New Zealand Orthopaedic Association
Level 12 Ranchhod Tower
39 The Terrace
Wellington 6011
Please attach
a recent
passport size
photograph
Application for admission to the SET Programme in
Orthopaedic Surgery for the 2018 Training year
Please attach all the documentation requested even if you have applied in previous years
Step 1 –Personal details and contact information
Surname
Given names
Date of birth
RACS ID number
Please state Citizenship/residency
status
Please provide copy of passport, residency
status, birth certificate, citizenship certificate as
appropriate. (Please DO NOT send originals)
Home address
Work address
Phone Home:
Work:
Email:
Mobile:
1
Step 2 –Mandatory requirements
Please provide evidence of how you meet the minimum eligibility criteria for selection as
an orthopaedic registrar in the training programme administered by NZOA on behalf of
RACS.
Note: Criteria 1 and 2 below must be completed by December 2017.
Pre-requisite Requirements
Documentary evidence
1 Completion of one Critical Care term in an Emergency
Unit
 An acceptable clinical rotation is a post-graduate
experience with a minimum duration of twelve
weeks, which has been under the supervision of an
appropriately qualified clinician (surgeon,
anaesthetist, intensivist, depending on the type of
term).
Please provide documentary
evidence as follows:
Attach RMO
Unit/Hospital
Administration
letter(s) with dates
and durations as
evidence of these
runs.

Highlight the
requisite runs.

