Information Required to Accompany Application for Request For

INFORMATION REQUIRED TO ACCOMPANY APPLICATION FOR REQUEST FOR

UNPAID LEAVE

Updated May 2012

The following must be included with your application for unpaid leave from your Specialist Registrar/Specialist Trainee training programme. Without the details below the Postgraduate Dean and the GMC* will not be able to consider your request:-

PMETB cannot accept applications from individual trainees or Colleges/SACs/Faculties

Please tick boxes below
Name
Specialty
Current contact address
Training number
GMC Number*
Current CCT date
Current placement
Proposed leave - dates
Written details of research/ clinical training
location
source of funding
Written Support from
Consultant Supervisor
Programme Director
Head of School
If you require your time out of programme to count towards your CCT written College confirmation of educational credit for proposed time to be spent out of programme MUST ACCOMPANY THIS APPLICATION. Please attach a copy of the correspondence from the College confirming they approve your Out of Programme time.*
A signed “provisionally agreed” copy of the OOPE form will only be provided for those Colleges who require a Deanery signed form before they can produce a College letter of support.

Both Deanery and College approval must have been given in writing before Specialist Registrar/Specialist Trainee can leave the programme.

OXFORD PGMDE

Request for Unpaid Leave (At least THREE MONTHS notice must be given)

Out of Programme Clinical Experience (OOPE) 0

Out of Programme Experience for Training (OOPT) 0

Out of Programme Experience for Research (OOPR) 0

Out of Programme for Career Break (OOPC) 0

Please indicate clearly which option

1. TRAINEE:

Name: ...... …………………………………………………………………...……

Date of Birth: ……………………………… GMC No: ………………………..

NTN No: …………………………………... ACF*: YES / NO

Speciality: ….……………………………… Hospital: ………………....……...

Contact address: ……………………...………………………………………………...

…………………………………………………………………………………………...

Work: Tel. No/Bleep No: ……………………… Email: …………………………...

Training Number (NTN/VTN) …………………. CCT date: …………..…………..

Mobile Number: ………………………………………………………………………..

I hereby request unpaid leave for the period:

Start date: …...... …(day)/……...... ….(month)/ …...... …(year)

End date: …...... ….(day)/…...... …… (month)/ ...... ……(year)

Please state clearly if this period of OOPE/OOPT/OOPR is to count towards your CCT

this now requires GMC approval YES NO

If YES the trainee MUST obtain a College letter of support to accompany this request to the Deanery for OOPE. The Deanery will be unable to make an application to the GMC without it.

Please indicate the length of time this request for Out of Programme is to count towards your

CCT ………………………………………………………………………………………………

Have you been on any previous OOPE/OOPT/OOPR (in any post): Yes/No

Start date: ...... (day) ...... (month) ...... (year) End date: ...... (day) ...... (month) ...... (year)

What was the reason for that OOPE/R/T request?

......

I have completed the section overleaf indicating how I intend to spend the period of unpaid leave and attach written College/Regional Adviser approval.

Trainee Signature: ……………………………………… Date: ……………….

2. CONSULTANT SUPERVISOR:

I DO/DO NOT SUPPORT* this request (* please delete as appropriate)

Name in BLOCK Capitals: ……………………………………………………………..

Signature: …………………………………………….…. Date: ……….………

3. STC/PROGRAMME DIRECTOR:

I DO/DO NOT SUPPORT* this request (* please delete as appropriate)

Name in BLOCK Capitals: ……………………………………………………………..

Please provide the reason(s) for your decision on a separate sheet.

If supported, please indicate:

(i) Whether the post will remain vacant/be filled with a LAT/Returning Researcher/Other …………………………………………………………………………………..

