ABNT Innovative E-learning Application Form 2015
Personal details
Full name:
GMC number:
Grade at time of application:
Current place of work:
Contact details
Mobile telephone number:
Email address (we advise that you provide an email account that you can use to access attachments on non-NHS computers):
General information
Are you currently part of the ABN mentor programme: YES / NO
If yes, please state the name of your mentor:
Is your mentor aware of this application: YES / NO
Statement of interest
In less than 150 words, please outline your reason(s) for wanting to become a part of this programme:
Topic choices
Refer to the topic selection document attached to this form. Please select your top five preferences for your script topic and rank them below (1= most preferred)
Declaration
I declare that the information provided above is true to the best of my knowledge. I am aware that in signing this form I agree to working with my mentor and the Innovative E-learning team to create a script based on the topic allocated to me. I also agree to participate in a short online survey before and after the creation of this script. I understand that failure to fulfil these requirements will result in a refusal by the Innovative E-learning team to publish the finalised script.
Signature: Printed name: Date:
Please note that the information in this form will be used solely for the Innovative E-learning Programme and will not be shared with any third parties aside from the ABN/ABNT. Contact information will be used Innovative E-Learning programme communication only. The data provided above will be used anonymously in our analysis of the programme.
Many thanks for applying to be a part of the ABNT Innovative E-learning programme. Please return this form to
We will email you to confirm receipt of your application. Topics will be allocated on a ‘first come first served’ basis and we will contact you shortly with your topic and further instructions. We look forward to working with you.
Best wishes,
The Innovative E-learning Team (Drs S.Vernon, S.RussellE.Tallantyre)
Topics to chose from
1. Abnormal sensation (paraesthesia and numbness)
2. Acute back pain
3. Acute paralysis
4. Blackout/ collapse
5. CNS infection
6. CNS tumours
7. Coma
8. Confusion/ delirium
9. Head injury
10. Involuntary movements
11. MND
12. MS
13. Physical symptoms in absence of organic disease
14. Progressive memory loss
15. Raised ICP
16. Speech disturbance
17. Swallowing difficulties
18. Unsteadiness/ balance disturbance/ vertigo
19. Visual disturbance
20. Weakness and paralysis
21. Epilepsy