SUPPLEMENTARY INFORMATION FOR MD ADMISSION

This supplementary form needs to be uploaded together with a copy of your Curriculum Vitae and a brief description of the proposed research project (preferably no more than two sides A4 paper).

Surname:
Forename(s):
Have you applied for out of programme research (OOPR) from the Deanery? / YES NO
Will you hold a salaried post during your MD? / YES NO
If yes - please provide further details / Post Title:
Funder:
Start Date:
End Date:
Renewable annually?
Number of Clinical Sessions per week during MD Project*:
Will you be required to work “out of hours” on call duties? / YES NO
Do you have GMC registration?
(Applicants will only be admitted onto the programme following their registration with the General Medical Council or, if an overseas candidate demonstration that an equivalent period of clinical training has occurred after the award of their medical qualification). / YES NO
Reg No: ______
Please state professional insurance agency and number:
Does your project require ethical approval?
Has this been granted? / YESNO
YES NO
If ethical approval is required later in the project, but not yet granted please provide a timeline detailing the research work that can be undertaken prior to ethical approval. / Timeline:

*For full-time study (2 years) MD students will be permitted to perform limited clinical duties as agreed with their supervisory team.. Such limited duties equate to one session per week and ‘out of hours’ on call duties only. Students will be required to devote the remaining time to the programme and to attend the Graduate Training Programme and University at all appropriate times. Students with greater clinical duties than those indicated above should register for part-time study (4 years). Part-time MD students are expected to devote a minimum of 5 sessions per week to their MD programme.

To Be Signed by the Applicant

Declaration:I certify that the information given in this application and in the supporting documents is accurate and complete. I understand that the submission of inaccurate information or failure to inform the Faculty MHS of changes in my clinical employment/circumstances may be sufficient cause for refusal of admission or termination of registration.

Signature of Applicant______Date______