Attach RMO
Unit/Hospital
Administration letter
 Must have been completed within the last 5 years
2 Completion of at least 52 working weeks of
orthopaedic surgical experience within the last 2
years (within 5 years if a period of full time study/
research in a medically related discipline is
demonstrated within application)
confirming rotation
has been scheduled
if due for completion
after application.
3 Surgical Sciences Exam Generic (pass)
Attach exam result
2
Office admin
only
Step 3 –Medical and technical expertise
A – Surgical and Medical Experience:
Note: This experience must have been completed within
the last two years and is additional to mandatory 52
week requirement.
Please note that to comply with College requirements, no
more than 10% of the total score of this tool can be
earned in section A.
Please 
if
achieved
Documentary
evidence
Office admin
only
Orthopaedic Registrar Surgical Term
(1 point per full year completed at time of application.
Part points will be awarded pro rata)
Date commenced:
Date completed:
Position:
Attach letter from
medical
administration
detailing work
history
Hospital:
Score A (maximum 2)
B – Skills Courses:
Courses delivered by a recognised training provider,
RACS or equivalent (please name). Points only awarded
for courses completed at time of application.
ASSET (½ point)
Date completed:
Please 
if
achieved
CCrISP (½ point)
Date completed:
Documentary
evidence
Office admin
only
Attach RACS or
alternative provider
transcript, copies of
certificates or other
documentation as
appropriate.
EMST (½ point)
Date completed:
CLEAR (½ point)
Date completed:
Score B (maximum 2)
C – Anatomy:
Max 1 Point can be scored for either course delivered by
Universities listed or equivalent (please provide details of
alternative course(s). A maximum of 2 points can be
3
Please 
if
achieved
Documentary
evidence
Office admin
only
scored for confirmed experience as an anatomy
demonstrator/prosector.
Either of the following courses: Postgraduate Diploma in Anatomy, Otago
University (1 point, pro rata)
 Surgical Sciences Course, Auckland University (1
point, pro rata)
 University of Otago Postgraduate Clinical
Anatomy Workshops (½ point- on completion)
 University of Otago Surgical Approaches for
Orthopaedic and Trauma Surgery (½ point- on
Attach
University
transcript or
enrolment
confirmation,
certificate of
attendance or
letter from
University stating
hours worked and
time period as
demonstrator
completion)
Course Dates:
And/or
Documented experience as anatomy
demonstrator/prosector
(1 point per year, pro rata, max 2)
Dates:
Score C (maximum 2)
Step 4 –Scholar and teacher
D –Qualifications:
Please 
if
achieved
Note. Qualifications in addition to MBcHB
Documentary
evidence
Medical School Prizes (½ point per prize)
Prize name:
University:
Date awarded:
Masters degree (non-Medical) (½ point)
Qualification:
University:
Date completed:
Masters degree (Medical) (1 point)
Qualification:
University:
Date completed:
Attach university
transcript(s)
PhD (non-Medical) (1 point)
Qualification:
University:
Date completed:
PhD (Medical) (2 points)
Qualification:
University:
Date completed:
Score D (maximum 2)
4
Office admin
only
E -Research
Please 
if
achieved
Undertaken in the last five years. List completed
research only.
Documentary
evidence
Completed research project
(1 point per project)
Supervisor’s name:
Title of research :
Please list your responsibilities on project:
Start and completion dates:
Ethics Committee number & approval date:
Completed research project
(1 point per project)
Supervisor’s name:
Title of research :
Please list your responsibilities on project:
Start and completion dates:
Ethics Committee number & approval date:
Completed research project
(1 point per project)
Supervisor’s name:
Title of research :
Please list your responsibilities on project:
Start and completion dates:
Ethics Committee number & approval date:
Score E (maximum 4)
5
Office admin
only
F -Presentations
Please 
if
achieved
Undertaken within the last five years. List only
presentations given by time of application, and those
personally delivered. Points scored for Orthopaedic
meetings only.
NZOA or International Orthopaedic Meeting –
personally delivered (1 point per paper)
Documentary
evidence
Name of meeting:
Venue:
Date:
NZOA or International Orthopaedic Meeting –
personally delivered (1 point per paper)
Name of meeting:
Attach meeting
schedule including
name of meeting,
venue, & date
Venue:
Date:
NZOA or International Orthopaedic Meeting –
personally delivered (1 point per paper)
Name of meeting:
Venue:
Date:
Registrar Paper Day (½ point per paper)
Paper Title:
Venue & year:
Registrar Paper Day (½ point per paper)
Paper Title:
Venue & year:
Presentation prizes
Highly Commended (½ point each)
Paper title:
Attach letter
confirming prize
Venue & date:
Best or Runner up Paper (1 point each)
Name of Paper
Venue & Date
Score F (maximum 4)
6
Office admin
only
G -Publications
Undertaken in the last five years. Points are awarded
for publications accepted but not yet published only if
validation from publisher is provided. List full papers
only – 0 points for abstracts, posters or letters.
Please 
if
achieved
Documentary
evidence
Book chapter / Major Journal (e.g. JBJS, Spine, JPO) (1st
author 2 points, 2nd author 1 point)
1st Author
2nd Author
Book/Journal & chapter/paper title
Year of publication
Volume/issue/pages
Book chapter / Major Journal (e.g. JBJS, Spine, JPO) (1st
author 2 points, 2nd author 1 point)
1st Author
2nd Author
Book/Journal & chapter/paper title
Attach copy of
paper/chapter.
Accepted work not
yet published must
be accompanied by
status validation
from the publisher.
Year of publication
Volume/issue/pages
Lesser Journal (e.g. ANZS) (½ point per paper)
Author’s name
Journal & paper title
Year of publication
Volume/issue/pages
Lesser Journal (e.g. ANZS) (½ point per paper)
Author’s name
Journal & paper title
Year of publication
Volume/issue/pages
Score G (maximum 4)
Score E+F+G (maximum 4)
7
Office admin
only
Step 5 –Management, Leadership & Collaboration

