Health Authority Abu Dhabi 2010

MR041002

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) Attach Recent
 Complete one application for each specialty applied to (UAE nationals only) Photograph
 Fill in your name at the bottom of each page in the space provided
please see
 Don’t leave unfilled spaces, If the question is not applicable to you please write (NA) instruction
 Sign and date the last page
 Attach all necessary documents to your application
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 (1) (2) (3) (4) (1) (2) (3) (4) (1) (2) (3) (4) (1) (2) (3) (4)
program, (please note that not all hospitals have all the programs) Al AIN HOSP MAFRAQ HOSP SKMC TAWAM HOSP
1 = most preferred 4=least preferred
4. Date of Birth Day Month Year 5.City of Birth 6.Country of birth

7. Passport Passport Number Country Issue city

information
Issue Date Expiratory Date

8. UAE Visa Visa Number Issue Date Expiratory Date

(for non UAE national)

9. Permanent Phone number and Email

Address I) II)
10. Medical Yes NO If Yes Council/Country
License
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)

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MR041002
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

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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?)

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First Name Last Name
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MR041002
24. Disciplinary Action Or Malpractice
 Have you ever been denied licensure by any authorities or countries or other jurisdiction? YES NO

 Has your license to practice in any authority or other jurisdiction ever been revoked, YES NO
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 YES NO
restriction?

 Have you ever been the subject of any administrative or judicial proceeding? YES NO
 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 YES NO
or ethics of your practice?

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

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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

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

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
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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

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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: ____________________________________