Forms - Faculty of Sexual and Reproductive Healthcare

This self-declaration form is to support the recertification of the MFSRH and FFSRH. It should be completed and submitted no sooner than 6- months prior to your recertification deadline. Please refer to the MFSRH information and the MFSRH/FFS RH recertification guide and example spreadsheet when considering your CPD.

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Personal Details

Title*

Mr
Mrs
Ms
Dr
Prof
Other

Forename(s)*

Surname*

FSRH membership number

GMC number (if applicable)

Preferred email address (as used with your MyFSRH account)*

Personal beliefs guidance

Please see the recertification section of the FSRH website to read the “Guidance for those undertaking or recertifying FSRH qualifications whose personal beliefs conflict with the provision of abortion or any method of contraception”. This was introduced at the FSRH in June 2017 and you should read this before submitting your recertification application. You are asked below to confirm you have read the guidance and will abide by the principles in it in your practice. This is part of the Faculty’s conditions for recertifying a FSRH qualification.

Confirmation*

I confirm I have read the 6 principles of care as outlined in the Personal Beliefs Guidance document (linked above) and agree to abide by them in practice.

CPD Requirements

To recertify, you need to collect at least 250 credits of Continuing Professional Development activity over the past five years to demonstrate that you have maintained and developed the necessary CPD.

Confirmation of non-clinical CPD*

I confirm that I have achieved the required 100 non-clinical CPD credits over the last 5 years.

Confirmation of Clinical CPD*

I confirm that I have achieved the required 150 Clinical CPD credits related to SRH over the last 5 years.

Declaration

I declare I have met the requirements to recertify my MFSRH/FFSRH. I understand the FSRH may request supporting evidence of my CPD. I am willing to provide any requested supporting evidence. I understand that if I am found to be making a false declaration it may result in the removal of my FSRH qualification and potential further action may be taken with my employer &/or regulatory body.

Confirmation*

I declare I have met the necessary requirements and will provide evidence if requested.

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Verification

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Last step

Recertification - Self declaration of CPD MFSRH FFSRH

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