No time limit for when these activities were undertaken but must be for a minimum of 12
months at time of application if part time, or 1 month if full time. Points will only be scored
with official validation
 Must be regular and voluntary – No points for commercial enterprise
 No points for individual/ad hoc team sporting participation such as charity matches, fun runs,
marathons etc
 Active involvement only (not passive such as charitable donations)
Please 
Office admin
Documentary
H – National level:
if
only
evidence
achieved
Significant leadership position, cultural or sporting
achievement at a national level (2 points per complete
12 months at time of application)
Position held
Organisation
Period of involvement
Please state weekly commitment in hours
I – Regional level:
Significant leadership position, cultural or sporting
achievement at a regional level
(1 point per complete 12 months at time of application)
Position held
Organisation
Period of involvement
Please state weekly commitment in hours
J – Community service:
e.g. VSO, Tsunami, earthquake relief etc ( 1 point per 12
months part time, 1 point per month full time at time of
application)
Service description
Attach letter
specifically
stating nature of
achievement/s,
positions held and
dates of
involvement from
official of the
organisation on
official letter
head.
N.B. Email
endorsements are
not acceptable.
No points scored
if validating letter
does not clearly
state the period
of involvement
and an indication
of time
commitment
weekly/monthly
Organisation
Period of involvement
Please state if part-time or full time
Score H+I+J (maximum 3)
Total
8
/15
Professional experience
Notes


Please list all appointments held since 2014.
Add an additional page if necessary. Please list all consultants who have supervised you
personally at each appointment.
 NZOA will contact at least three additional referees from any institution at which you have
worked. If there is any person whom you do not wish the NZOA to contact, you must add an
attachment to your application detailing the reasons why.
 Please follow preferred format as below:Period of
Appointment and
Consultant name & specialty
appointment
hospital
Address, Email, Mobile
Please format as example below:Mr. Bill Sykes (Cardiothoracic Surgeon)
Most recent first Please indicate
Middlemore Hospital
clearly if the post
Auckland
was a rotating or
[email protected]
relieving position
0274 564 3987
9
Nominated Referees – Surgeons





Please enter the names, current addresses and contact details of three referees who are
surgeons with whom you have worked in the previous two years (five years if you have been
in fulltime study/research during the past two years).
A maximum of 4 surgeons per rotation are allowed.
Please ensure that you list the most suitable email address for referees you nominate.
You are strongly advised to ask permission of anyone nominated as your referee to ensure they
are available between April and May, and are willing to act in this capacity.
NZOA will make every effort to ensure all your references are received in time.
Name
Address
Telephone number
Mobile number
Email (essential)
Name
Address
Telephone number
Mobile number
Email (essential)
Name
Address
Telephone number
Mobile number
Email (essential)
Please enter the name, current address and contact details of a backup referee who is a surgeon with whom
you have worked in the previous two years.
Name
Address
Telephone number
Mobile number
Email (essential)
10
Applicant’s Statement
In submitting this form I certify that I have met the following conditions/requirements:



I have completed SET Selection Registration with the Royal Australasian College of Surgeons
By December 2017 I will have completed an emergency term within the last five years –
validated by a letter of intent from medical administration
By December 2017 I will have had 52 working weeks of cumulative orthopaedic experience
within the last two years (within five years if I have been in full time study/research) –
validated by a letter of intent from medical administration
I have downloaded and read the information entitled “Selection Regulations Surgical Education and
Training Program Orthopaedic Surgery - 2018 Intake” from the NZOA Website (www.nzoa.org.nz).
I understand and accept the process for selection into the Surgical Education and Training
Programme in Orthopaedics.
I am prepared to accept a training post in the Orthopaedic Programme for which I have listed my
five top preferences from:Whangarei, Auckland, Waikato, Tauranga, Taranaki, Hawkes Bay, Palmerston North, Whanganui,
Wellington, Nelson, Christchurch, Dunedin, Invercargill. (Please note that some of these centres may
not be available due to existing trainee choice for 2018)
Preference 1.
Preference 2.
Preference 3.
Preference 4.
Preference 5.
I understand that if I am selected, I will be required to move to different training posts throughout
New Zealand during the training programme.
I understand that submission of an application does not guarantee an automatic offer to attend an
interview.
In the event that I am granted an interview, I agree to make myself available for interview and will
bear any costs not reimbursed by the Association.
I certify that all of the information contained in this document and its attachments is accurate.
Name
Signature
Date
11
NZOA SET Selection Application Fee
Tax Invoice
NZOA
PO Box 5545
Wellington
GST No: 17-688-529
Application fee
GST @ 15%
Total fee payable
$695.66
$104.34
$800.00
Applicant Name:



