APPLICATION FORM

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APPLICATION FORM

  1. 1. Prepared by S Tekgul ( using EBU forms as reference) Ankara 13:24 20.10.2010 APPLICATION FORM PART I PARTICIPATING INSTITUTION(S) Date Name of Programme Primary Institution Affiliated Institution(s) Programme director Local Head Signature Type of department Urology/ Peeadiatric Surgery /Paediatric Urology Name of Institution Street ,no Postal code & Town Country Telephone Fax E mail Type of Institution1 Distance from Primary Institution If there is more than one institution involved in the training programme this form needs to be completed by each of the affiliated Institutions as well as the Primary institution. 1 Community hospital, private clinic, university hospital, goverment institution, military hospital, other.
  2. 2. Prepared by S Tekgul ( using EBU forms as reference) Ankara 13:24 20.10.2010 PART II DEFINE HOSPITAL TYPE: HOSPITAL STATISTICS Total Hospital ( No ) Number of beds Total Paediatric Day Care Number of admissions/year Medical Specialities Concerning Y/N Medical Specialities Concerning Y/N Child Care1 Child Care 1 Urology Oncology Radiology Radiotherapy Nuclear Medicine Renal Transplantation Neurology Neurosurgery Psychiatry ( including child care) Nephrology Paediatric Intensive care unit Dialysis Neonatal intensive care unit Emergency Department General Surgery Clinical Biology General Paediatric Surgery Vascular Surgery Microbiology Thorasic Surgery Orthopaedics Pathology Anaesthesiology Dermatology ENT Ophtalmology Internal Medicine Physical Therapy Cardiology Haematology Rheumatology Gynaecology/Obstetrics Other Perinatology Unıt 1 Please indicate if available(Y), non- existant (N)
  3. 3. Prepared by S Tekgul ( using EBU forms as reference) Ankara 13:24 20.10.2010 DEFINE HOW THE DEPARTMENT OF PAEDIATRIC UROLOGY IS ESTABLISHED 1 : DEFINE HOW THE DEPARTMENT IS ESTABLISHED? Main Department name (Paediatric Surgery/ Urology) Total Number of Qualified Staff Number Of Paediatric Urologists within the Staff Total Number of Residents Total Number of Fellows Number of Fellows in Paediatric Urology Urology / Paediatric Surgery Dpt ( No) Number of Beds Total Paediatric Urology Day Care Number of outpatients /year Total Paediatric Urology DIAGNOSTIC FACILITIES Y/N DIAGNOSTIC Y/N FACILITIES Ultrasound CT Endoscopy Unit MRI Urodynamic Unit Angiography Interventional Radiology Nuclear Medicine 1 Established independently , under Urology or under Paediatric surgery departments.
  4. 4. Prepared by S Tekgul ( using EBU forms as reference) Ankara 13:24 20.10.2010 Paediatric Urological Procedures Open Surgery Total Number: No/yr No/yr KIDNEY RETROPER./NODES/VASC Nephrectomy Retroperiteneum .Tumour .adrenal surgery -Wilms .Retoperitoneal Tumour -Neuroblastoma Nodes .Non Tumour .Periaortic Nephrouretectomy .Retroperitoneal Partial Nephrectomy .Pelvic Pyelolithotomy/Neprolitotomy .Inguinal Open Nephrostomy Vascular Open Biopsy . Cavotomyfor tumour thrombus Nephropexy .Microvascular orchidopexy Pyeloplasty .Other Ureterocalycostomy Other(Anomalies/Injury) URETER EXTERNAL GENITALIA Ureterotomy-ureterolithotomy Penis Uretero-uretostomy .Circusion Ureteroplasty .buried Penis Ureterectomy .Penoscrotal web Uretero-neocystostomy(No Ureters) . Penoscrotal Transposition -Extravesical .Priapism -Intravesical .Penil Curvature -Psoas Hitch Testis Remodelling of megaureter .Radical orchidopexy Surgery for ureteral duplication .Inguinal hernia External urinary diversion .Inguinal Orchidopexy Internal urinary diversion .Two stage Orchidopexy Revision urinary diversion Epididim,spermatic cord,scrotum Other .Hyrocele .varicocele .scrotum excision Other BLADDER No/yr OTHER No/yr
  5. 5. Prepared by S Tekgul ( using EBU forms as reference) Ankara 13:24 20.10.2010 Augmentation Laparotomy(explotary) .Intestinal Appendectomy .Gastric Herniorapy .Ureteral Vaginoplasty . Autoaugmentation Cliteroplasty Mitrofanoff Procedure Other Bladder Substitution Diverticulectomy Excion urachal cyst/ tumor Cystotomy/Cystostomy Extrophy Repair Cloacal Repair Fistula Trauma repair Incontinence surgery .Bladder Neck Plasty .Sling .Artificial urinary sfincter .Closure Other URETHRA TRANSPLANTATION Uretroplasty(all except Renal Transplantation Hypospadias) .Transplantation Hypospadias .Donor Nephrectomy .Distal .Transplant Nephrectomy .Penil .Revision .Penoscrotal Dialysis surgery .Chordee .CAPD .Re-do Replacement .Fistula repair Revision Epispadias .Vascular Access For dialysis Other Other
