Apply or Re-register to become a Vasectomy Principal Trainer

Before completing this form, please ensure that you have a MyFSRH account. Find out how to create a MyFSRH account here.

Please ensure you complete all sections of this part of the form as it will help us to process your application more quickly.

If you would like a copy of your responses (which can be useful, should you apply for other things in the future), please add your email address in the relevant field at the bottom of this form.

The information you have shared on this form will be used by the relevant FSRH Committee and FSRH staff for the purposes of administration only. FSRH will keep this information securely on our systems. Our full privacy policy can be viewed here.

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Part One: Principal Trainer's Details and Training Centre Details

Please ensure you complete all sections of this part of the form as it will help us to process your application more quickly.

Principal Trainer Name*

Principal Trainer's Current Post or Role*

Principal Trainer's Email Address*

GMC Number:*

Principal Trainer's Medical Qualifications*

Principal Trainer's Contact Telephone Number*

Training Centre Name*

Main Training Location Address (including postcode)*

Part Two: About the Clinic or Service - Vasectomy

Please indicate:

The number of years experience performing vasectomy surgey independently (please note it's a minimum of 2 years)
Number of vasectomy procedures that you perform annually (minimum of 60)

Number of years experience*

Number of vasectomy procedures*

Part Three: Teaching Qualifications - Vasectomy

Please confirm your teaching qualifications (tick at least one box below)

Indicate your teaching qualifications:*

LoC Med
Training the Trainers
GP Trainer
PGA in Medical Education in SRH (Postgraduate Award)

Part Four: Confirmation of Training

There are two routes into becoming an SSM trainer that we will recognise:

Option One:

Confirm that you have been trained in assessment methodology and feedback

Option Two:

If you have not completed any of these we will ask you to confirm whether you have worked through the following three modules:

Structured assessment of Clinical competence
Workplace based assessments
Teacher’s Toolbox: Guidelines for giving and receiving feedback

Option One: I confirm that I have been trained in methodology and feedback.

Option Two: I confirm completion of these three modules:

Structured Assessment of Clinical competence
Workplace based assessments
Teacher’s Toolbox: Guidelines for giving and receiving feedback

Part Five: Audit - Vasectomy

Please indicate whether you:

Audit your own practice - Yes/No
Are able to offer training in no-scalpel vasectomy - Yes/No

Are you auditing your own practice?*

Are you able to offer training in no-scalpel vasectomy?*

Part Six: Data Protection Statement and Confirmation - Vasectomy

I confirm that I meet the Faculty minimum standards for Principal Trainers and I am able to provide training as described in the Faculty of Sexual and Reproductive Healthcare Special Skills Module ‘Vasectomy’

Data Protection Information

The Data Protection Act (1998) requires organisations or agencies collecting personal data on individuals to gain their consent before collecting, storing, publishing or analysing their data. By completing and signing this application form you are giving your consent for your data to be stored on databases used by the FSRH of the RCOG for the purposes of administrating its membership database. All data will be treated with the strictest confidence and will only be used for legitimate FSRH purposes.

I confirm:*

Part Seven: Publication of Details on our 'Find a Trainer' Map - Vasectomy

We ask all special skills trainers to confirm whether they are happy to have their contact details given on our 'Find a Trainer' map. This map is available on the FSRH website for candidates to search for trainers.

I would like to be included on the 'Find a Trainer' map on the FSRH's website, so that those who wish to identify a trainer can contact me directly.

Please indicate:*

Yes
No (This means your data will still be on our database, but not publicly available via our find a trainer map)

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Verification

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