Application to be a Mentor

Name:*

First NameLast Name

Occupation:*

If Other Please Specify

Employing Trust:*

Email*

example@example.com

BSUG Member:*

YesNoBAUS Member

Previous Training*

If Other Please Specify

What procedures are you happy to train (Tick all that apply)

Colposuspension (open)

What procedures are you happy to train

Colposuspension (laparoscopic)

What procedures are you happy to train

Autologous fascial sling

What procedures are you happy to train

Sacrocolpopexy – open

What procedures are you happy to train

Sacrocolpopexy – laparoscopic

I am happy to mentor BSUG or BAUS members (all approved members have the right to refuse to mentor members on a case by case basis)

YesNo

Both colposuspension and autologous fascial slings are procedures that are covered by high vigilance scrutiny arrangements as laid out in the letter from NHS Improvement and NHS England to Trust Medical Directors and clinicians involved in the care of patients with stress urinary incontinence and pelvic organ prolapse in July 2018 (attached). https://bsug.org.uk/news-details/vaginal-mesh-high-vigilance-restriction-period/76/0/0.

As part of the Governance arrangements of this scheme, BSUG also require all Mentors to provide evidence that they have been signed off in advance by their own Medical Directors, following the high vigilance process.

I have been signed off by my own medical director*

YesNo

I confirm I am a current user of the BSUG audit database*

Yes

I confirm I submit data to BAUS audit (Urologists only)

Yes

Mentor Application Details

High Vigilance Restriction Period