Graduate Diploma In Mental Health (GDMH) Intake

Transcription

1 Graduate Diploma In Mental Health (GDMH) Intake Please tick the appropriate boxes accordingly. * Delete where applicable APPLICATION FORM (A) PERSONAL PARTICULARS Name (as in NRIC/Passport): Residential Address : Postal Code: NRIC / Passport Number: (Please attach a copy of NRIC (front & back) with this application) Marital Status: Single / Married / Divorced* Gender: Male / Female* Citizenship : Singaporean / Others* (please specify): Place of Birth : Date of Birth: Race : Address (must be legible) : 2 coloured passport-sized photographs required. Paste ONE photograph in this space. Clip the SECOND photograph together with the application form. Telephone (Home): Name of Next-of-Kin: Mobile Phone Number: Relationship: Address of Next-of-Kin: (B) PRACTICE INFORMATION MCR Number : Year of SMC Registration: Medical Registration Type : Full / Conditional / Temporary* Type of Practice : Government NHG SingHealth Locum Private Group Private Solo Others: Hospital / Polyclinic / Clinic Name : Hospital / Polyclinic / Clinic Address : Postal Code : Telephone (Office) : Fax (Office) : Please indicate your preferred mailing address with a tick: Residential Address Practice Address 1

2 (C) Other Information Degrees / Diplomas Awarded (Attach a separate sheet if necessary) Photocopies of the certificates are required Qualification Year Employment History List all postings since Medical Officer (Attach a separate sheet if necessary) Position Held Department in Hospital / Medical Group / Practice From (Month / Year) To (Month / Year) Remarks (if any) 2

3 (D) Mode of Study Please tick where applicable. Participants who have attended Introductory Training to GPs by IMH will sit for a proficiency test to determine eligibility for Module 1 exemption. 1. Have you attended Introductory Training to GPs (conducted by IMH)? Yes. (Please proceed to option 2b) No. (Please proceed to option 2a) 2. I would like to: a. Apply for full course, payable fee: $6, (early bird rate for submission to IMH by 31 st May 2017) or $6, (application submitted to IMH from 1 st June 2017 onwards) (Applicant shall pay an exam admin fee of $600 to NUS upon successful enrolment into GDMH. NUS will notify applicant via to make this payment online in due course.) b. Apply for full course with Module 1 exemption, payable fee: $5, (early bird rate) or $5, (application submitted to IMH from 1 st June onwards) (Applicant shall pay an exam admin fee of $500 to NUS upon successful enrolment into GDMH with exemption from module 1. NUS will notify applicant via to make this payment online in due course. Applicants who select this option are required to pay the payable fee of either $6, (early bird rate) or $6, (application received by IMH from 1 June onwards) during registration. Once application for exemption from Module 1 is approved, a refund of $1,070 will be made.) Note: MOH sponsors 80% of the course fee (GST inclusive). MOH s subsidy will be reimbursed to all eligible applicants upon successful completion of the final exam. (E) Declaration 1. I hereby make an application to the Graduate Diploma in Mental Health (GDMH) and declare all information I have provided on this application form is complete and correct. 2. I acknowledge that my application for enrolment is subject to admission criteria and examination eligibility as advised by DGMS and IMH, both of which have the power to impose conditions. 3. I agree to participate in the Mental Health GP Partnership Programme upon completing the course. 4. By signing this form, I acknowledge that I have read and agree to abide by the Terms and Conditions stated under Important Notes. 5. I declare that I am a practicing doctor. 6. I declare that I am free from any legal proceedings, investigation or disciplinary action by the Singapore Medical Council. Signature of the Applicant: Date: 3

4 (F) Terms & Conditions 1. The applicant shall adhere to requirements stated in the GDMH Programme Guide. 2. The applicant shall abide by the Non-Disclosure & Security Awareness Agreement. 3. The applicant shall abide by the rules and regulations governing use of IMH premises and library facilities. 4. The applicant shall adhere to guidelines for course work completion, such that all criteria for examination eligibility are met. 5. The applicant should be free from any legal proceedings, investigation or disciplinary action by the Singapore Medical Council (SMC). If there are legal proceedings, investigation or disciplinary action pending against the applicant, this must be informed to IMH. 6. Strictly no refund of fees if there is a notice of withdrawal from GDMH or any of its modules upon course commencement. A written notice of withdrawal must be submitted for consideration. 7. IMH and/or NUS may, at their discretion, vary terms and conditions governing GDMH at anytime, without notice. I acknowledge that my enrolment to GDMH is subject to the admission criteria and examination eligibility as advised by DGMS and IMH, both of whom have the power to impose conditions. I accept enrolment to GDMH and hereby agree to abide to all Terms and Conditions. Name : MCR number : Signature : 4