Payment by Cheque made out to NZ Orthopaedic Assn
Payment via Direct Credit to: BNZ 02-0719-0131220-000
Please quote Surname
Payment via Credit Card:
Mastercard 
Expiry:
Card No:
Visa 

Month

Year
   
Card Holder Name:
__________________________________________________________________________
Please keep a copy of this invoice for your records. You will receive a tax/gst
receipt once payment has been processed.
12
Please  when checked
Checklist for the application form
All boxes completed on the form according to instructions

Referee contacts details correct

Permission of nominated referees has been sought, suitable email
address established and availability in April/May confirmed
Applicant’s statement on previous page has been read, signed and
dated
Placement preferences completed
– Refer to page 11
Checklist for CV validation documentation
Step 1 – Personal details
I have checked my personal contact details are complete and
correct & have attached evidence of my residency/citizenship
status and a recent photograph
Step 2 – Mandatory requirements
I have attached the necessary documentary evidence to support the
mandatory prerequisite training requirements of SET
Step 3A – Medical & Technical Expertise
I have attached the necessary documentary evidence to support my
claims of surgical and medical experience
Step 3B/C –Skills courses/Anatomy
I have attached the necessary documentary evidence to support
my claims of skills courses
Step 4D – Scholar & teacher
I have attached the necessary documentary evidence to support my
claims of higher level qualifications and medical school prizes
Step 4E – Research
I have attached the necessary documentary evidence to support my
claims of research
Step 4F – Presentations
I have attached the necessary documentary evidence to support my
claims of presentations and any prizes won
Step 4G – Publications
I have attached the necessary documentary evidence to support my
claims of publications
Step 5H,I,J – Management, leadership & collaboration
I have attached the necessary documentary evidence to support my
claims which specifically state the specific nature of regional,
national or international achievements. These have been provided
by the endorsing organisation on official letterhead.
13



Please  when checked









Please retain pages 14-15 for reference
Application Fee Payment
A non-refundable application fee of $800.00 (incl GST) must accompany
your application.
Please complete the payment form on page 12 and ensure this is included
with your application.
NZOA only accepts MasterCard and Visa credit cards.
Submitting your application


Please ensure you have completed the form as per the instructions.
Staple the application form together in the correct order. Please do not include the
supporting documents within this booklet.

Provide the required supporting documentation in the order requested in the
application form as a separate booklet.

Provide one original copy, and one additional copy each of the application form and
the supporting documentation booklets.

Pay application fee – note that applications are not be processed until payment has
been received.

Make sure you have signed and dated the application form!

Please courier your application to:Helen Glasgow
Education and Training Manager
New Zealand Orthopaedic Association
Level 12, Ranchhod Tower
39 The Terrace
Wellington 6011
This application must be submitted no later than 12.00 pm (Australian Eastern Standard
Time) Friday 31 March 2017.
Late applications will not be accepted under any circumstances.
14
What happens next?

NZOA will acknowledge receipt of your application as soon as it arrives if this is
during normal office hours, and as soon as practicable outside normal office hours.

A tax receipt for your application fee will be sent.

NZOA will be in touch if further information or clarification is required. If there are
no problems with your application, NZOA may not be in contact with you until the
short listing stage, Friday May 26th 2017.

Please do not contact your referees. NZOA will contact the referees.

Please note that application forms and supporting documentation are not available
to the Selection Panel prior to short listing or interviews.

Please note that referee reports are not made available to the Selection Panel prior
to short listing for an interview.

Referee reports are provided in confidence, therefore individual scores and
comments will not be shared with applicants.

If you have any questions regarding the selection process , please refer to the NZOA
website, or contact:
Helen Glasgow
Education and Training Manager, NZOA
04 913 9898 or [email protected]
15