ERTC Quality Label - Renewal applications

ERTC Quality Label - Renewal applications

ERTC ID number (provided during the first application)

Contact person (NAME in capital letters & Surname in small letters)*

The name will be published on our website next to the Training Centre's name.

ESC ID of the contact person*

The contact person should create its own account via MyESC platform providing clear, valid and complete contact details: https://escol.escardio.org/MyESC/modules/User/register_step1.aspx

Contact person email address*

The e-mail will be published on our website next to the Training Centre's name.

Contact person phone number*

Name of the Centre*

This name should be the same as on your Quality Label certificate. However please write the updated name if changes occured.

This name will be automatically written on your certificate of renewal.

City of the Centre*

Country of the Centre*

Website of the Centre (if any)

Please indicate if the Centre is*

Select

Please indicate the type of the Centre*

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Please describe the training facilities and expertise of the Centre*

(150 words maximum)

Please select the modality/ies of your previous ERTC Quality Label*

Please provide previous ERTC Quality Label certificate(s) in the "File Attachments" section at the end of the document

Select

Year of establishment of the Centre in CP*

Year of establishment of the Centre in EP*

Start & end dates of your previous ERTC Quality Label*

Renewal*

Select

EP & CP

I. Staff Centre Requirements

1. Please confirm that in your Centre you have 2 Senior Electrophysiologists with more than 5-year experience who are EHRA Members of the current year*

Yes

Full name of the EHRA Member 1 - Senior Electrophysiologist*

ESC ID of the EHRA Member 1 - Senior Electrophysiologist*

Full name of the EHRA Member 2 - Senior Electrophysiologist*

ESC ID of the EHRA Member 2 - Senior Electrophysiologist*

2. Please confirm that the above mentioned 2 Senior Electrophysiologists will renew automatically their EHRA Membership for the next 4 years*

Select

3. Please confirm that at least one of your staff members has successfully completed the EHRA exams for electrophysiology*

Select

3. Please confirm that at least one/two of your staff members has/ve successfully completed the EHRA exams for cardiac pacing and electrophysiology

Select

Full name of the staff certified in EHRA EP*

ESC ID of the staff certified in EHRA EP*

If not certified, please provide the name and ESC ID of one staff within your department who will sit for the exam in EP in the next five years*

3. Please confirm that at least one of your staff members has successfully completed the EHRA exams for cardiac pacing*

Select

Full name of the staff certified in EHRA CP*

ESC ID of the staff certified in EHRA CP*

If not certified, please provide the name and ESC ID of one staff within your department who will sit for the exam in CP in the next five years*

4. Please confirm that the Programme Director of your Centre is currently an EHRA Member and has more than 5-year experience in electrophysiology and/or cardiac pacing*

Yes

Full name of your Programme Director*

ESC ID of your Programme Director*

II. Centre Participation Requirements

5.a. Please confirm if the number of Training Fellows in the Centre allows each of them to fulfill the requirements of the EHRA logbook for certification*

Select

5.b. Please confirm that the Centre allows its enrolled Training Fellows to visit at least one EHRA event (endorsed course, meeting, EHRA congress, etc.) per year*

Select

5.c. Please confirm that the Centre will encourage its enrolled Training Fellows to pass the EHRA certification exams*

Select

III. Information about Centre

General-1. Your Centre has a full cardiology service*

Select

General-2. Your Centre has a cardiac surgery service (recommended but not required)

Select

General-3. Your Center publishes/will publish the number of procedures and Fellows in training*

Select

General-4. Your Centre conducts weekly tracing rounds/trouble shooting*

Select

General-5. Your Centre documents and reviews complications as part of the training*

Select

General-6. Your Centre has been established for more than 3 years*

Select

EP-1. Invasive Cardiac Electrophysiology: 200 procedures*

Select

EP-2. Fellows able to perform 1st operator >50 ablations*

Select

EP-3. Number of procedures availability 3D mapping*

Select

EP-4. Number of procedures LA ablations >50*

Select

EP-5. Number of procedures VT ablations >20*

Select

CP-1. Pacemaker, ICD and CRT implants: 300 device*

Select

CP-2. Fellows able to perform 1st operator >50 device*

Select

CP-3. Number of procedures ICD new implants >50*

Select

CP-4. Number of procedures CRT P/D new implants >50*

Select

CP-5. One dedicated CP cath lab*

Select

IV. Centre Fellow's Participation Requirements

Please provide information on at least 2, maximum 4 Fellows which has been starting their training at your Centre during the past 4 years.

Fellow 1 - Title*

Select

Fellow 1 - Full name*

Fellow 1 - ESC ID*

Fellow 1 - Email address*

Fellow 1 - Training Fellowship starting date*

included between past 4 years and today

Fellow 1 - Training Fellowship ending date*

Fellow 2 - Title*

Select

Fellow 2 - Full name*

Fellow 2 - ESC ID*

Fellow 2 - Email address*

Fellow 2 - Training Fellowship starting date*

included between past 4 years and today

Fellow 2 - Training Fellowship ending date*

Fellow 3 - Title

Select

Fellow 3 - Full name

Fellow 3 - ESC ID*

Fellow 3 - Email address

Fellow 3 - Training Fellowship starting date

included between past 4 years and today

Fellow 3 - Training Fellowship ending date

Fellow 4 - Title

Select

Fellow 4 - Full name

Fellow 4 - ESC ID*

Fellow 4 - Email address

Fellow 4 - Training Fellowship starting date

included between past 4 years and today

Fellow 4 - Training Fellowship ending date

File Attachments (ERTC Quality Label certificate, ...)

Drag and drop files here or

Centre Billing Information

Please check with your Finance Department and indicate the following information in the fields below

• the billing Centre’s address that must appear on the invoice

• the Centre’s VAT number if it has one (2/4 letters + numbers)

• the Centre's PO (Purchase Order) number if you have one.

WARNING : Please note that the invoice will be edited and sent only ONCE. So make sure that all the billing information provided below is correct. No invoice modification will be made. Thank you.

Centre's billing exact name and address*

Centre's VAT number/ID (letters + numbers)

Centre's Purchase Order number (if any)

Acceptance and Conditions

PERSONAL DATA PRIVACY The information collected is subject to a computerized process to record, and track your centre application. The recipients of the data are:

• The staff in charge of processing "EHRA Recognised Training Centre" applications

• Persons to whom the request will be sent for review and evaluation

In accordance with the French law N°78-17 of January 6,1978, amended in 2004, relating to the protection of individuals with regard to the processing of personal data, you have the right to access and rectify information concerning you, which you can exercise by contacting:

Customer Services

European Society of Cardiology

Les Templiers, 2035 Route des Colles

CS 80179 Biot

06903 SOPHIA ANTIPOLIS CEDEX, FRANCE.

You can also, for legitimate reasons, oppose the processing of data about you.

I've uploaded the letter of support from my EP National Cardiac Society / Working Group.*

I've uploaded the previous Quality Label certificate that my Centre obtained

I confirm that I have read and answered accurately and correctly the EHRA Recognised Training Centres requirements to the best of my knowledge and belief*

Select

Send me a copy of my responses

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