5 Please send the completed application form (with two photographs attached), a photocopy of the certified true copy medical degree certificate, photocopy of the certified true copy supporting certifications and a photocopy of your NRIC (front and back) together with cheque payable to Institute of Mental Health. Mail to: Buangkok Green Medical Park, 10 Buangkok View Singapore Attention: Ms Nirhana Japar / Ms Tan Yen Nee (Education Office) 1) What is/are your objective(s) in taking up the Graduate Diploma in Mental Health (GDMH)? 2) How did you find out about the Graduate Diploma in Mental Health (GDMH)? SMA Website GP Workshop SMA Newsletter IMH Website Mailer Poster Singapore Medical Journal NUS Website Newspaper Article SMA blast MOH Website Friends Others: IMPORTANT NOTES 1. Fees are applicable as follows: Registration Fee (non-refundable) Course Fee (for all 6 modules) Book Fee Module 1 Book Fee Module 2 Book Fee Module 5 $107 (Early bird rate if application received by IMH by 31 st May 2017) $250 (Registration fee received by IMH from 1 st June 2017 onwards) $6,420 (MOH subsidizes 80% of the course fee. Course fee will be reimbursed to all candidates upon successful completion of the final exam) $70 ( Essential Guide to Psychiatry ) $15.50 ( Delusions, Possession or Imagination? ) $82.00 ( A Primer of Child and Adolescent Psychiatry ) 5

6 2. Please ensure that copies of your medical degrees/academic qualifications are stamped certified true copy before mailing your application. The supporting documents should be stamped certified true copy and signed by any of the following parties: Notary public (lawyer) Issuing university or school and Head of the Department bearing his official designation, department and signature. However, if you are submitting your documents in person to IMH, the GDMH administrators will be able to stamp Original Sighted and sign on your supporting documents. Please present the original versions for verification purposes. 3. Deferment A 10% administrative fee per module ($107 per module) will be payable by candidates who wished to defer any module. Please be informed that this fee is non-refundable. Candidate is required to inform the GDMH administrator on the request and fill up the deferment form at least 3 months before the module. The request is subject to Programme Director s approval, on a case-by-case basis. 6

7 Information Access Authorisation Form By signing this GDMH Information Access Authorisation Form, you agree that Institute of Mental Health may collect, use and disclose your personal data, as provided in this form, or (if applicable) obtained by our organisation as a result of your training here, for the following purpose in accordance with the Personal Data Protection Act 2012 and our data protection policy (available on our website: (a) the processing of GDMH course registration; (b) the administration of the GDMH course; (c) Sharing of information with Mental Health GP-Partnership Programme (GPPP) for recruitment of GPs into the programme; and (d) Allow/ Disallow (circle one) sharing of the selected information* with healthcare agencies such as MOH, AIC and VWOs for the purpose of referring of patients to GDMH-trained GPs. *For (d), please select the type of information that you are agreeable to disclose: Name of Doctor Name of Clinic Clinic Address Clinic phone and fax number Address You have the right to revoke this authorization at any time, provided you do so in writing. If you revoke your authorization, we will no longer use or disclose information about you for the reasons covered by your written authorization, but we cannot take back any uses or disclosures already made with your permission. Please visit our website at for further details on our data protection policy, including how you may access and correct your personal data or withdraw consent to the collection, use or disclosure of your personal data. Name Signature Date : : : 7

8 Withdrawal of Authorisation Clause You have the right to revoke this authorization at any time, provided you do so in writing. Revoking the authorization means that we will no longer use or disclose information about you for the reasons stated in your written authorization. However, we cannot take back any uses or disclosures already made with your permission. To revoke this authorization, please send an or a written statement to GDMH Administrator at GDMH@imh.com.sg or mail to: GDMH Administrator Education Hub Institute of Mental Health 10 Buangkok View Buangkok Green Medical Park Singapore In the letter, please include the following: the recipient of the information identified in the authorization; state that you are revoking this authorization; and the date you signed this authorization Please visit our website at for further details on our data protection policy, including how you may access and correct your personal data or withdraw consent to the collection, use or disclosure of your personal data. 8

9 Note: All fees quoted are inclusive of 7% GST. NUS & IMH reserve the right to make any amendments to the course structure and fees without any prior notification or whatsoever to the parties involved. Refund Policies Request for withdrawal must be made in writing to the Programme Director. Policies for course fee refund are as follows: % refund if the request for course withdrawal is made in writing more than 30 calendar days before course commencement % refund if the request for course withdrawal is made in writing no less than 15 calendar days before course commencement. 3. Strictly no refund of fees if request for course withdrawal is less than 15 calendar days before course commencement and/or after the course commences. Note: Calendar days include Saturday and Sunday. All feedback and correspondences should be addressed to: Ms Nirhana Japar (Executive, Education Office) Ms Tan Yen Nee (Senior Executive Assistant, Education Office) Institute of Mental Health Buangkok Green Medical Park 10 Buangkok View, Singapore Telephone : (Nirhana Japar) (Tan Yen Nee) nirhana_japar@imh.com.sg Yen_Nee_Tan@imh.com.sg GDMH@imh.com.sg Website : Fax : * The date is based on the day when IMH receives the letter of withdrawal. ** Calendar days include Saturday and Sunday. (H) For Official Use Only Fee Paid : S$ Cheque Number : Acknowledgement Date : Official Receipt Number : Checked By : 9

10 Degrees / Diplomas Awarded (Additional copy) Qualification Year 10