Application Form for Initial Credentialling for Endovascular Neurointerventional Procedures

Applicants should read the “Guidelines on Credentialling for Endovascular Neurointerventional Procedures” (the Guidelines) carefully, and make sure all essential information is enclosed with this form. Supporting documents should be provided upon request.

Application Category:

☐ I - Credentialling on Endovascular Neurointerventional Procedures

☐ II- Credentialling on Neurointerventional Procedures for Acute Ischaemic Stroke *

* There is no need to apply for Category II separately if you have applied for Category I.

Important Notes to Applicants

As stated in the Guidelines, Category I has covered the scope of Acute Ischaemic Stroke and therefore applicants applying for Category I do no require to apply for Category II. On the other hand, Category II is designed for those who would perform neurointerventional procedures for Acute Ischaemic Stroke only.

Supporting documents for applicants’ training and qualifications / procedures performed etc. are not required for submission at the time of application, but need to be made available upon request when needed during the vetting process.

Interview may be arranged with applicants if deemed necessary.

Applicants should ensure that all information provided in this application is true, complete and correct to the best of applicants’ knowledge and belief. Relevant records stated by the applicants are subject to random checking / audit mechanism in future for on-going maintenance of respective credentialling status.

Application(s) would be accepted throughout the year and will be reviewed in batches, normally twice a year.

Please submit the completed and signed application form by email to: credential-application@hkam.org.hk.

Personal Particulars

Name in English: Click or tap here to enter text. (Surname)	Click or tap here to enter text. (Given Names)
Name in Chinese: Click or tap here to enter text. (if applicable)
Registration. No. with MCHK: Click or tap here to enter text.
HKAM Fellowship No.: Click or tap here to enter text.	Year of Fellowship Conferred: Click or tap here to enter text.
Specialty College: Click or tap here to enter text.	Specialty registered with MCHK: Click or tap here to enter text.
Correspondence Address: Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text.
Email Address: Click or tap here to enter text. Contact Tel. No.: Click or tap here to enter text.

Relevant Professional Qualifications / Training and Experience

Please provide a brief CV or summary in the following box to illustrate your relevant professional qualifications / training and experience.

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The relevant training and experience can be summarized in the table below, if appropriate:

Date	Course Name	Nature	Duration	Place / Institute
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Procedures Performed

According to the Guidelines, doctors are required to:

have performed diagnostic catheter cervico-cerebral or spinal angiograms during at least 60 procedures (which can include pre-interventional diagnostic examinations), with a complication rate within an acceptable range, under the direct supervision of a neurointerventionalist credentialled under this set of Guidelines within a period of two consecutive years.

have training and experience in patient assessment and the conduction of 60 neurointerventional procedures* under the direct supervision of a neurointerventionalist credentialled under this set of Guidelines within a period of three consecutive years after becoming an HKAM Fellow or the equivalent. In at least 30 of these 60 procedures, the doctor should have assumed the role of the primary operator in completing a major portion of the procedure or in completing a significant component of a major complex interventional procedure.

Please refer to the Guidelines for more details.

* For Application Category II, the procedures should include at least 30 nos. being the mechanical thrombectomy for acute ischaemic stroke.

Please list out ALL the required procedures you have performed in below. You may attach extra sheets if below space is not enough.

Diagnostic catheter cervico-cerebral or spinal angiograms

No.	Date	Details of Patient	Hospital	Diagnosis	Procedure performed	Remarks (e.g. procedure-related complications)
Age	Sex	HKID (first 4 letter and digits)	HN no. / Hospital record no.
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Neurointerventional Procedures

Note: Please be prepared to provide necessary supporting documents for the neurointerventional procedures performed when requested, in which your role should be clearly indicated. If the required information is not available or incomplete, the Academy reserves the right to reject the application.

No.	Date	Role (primary operator / assistant operator / supervisor)	Details of Patient	Hospital	Diagnosis	Procedure performed	Remarks (e.g. procedure-related complications)
Age	Sex	HKID (first 4 letter and digits)	HN no. / Hospital record no.
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CME/CPD Activities

☐	I hereby confirm that I have had relevant CME/CPD activities related to neuroimaging and neurointervention / the procedure in each CME/CPD cycle and will provide	relevant proof upon request.

Consent on inclusion of the name on HKAM Website

☐	I GIVE consent to allow my name, specialty and MCHK registration no. to be included in the form of a list (or similar) on the website of the Hong Kong Academy of Medicine in future if my credentialling application is successful.

☐	I DO NOT GIVE consent to allow my name, specialty and MCHK registration no. to be included in the form of a list (or similar) on the website of the Hong Kong Academy of Medicine in future if my credentialling application is successful.

Declaration

I, the undersigned, declare that all information given in this application is true, complete, and correct to the best of my knowledge and belief.

Applicant’s Signature:	Date:	Click or tap to enter a date.
Note: An HKAM Fellow is required to counter-sign and certify to his / her best knowledge that all information provided by the applicant is true, complete and correct to the applicant’s best knowledge and belief, as below:
Certified by (Name):	Click or tap here to enter text.	HKAM Fellowship no.: Click or tap here to enter text. OR	MCHK registration no.: Click or tap here to enter text.
Signature:	Date:	Click or tap to enter a date.

IMPORTANT All information provided in this application form will be used by the Academy solely for purposes relating to this application process. In addition, the Academy may use the collected data for statistical research and analysis. Data held by the Academy will be kept confidential and safeguarded carefully. Personal data will only be collected and used for purposes directly related to the purposes stated, unless otherwise prior consent has been obtained from the applicant. Personal data will not be kept longer than the time needed for the intended purposes. All personal data will be destroyed if the application is unsuccessful.