APPLICATION FORM
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Transcript of APPLICATION FORM
Prepared by S Tekgul ( using EBU forms as reference) Ankara 01:24 08.04.2023
APPLICATION FORM
PART IPARTICIPATING INSTITUTION(S)
Date Name of Programme Primary Institution
Affiliated Institution(s)
Programme director
Local Head
SignatureType of department
Urology/ Peeadiatric Surgery /Paediatric Urology
Name of InstitutionStreet ,no
Postal code & TownCountry
TelephoneFax
E mailType 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.
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PART II
DEFINE HOSPITAL TYPE:
HOSPITAL STATISTICSTotal Hospital ( No )
Number of beds Total Paediatric Day Care Number of admissions/year
Medical Specialities Concerning Child Care1
Y/N Medical Specialities Concerning Child Care 1
Y/N
Urology OncologyRadiologyRadiotherapyNuclear Medicine
Renal Transplantation NeurologyNeurosurgeryPsychiatry ( including child care)
NephrologyDialysis
Paediatric Intensive care unitNeonatal intensive care unitEmergency Department
General SurgeryGeneral Paediatric SurgeryVascular SurgeryThorasic SurgeryOrthopaedics
Clinical Biology
Microbiology
PathologyAnaesthesiology Dermatology
ENTOphtalmology
Internal MedicineCardiologyHaematologyRheumatology
Physical Therapy
Gynaecology/ObstetricsPerinatology Unıt
Other
1 Please indicate if available(Y), non- existant (N)
Prepared by S Tekgul ( using EBU forms as reference) Ankara 01:24 08.04.2023
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 StaffNumber Of Paediatric Urologists within the StaffTotal Number of ResidentsTotal Number of FellowsNumber of Fellows in Paediatric Urology
Urology / Paediatric Surgery Dpt ( No)
Number of Beds Total Paediatric Urology Day CareNumber of outpatients /year Total Paediatric Urology
DIAGNOSTIC FACILITIES Y/N DIAGNOSTIC FACILITIES
Y/N
Ultrasound CTEndoscopy Unit MRIUrodynamic Unit AngiographyInterventional Radiology Nuclear Medicine
1 Established independently , under Urology or under Paediatric surgery departments.
Paediatric Urological Procedures
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Open Surgery Total Number:
No/yr No/yr
KIDNEY
Nephrectomy .Tumour -Wilms -Neuroblastoma .Non TumourNephrouretectomyPartial NephrectomyPyelolithotomy/NeprolitotomyOpen NephrostomyOpen BiopsyNephropexyPyeloplastyUreterocalycostomyOther(Anomalies/Injury)
RETROPER./NODES/VASC
Retroperiteneum .adrenal surgery .Retoperitoneal TumourNodes .Periaortic .Retroperitoneal .Pelvic .InguinalVascular . Cavotomyfor tumour thrombus .Microvascular orchidopexy .Other
URETER
Ureterotomy-ureterolithotomyUretero-uretostomyUreteroplastyUreterectomyUretero-neocystostomy(No Ureters) -Extravesical -Intravesical -Psoas HitchRemodelling of megaureterSurgery for ureteral duplicationExternal urinary diversionInternal urinary diversionRevision urinary diversionOther
EXTERNAL GENITALIA
Penis .Circusion .buried Penis .Penoscrotal web . Penoscrotal Transposition .Priapism .Penil CurvatureTestis .Radical orchidopexy .Inguinal hernia .Inguinal Orchidopexy .Two stage OrchidopexyEpididim,spermatic cord,scrotum .Hyrocele .varicocele .scrotum excisionOther
BLADDER
Augmentation
No/yr OTHER
Laparotomy(explotary)
No/yr
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.Intestinal .Gastric .Ureteral . AutoaugmentationMitrofanoff ProcedureBladder SubstitutionDiverticulectomyExcion urachal cyst/ tumorCystotomy/CystostomyExtrophy RepairCloacal RepairFistulaTrauma repairIncontinence surgery .Bladder Neck Plasty .Sling .Artificial urinary sfincter .ClosureOther
AppendectomyHerniorapyVaginoplastyCliteroplastyOther
URETHRA
Uretroplasty(all except Hypospadias)Hypospadias.Distal.Penil.Penoscrotal.Chordee.Re-do.Fistula repairEpispadiasOther
TRANSPLANTATION
Renal Transplantation .Transplantation .Donor Nephrectomy .Transplant Nephrectomy .RevisionDialysis surgery .CAPD Replacement Revision .Vascular Access For dialysisOther
Endoscopic Surgery Total Number:
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No/yr No/yrPERCUTANEOUS UPPER TRACTKIDNEY /URETER
StoneStrictureOther
URETHRAInternal uretrotomyTUR posterior urethral valvesOther
RETROGRADE UPPER TRACTKIDNEY/URETER
StoneStrictureInternal StendsOther
LAPAROSCOPY
TestisVaricoceleKidneyBladderother
BLADDER
TUR tumour/biopsyStone /foreign BodyInjection therapy for refluxBladder neck injectionOther
DIAGNOSTIC ENDOSCOPY
Urethro/cystoscopyUreteral catheterisationUrethral dilationother
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 .BiofeedbackINVESTIGATIONAL PROCEDURES (define)
OTHER Peritoneal catheter placement Central line placement
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PAEDIATRIC UROLOGY OUTPATIENT UNIT
No Pts Total (per year)
% New Pts (average)
Total
Units
General
Urodynamics / urotherapyOncology
Congenital defects
Others(specify)
PART III
Prepared by S Tekgul ( using EBU forms as reference) Ankara 01:24 08.04.2023
FELLOW TRAINING PROGRAMME
PAEDIATRIC UROLOGY TEACHING STAFF
Total No 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
No
List below those staff members who currently participiate in the education of the paeditric urology fellow Name Title Position Speciality Year of
certification1.23.4.5.6.7.8.9.
Attach a curriculum vitea of each staff member.
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FELLOWS AT PRESENT
Please note that a questionnaire will be sent to the residents
Name Md graduate (year)
Training Years before Paed. Urology
Years of Paed. Urology Training
Total Years Training (Paed. Surg/ Urology +Surgery)
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
Scheduled weekly rotation
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Scheduled weekly work in Hours
Ward
Outpatient Clinic
Operation theatre
Administration
Research
Supervision
Yes / NoDoes 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.
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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 ?CONFERENCESAre 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 FACILITIESDo fellows have a room where they can work or study?
Are fellows allowed study leave? RESEARCH FACILITIESIs 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)WORKLOADWhat 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
Prepared by S Tekgul ( using EBU forms as reference) Ankara 01:24 08.04.2023
Please list below and comment upon the strong points in your training programme.