residency

Health Authority Abu Dhabi 2010

MR041002

1

Application for Medical Residency in the Emirate of Abu Dhabi (TANSEEQ)

General Information

Read the instructions provided before starting your application

Complete all questions ( 1 to 25)

Complete one application for each specialty applied to (UAE nationals only)

Fill in your name at the bottom of each page in the space provided

Don’t leave unfilled spaces, If the question is not applicable to you please write (NA)

Sign and date the last page

Attach all necessary documents to your application

Attach Recent Photograph

please see instruction

1.Name First Middle Last

2. Nationality UAE National NON UAE National

3. I am applying to the following program

Your hospital preferences to conduct residency program, (please note that not all hospitals have all the programs)

1 = most preferred 4=least preferred

(1) (2) (3) (4) (1) (2) (3) (4) (1) (2) (3) (4) (1) (2) (3) (4)

Al AIN HOSP MAFRAQ HOSP SKMC TAWAM HOSP

4. Date of Birth Day Month Year 5.City of Birth 6.Country of birth

7. Passport information

Passport Number Country Issue city

Issue Date Expiratory Date

8. UAE Visa (for non UAE national)

Visa Number Issue Date Expiratory Date

9. Permanent Address

Phone number and Email I)

II)

10. Medical License

Yes NO If Yes Council/Country

EDUCATION

Undergraduate 11.Name of Medical School 12. Degree

City Country

Month/Year of Enrollment Month/Year (Anticipated) Graduation

13. Grade/GPA (Cumulative) Grade/GPA (specialty your applying to)


MR041002

2

Internship 14.Name of Hospital(S) 1)

2) 3)

15. Month/Year of Enrollment Month/Year (Anticipated) completion

Postgraduate

16. Are you already enrolled in a residency program? Yes No If Yes Program Hospital Date of enrollment(Month/Year)

17. Are/were you employed? Yes No If Yes Name&Address of Previous Employer Job Title Dates of Employment

I) II) III)

Scholarly activities and Awards 18. Medical Examinations Passed (e.g. USMLE, MCCEE, MRCP, etc)

Name of Exam and part/step Date Taken Validity

19. Research activities/Publication

Type of Research/Publication Date

20. Award

Name of Award Date

First Name Last Name


MR041002

3

21. Extracurricular Activities relevant to medicine (special skills, volunteer experiences, etc)

Name of Activity Date

22. Reference

Name of the referenced person Hospital Department Phone Email

23. Personal Statement (Why did you chose to apply to the residency in Abu Dhabi and why this particular specialty?)

First Name Last Name


MR041002

4

24. Disciplinary Action Or Malpractice

Have you ever been denied licensure by any authorities or countries or other jurisdiction?

Has your license to practice in any authority or other jurisdiction ever been revoked, suspended, or otherwise encumbered, or have you surrendered your license to avoid a disciplinary proceeding?

Has your participation in any residency program been terminated, suspended, or restricted, or have you resigned, withdrawn or taken a leave in order to avoid termination, suspension, or restriction?

Have you ever been the subject of any administrative or judicial proceeding?

Are you currently involved in any proceeding, or has any proceeding been threatened, that relates to your licensure in any country, your participation in a residency program or the quality or ethics of your practice?

YES YES YES YES YES

NO NO NO NO NO

25. Disclosure

A. I certify that the information submitted in this application is complete and correct to the best of my

knowledge and belief. I grant the HAAD postgraduate education office to request additional information, if

necessary, from previous schools and employers concerning my academic records and professional ability.

B. I understand this is an application process and by no means grants my selection, recruitment or

employment to a residency program.

C. I understand that it is my responsibility to complete the application and submit the application with all necessary documents by the stated deadlines. I understand that if my application or the attached documents are not complete, the Health Authority Abu Dhabi reserves the right to reject my application.

