APPLICATION FORMProfessional Diploma in General Endocrinology & Metabolism

FOR OFFICE USE ONLY Application No: Student No:Checked by: Date:

For enrollment, please fax the completed application form to 2637 3929 or email at gdem@cuhk.edu.hk. The original copy and relevant documents should be mailed with crossed cheques payable to “The Chinese University of Hong Kong” to the following address:

Hong Kong Institute of Diabetes and ObesityThe Chinese University of Hong Kong4/F, Block B, Staff QuartersPrince of Wales HospitalShatin, NT, Hong Kong

ACADEMIC QUALIFICATIONS (IN CHRONOLOGICAL ORDER)

PROFESSIONAL QUALIFICATIONS (IN CHRONOLOGICAL ORDER)

WORKING EXPERIENCE (IN CHRONOLOGICAL ORDER)

FEES*

DECLARATION

Title*: Prof Mr MsDr

Application Fee (Non-refundable) HK$200Exemption Fee (Non-refundable) HK$200Programme Fee HK$54,054Programme Fee for applicants who have applied exemption of Module 1 from Basic Course in General Endocrinology & Metabolism 2014 onwards HK$52,322Programme Fee for applicants who have applied exemption of Module 1 from Basic Course in General Endocrinology & Metabolism 2016 onwards HK$51,925

Gender*: M F Date of Birth (dd / mm / yy): Correspondence Address:E-mail : Contact No : Mobile No :

Hong Kong Identity Card / Passport No :

Name: (English) Surname Given names

(Chinese)

Date of Attendance Major / Minor Subject Dip / Degree Mode of Study# Location of Study Date of AwardInstitution / Country

Professional Qualification Abbreviation Awarding Institution / Country Date of Award

Institution and Location

Name of Applicant Signature of Applicant Date

Position Date (From / To)

#Mode of Study: e.g. Full-Time, Part-Time, Distance LearningGraduation Year of Professional Diploma / Basic Course in Diabetes Management and Education: ______________________________________

1. I authorize The Chinese University of Hong Kong (below “the University”) to use my data to carry out checks on my application foradmission and records of my previous studies in the University and other institutions.

2. I understand that, upon my registration in a programme, the data will become part of my student record and may be used for allpurposes relating to my studies in accordance with the procedures of the University.

3. I declare that the information given in support of this application is accurate and complete, and understand that anymisrepresentation will result in disqualification of my application and subsequent enrollment in the University.

* Please check the box(es)

Professional Diplomain

GeneralEndocrinology & Metabolism

Hypothalamus- Pituitary Axis

Thyroid & Parathyroid

BoneMetabolismEnergy

Metabolism

Adrenal Glands

Pancreas & Gut Hormones

Reproduction

Appl icat ion Deadl ine

16 March 2018CME

Accreditation By Over 20

Professional Institutions

This one-year part-t ime programme is designed to update both communityand hospital health care profess ionals to recognize the complex and

interdiscipl inary nature in the diagnosis , assessment and management of endocrine and metabol ic disorders with emphasis on local perspectives through lectures (21 hours), interactive workshops (25 hours) and cl in ical attachments (24 hours).  

Module 1 Lectures (7 sessions)

Overview of epidemiology, pathophysiology and management of common endocrine disorders.

Module 2 Interactive Workshops (5 sessions)

Demonstrate the pr inciples of diagnost ic evaluation and interdiscipl inary management of common endocrine disorders us ing case discuss ions.

Module 3 Cl inical Attachments (8 sessions)

I l lustrate the outpatient and inpatient management through cl in ical attachments.

P rogramme Director

Dr Andrea OY Luk  Associate Professor, Department of Medicine and Therapeutics Hong Kong Inst i tute of Diabetes and Obesity, CUHK

Deputy Directors

Prof Jul iana CN ChanChair Professor of Medicine and TherapeuticsDirector of Hong Kong Inst i tute of Diabetes and Obesity, CUHK

Dr Al ice PS KongAssociate Professor, Department of Medicine and Therapeutics Hong Kong Inst i tute of Diabetes and Obesity, CUHK

Admission Requirements  Appl icants should either be (a) a degree holder or (b) a health care profess ional holding relevant qual i f icat ions with 5 years of exper ience in endocrinology care or research.

Confidential recommendation is required for those who do not hold a univers i ty degree.

Assessment MethodsCandidates wi l l be awarded the diploma qual i f icat ion upon sat isfactor i ly ful f i l l ing the fol lowing requirements:1. 75% of attendance in each module2. Pass ing a MCQ assessment3. Pass ing 10 case studies on diagnosis and management of

endocrinology and related diseases4. Pass ing a 5000-word dissertat ion on an endocrinology- related topicRequirements 2-4 wi l l be graded from A to F with Grade C or above being regarded as a pass.

FeesProgramme Fee HK$54,054Programme fee for appl icants who have appl ied exemption of Module 1 f rom Basic Course in General Endocrinology & Metabol ism 2014 and 2016 would be HK$52,322 and HK$51,925 respectively.Appl icat ion Fee (Non-refundable) HK$200Exemption Fee (Non-refundable) HK$200

Application Procedures1. Appl icat ion must be made us ing the Appl icat ion Form

(photocopy is also welcome) and returned to theProgramme Off ice with ful l fees on or before 16 March 2018 .

2. Please also submit the fol lowing documents together withthis form:

a. a recent passport s ize photob. a copy of your Hong Kong Identity Card / Passportc. copies of your academic cert i f icatesd. copies of attendance cert i f icate(s) of the Basic

Course in General Endocrinology & Metabol ism(if any)

e. separate crossed cheques for appl icat ion fee andexemption fee ( i f appl icable) made payable to"The Chinese Univers i ty of Hong Kong"

Please mai l your appl icat ion to the Programme Off ice:Hong Kong Inst i tute of Diabetes and ObesityThe Chinese Universi ty of Hong Kong4/F, Block B, Staff QuartersPr ince of Wales HospitalShatin, New Terr i tor iesHong Kong3. Confidential recommendation is required for appl icantswho do not hold a univers i ty degree. The Recommendationand Exemption Forms can be downloaded from theprogramme website or obtained from the Programme Off ice.

Exemption Graduates of Basic Course in General Endocrinology & Metabol ism 2014 and 2016 are el igible to apply for exemption of Module 1 with a lower programme fee

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CME Accreditat ionCollege of Ophthalmologists of Hong KongHong Kong College of Anaesthesiologists Hong Kong College of Community Medicine Hong Kong College of PaediatriciansHong Kong College of Physicians Hong Kong College of Radiologists Hong Kong Dietit ians Association Hong Kong Physiotherapy Association Hong Kong Podiatrists Association International Podiatrists Association of Hong Kong Medical Laboratory Technologists Board Pharmacy Central Continuing Education Committee The College of Dental Surgeons of Hong Kong The College of Surgeons of Hong Kong The Hong Kong College of Family Physicians The Hong Kong College of Obstertr icians and Gynaecologists The Hong Kong College of Orthopaedic Surgeons The Hong Kong College of Otorhinolaryngologists The Hong Kong College of Pathologists The Hong Kong College of Psychiatrists The Medical Council of Hong Kong CME Programme (non-specialists) The Nethersole School of Nursing

Application and Enquir ies Enquiry Hotl ine: 3505 1419 Fax: 2637 3929Email: gdem@cuhk.edu.hk www.hkido.cuhk.edu.hk

Details of exemption for Module 3 are available on our programme website