MSF-OCB Emergency Medicine – Intensive Care
Name of applicant: .......................................................
Date of application: .......... / .......... / ..........
Did you pass a post-graduate training program in Emergency Medicine ?
Did you pass a post-
If Yes, what was the duration of that training ? .......... ..........
If Yes, when did you qualify ? .......... /.......... / ..........
Please specify the name and address of the University where this program was delivered:
..........................................................................................................................................
..........................................................................................................................................
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As a full-time Emergency Medicine doctor, how many years of experience do you have ? ............ years
As a full-time Intensive Care doctor, how many years of experience do you have ?
............ years
If you have not passed any training in Emergency Medicine, how many years of experience working in an Emergency Department do you have?................. years
If you have not passed any training in Intensive Care Medicine, how many years of experience working in an Intensive Care Unit do you have?................ years
Are you ALS certified ?
(Please provide your valid certificate)
(Please provide your valid certificate)
Are you PALS or APLS certified ?
(Please provide your valid certificate)
Are you an instructor in any of these specific trai
(Please specify).............................................................
Are you qualified in disaster medicine or multiple casualty management ?
(Please specify).............................................................
Any other qualification you would like to mention ?
(Please specify).............................................................................................................

MSF-OCB
Technical skills :
Not trained
Bag-valve-mask ventilation
Non-invasive ventilation
Intubation
Ventilator settings
Procedural sedation
Anaesthesia
Chest drain insertion
FAST ultrasound scan
PICC access
Intra-osseous access
Central venous access
ECG interpretation
Thrombolysis for ACS
Conservative fracture management
Burn management
Wound care
Psychiatry
Pre-hospital care
End of life care
Normal deliveries
Caesarean section
Fasciotomy
Signature of applicant:
Many thanks for completing this form.
Emergency Medicine – Intensive Care
Only under supervision
Autonomous practice
Expert