Name Date ------------------------------------------------------------------------------- ------------------------------------------------- Signature -------------------------------------------------------------------------------

For official use only Service Status Date

1. Costumer Service Application approved

2. Postgraduate Medical Education Application approved

3. Postgraduate Medical Education Interview scheduled

4. Costumer Service Candidate contacted Date_______________Time____________

Date_______________Time____________

5. Costumer Service Candidate E-Ticket

6. Postgraduate Medical Education Interview Conducted


MR041002

5

Introduction TANSEEQ is a comprehensive process that addresses all components of the medical residency application including the

allocation of training posts to facilities, the residency application process and applicant ranking system, and finally, the

distribution of applicants to training facilities across Abu Dhabi. This is a merit based process where applicants with

higher ranks will have their preference of training program/hospital over candidates with lower ranks.

General Instructions

Required Documents/Information:

1) Application Form

Download and print from HAAD website or pick up from Academic Affairs office (or equivalent) in SEHA residency training facilities

Please note you must limit your application to the following specialties and hospitals:

Hospital OBGyn Emergency Medicine Family Medicine Obstetrics/Gyn Pediatrics Psych

Mafraq NA NA NA NA A NA

Tawam/Alain A A A A A A

NA: Not available, A: Available

For NON UAE National Please Note the Following

In view of the limited seats available for training the criteria for applying to the residency

program in the Emirate of Abu Dhabi are:

1. Must have graduated from medical school after 1st of January 2005

2. The MD/MBBS cumulative GPA of more than 3.5 equivalent

3. Must have a resident visa (Iqama)

4. Understand and speak Arabic language


MR041002

6

2) Copy of the MD or MBBS certificate (all applicants with non UAE MD/MBBS certificates should provide the original certificate or an authenticated copy of the certificate) 3)Copy of the official transcripts for MD/MBBS (non UAE transcripts should also be original or authenticated copies) 4) GPA calculation:

Alphabetical System Qualitative System GPA

A Excellent ممتاز 4

A- 3.7

B+ 3.3

B Very Good جيد جدا 3

B- 2.7

C+ 2.3

C Good جيد 2

C- 1.7

D+ 1.3

D Pass/Satisfactory مقبول 1

5) Internship

- If you have not completed your internship during time of application, fill in internship start date and expected end date (please note you must have completed your internship by August 31st, 2010)

- Attach original signed and stamped Dean’s Letter attesting to expected completion date and current grades obtained for MD/MBBS degree.

6) Complete examination information if applicable (provide official transcripts of test results) 7) Complete employment information if applicable (provide official employment certificates) 8) Copy of no objection letter from you sponsor if applicable 9)Complete Research/Scholarly Activity information if applicable (provide copies of awards received or publications/poster presentations). 10) Complete extracurricular activities information 11) Provide contact information for 3 people you have selected as professional references (please note you need 3 references for each specialty applied for)

o These individuals should be physicians you have worked with closely who can attest to your professional and medical skills

o Sign the upper part of the letter of recommendation form to waive the right to review the recommendation. All letters of recommendation are to remain strictly confidential, applicants may not view them at time of application. Any attempts to do so will invalidate the letter.

o Give the recommendation to each reviewer and instruct them to return it to you in a sealed envelope with signature and stamp evident on the front seal


MR041002

7

LETTER OF THE RECOMMENDATION Applicant Name: ______________________________________________________________________________ (Print: First, Last)

I waive the right to review this recommendation: ______________________________________________________ (Applicant Signature)

Reference Name: ________________________________________________________________________

Title: _________________________________________________________________________________

Address: ______________________________________________________________________________

Telephone: _____________________

FOR REVIEWER USE ONLY

Please rank the applicant on the following traits in comparison with others at the same level of experience and training. Unsatisfactory Satisfactory Exceptional

Ability to communicate effectively 1 2 3 4 5

Ability to express self in writing 1 2 3 4 5

Ability to organize work/establish priorities 1 2 3 4 5 Ability to work and cooperate with others 1 2 3 4 5 Clinical skills 1 2 3 4 5 Distribution skills 1 2 3 4 5 Medical Knowledge 1 2 3 4 5

Leadership skills 1 2 3 4 5 Motivation 1 2 3 4 5 Professionalism 1 2 3 4 5 Teaching skills 1 2 3 4 5

Recommendation for acceptance into the residency

The applicant has my highest recommendation

I recommend the applicant with confidence

I recommend the applicant with reservation

I am unable to recommend this applicant

Signature: ________________________________ Date: ____________________________________