  6. 6. Prepared by S Tekgul ( using EBU forms as reference) Ankara 13:24 20.10.2010 Endoscopic Surgery Total Number: No/yr No/yr PERCUTANEOUS UPPER URETHRA TRACT Internal uretrotomy KIDNEY /URETER TUR posterior urethral valves Other Stone Stricture Other RETROGRADE UPPER TRACT LAPAROSCOPY KIDNEY/URETER Testis Stone Varicocele Stricture Kidney Internal Stends Bladder Other other BLADDER DIAGNOSTIC ENDOSCOPY TUR tumour/biopsy Urethro/cystoscopy Stone /foreign Body Ureteral catheterisation Injection therapy for reflux Urethral dilation Bladder neck injection other Other No/yr ESWL(all sessions/all sites) .Kidney .Ureter .Bladder DIAGNOSTIC& MINOR PROCEDURES 1.Interventional uroradiology .Percutaneous nephrostomy .Drainage .Percutaneous cystostomy 2.Urodynamics studies (excluding flow) .Urodynamics studies .Radio urodynamic studies .Biofeedback INVESTIGATIONAL PROCEDURES (define)
  7. 7. Prepared by S Tekgul ( using EBU forms as reference) Ankara 13:24 20.10.2010 OTHER Peritoneal catheter placement Central line placement PAEDIATRIC UROLOGY OUTPATIENT UNIT No Pts Total (per year) % New Pts (average) Total Units General Urodynamics / urotherapy Oncology Congenital defects Others(specify)
  8. 8. Prepared by S Tekgul ( using EBU forms as reference) Ankara 13:24 20.10.2010 PART III FELLOW TRAINING PROGRAMME PAEDIATRIC UROLOGY TEACHING STAFF No o Total N of positions for full time Paed. Urologists Total No of positions for part time Paed. Urologists No other specialists in the department of Paed.Urology List below those staff members who currently participiate in the education of the paeditric urology fellow Name Title Position Speciality Year of certification 1. 2 3. 4. 5. 6. 7. 8. 9. Attach a curriculum vitea of each staff member.
  9. 9. Prepared by S Tekgul ( using EBU forms as reference) Ankara 13:24 20.10.2010 FELLOWS AT PRESENT Please note that a questionnaire will be sent to the residents Name Md Training Years of Total Years graduate Years Paed. Training (Paed. (year) before Urology Surg/ Urology Paed. Training +Surgery) Urology 1. 2. 3. 4. Total number of training positions at the clinic No Duration of training in the Paediatric Urology Department ………..Months. Scheduled Rotation between Subspecialites within the institution. Subspeciality Months Urodynamics/ Urotherapy Paediatric Nephrology Paediatric Radiology Endourology / ESWL Others
  10. 10. Prepared by S Tekgul ( using EBU forms as reference) Ankara 13:24 20.10.2010 Scheduled weekly rotation Scheduled weekly work in Hours Ward Outpatient Clinic Operation theatre Administration Research Supervision Yes / No Does every fellow have a personal written training programme? Does every fellow have a personal tutor/ supervisor? Does every fellow have a personal logbook? Are all fellows supervised ? Please attach the training programme and a copy of log-book for each fellow.
  11. 11. Prepared by S Tekgul ( using EBU forms as reference) Ankara 13:24 20.10.2010 FELLOW TRAINING FACILITIES MEDICAL RECORDS Y/N Do all patients have medical report kept up date? Are patients’ records available for research? How many secretaries are working for the department ? TEACHING FACILITIES Number of conference rooms Do you have national reference facilities (e.g. Medline) ? Is there a departmental library with at least…… international paediatric urology journals ? CONFERENCES Are there regular conferences on (Please indicate frequency/ month) Pathology ……/month Radiology ……/month Morbidity/ mortality ……/month Basic science ……/month Journal club ……/month Other ……/month Are there regular teaching ward rounds? STUDY FACILITIES Do fellows have a room where they can work or study? Are fellows allowed study leave? RESEARCH FACILITIES Is clinical research offered to the fellows? Is basic research offered to the fellows? Is statistical advice available for the fellows? Number of papers or posters presented by fellows at (inter)national meetings during the last year (attach list with names,titles and meetings and provide reprint or copy) WORKLOAD What are the scheduled working hours from…..am, until…….pm How many hours average does each fellow spent in the institution per week (including on call periods) ? ………../week How many nights is each resident on call? ………./week
  12. 12. Prepared by S Tekgul ( using EBU forms as reference) Ankara 13:24 20.10.2010 Please list below and comment upon the strong points in your training programme.

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