you certify that all the educational activities will be delivered in English? YES / NO ___________________________________________________________ 9 Do you have restrictions to welcome foreigners? What are the requirements in your country and/or your centre: • Working permit? YES / NO • To be compliant with the EU regulation 36-2005, does the applicant need to speak the native language of your country? YES / NO If YES: Required level Basic / Fluent Is this level required upon his/her arrival already YES / NO Does the applicant need to provide a certificate on the native language of the country to be able to work on patients? YES / NO If NO: Please indicate which language(s) the applicant needs to speak: PLEASE BE AWARE THAT COMPLIANCE WITH THE EU REGULATION 36-2005 REMAINS THE RESPONSIBILITY OF YOUR CENTRE AND EHRA CANNOT BE HELD RESPONSIBLE FOR ANY INFORMATION / REQUIREMENT THAT YOU HAVE NOT MENTIONED. • Others requirements? To improve the quality of life of the European population by reducing the impact of cardiac arrhythmias. The European Heart House – 2035 route des Colles – Les Templiers – BP 179 – 06903 Sophia Antipolis Cedex – France Web site: www.escardio.org/EHRA - Email contacts: EHRA@escardio..org
  • 7. EUROPEAN HEART RHYTHM ASSOCIATION A Registered Branch of the ESC ___________________________________________________________ 10 As part of the Programme, the Department will be requested to publish documents in the Europace Journal or in a peer journal. Please give the references of three recent papers on cardiac pacing/defibrillation published from your institution in an international peer-reviewed cardiology journal (authors, title, journal, pages): Acceptance and Conditions: I am aware that as a Training Centre in the EHRA Training Fellowship Programme, for all fellows appointed by EHRA, there will be a fixed-term contract of engagement for the period of the fellowship between the fellow and the Centre. This is a non-salaried position although the fellow would benefit from all the usual employee benefits of the Training Centre as well as any state benefits relating to sickness. I confirm that I have read and understood the Rules for the EHRA Training Fellowship Programme for cardiac pacing with emphasis on ICD/CRT and that, if an appointment is made, the fellow would be accepted in the Department in accordance with the regulations and terms of employment for the EHRA Training Fellowship Programme. I expressly agree to Paragraph 1.3 of the Terms and Conditions contained in the before mentioned Rules. The EHRA undertakes to respect the confidentiality of personal data according to the Law on data processing and Civil Liberties 78-17 of 6 January 1978, including the absolute right to access, amend and oppose any use of this personal data by contacting in writing the EHRA, at the following address: European Heart Rhythm Association, Training Fellowship Programme, 2035 Route des Colles, Les Templiers, BP 179, 06903 Sophia Antipolis, France. Signature of Head of Department: Date: Signature of Supervisor: Date: Signature of Administrator: Date: To improve the quality of life of the European population by reducing the impact of cardiac arrhythmias. The European Heart House – 2035 route des Colles – Les Templiers – BP 179 – 06903 Sophia Antipolis Cedex – France Web site: www.escardio.org/EHRA - Email contacts: EHRA@escardio..org
  • 8. EUROPEAN HEART RHYTHM ASSOCIATION A Registered Branch of the ESC You have personal data, which is, according to the Law on data processing and Civil Liberties 78-17 of 6 January 1978 modified, registered with the European Society of Cardiology (ESC). The information you supply will be held in the ESC customer data files and may be used for marketing and communication purposes by the ESC only. You have the absolute right to access, amend and oppose any use of this personal data by writing to the ESC at the address mentioned below or by email at usercontact@escardio.org European Society of Cardiology – User Relations Group 2035 Route des Colles - Les Templiers - BP 179 - 06903 Sophia Antipolis Cedex – France To improve the quality of life of the European population by reducing the impact of cardiac arrhythmias. The European Heart House – 2035 route des Colles – Les Templiers – BP 179 – 06903 Sophia Antipolis Cedex – France Web site: www.escardio.org/EHRA - Email contacts: EHRA@escardio..org