(ii) How much of the period of leave will count towards accreditation ………………

(iii) Whether the original CCT date is unchanged/postponed by: ………….. months

Signature: …………………………………………….…. Date: ……….………

Please confirm that the trainee has discussed plans regarding pension arrangements whilst on OOP with local Human Resources Department:

Yes No

4. HEAD OF SPECIALTY SCHOOL:

I DO / DO NOT SUPPORT* this request ( * please delete as appropriate)
Name in BLOCK Capitals: ...... ……..…..

Signature: ...... Date: ......

5. CONTACT DETAILS WHILST OUT OF PROGRAMME:

Address: ……………………………………………………………………………………

…………………………………………………………………………………….

Telephone: ……………………………………. Email Address: …………………….

(if different from overleaf)

Mobile Number: …………………………………………………………………………………

SOURCE OF FUNDING CONFIRMED AS:

………………………………………………………………………………………………………

6. POSTGRADUATE DEAN

I APPROVE/NOT APPROVE * this request (* please delete as appropriate)

Signature: ……………………………………….. Date: ………………

7. EXTENSION TO OOPE

Please note any extension of an OOPE should be made in a written request to the Training Programme Director at least 3 months before the agreed return date and MUST HAVE the written approval of the Postgraduate Dean. Reasons must be given why the extension is required.

8. ACF APPLICANTS

Out of programme time may only be approved for exceptional reasons. The ACF appointment would cease if a period of research leading to a higher degree is requested.

REASONS FOR REQUEST (Section 1)

NB: If you are planning to undertake research during the period of proposed leave, you must provide the name, contact address, telephone number and email address of your research supervisor.

If you are planning to undertake clinical training during the period of proposed leave, please provide details.

………………………………………………………………………………………………………

Please continue on a separate sheet if necessary

When signatures in Sections 1, 2, and 3 have been obtained please forward to

Vicky Beal, P. A. to Postgraduate Dean, Oxford PGMDE,

The Triangle, Roosevelt Drive, Headington, Oxford OX3 7XP.

Oxford Deanery Heads of School (contacts details can be found on deanery web site)

School of Medicine Dr. Anthony Bradlow

School of Emergency Medicine Dr. Peter Thomas

School of Radiology Dr. Niall Moore

School of Anaesthetics Dr. Oliver Dyar

School of Paediatrics Dr. Julie Edge

School of Ophthalmology Mr. Bruce James

School of Surgery Mr. Jeremy Noble

School of Psychiatry Dr. Denis O’Leary

School of Obstetrics and Gynaecology Miss Felicity Ashworth

School of Pathology Dr. Sanjiv Manek

Foundation School Dr. Anne Edwards

OUCAGS Dr. Kenneth Fleming

GMC DEFINITIVE LIST OF APPROVED SINGLE SPECIALTIES AND APPROVED

SUB-SPECIALTIES as at 3 DECEMBER 2009

Royal College of Anaesthetists

Anaesthetics

Royal College of Radiologists

Clinical Oncology

Clinical Radiology

College of Emergency Medicine

Emergency Medicine (also known as Accident and Emergency Medicine)

Royal College of General Practitioners

General Practice

Royal College of Anaesthetists

Intensive Care Medicine

Joint Royal Colleges of Physicians Training Board

Physicianly Specialties:

Acute Internal Medicine

Allergy

Audiological Medicine

Cardiology

Clinical Genetics

Clinical Neurophysiology

Clinical Pharmacology and Therapeutics

Dermatology

Endocrinology and Diabetes Mellitus

Gastroenterology

Genito-urinary Medicine

Geriatric Medicine

General (Internal) Medicine

Haematology

Immunology

Infectious Diseases

Medical Oncology

Medical Ophthalmology

Neurology

Nuclear Medicine

Paediatric Cardiology

Palliative Medicine

Pharmaceutical Medicine

Rehabilitation Medicine

Renal Medicine

Respiratory Medicine

Rheumatology

Sport and Exercise Medicine

Tropical Medicine

Joint Committee of Surgical Training

Surgical Specialties:

Cardio-thoracic surgery

Otolaryngology

General surgery

Neurosurgery

Oral and maxillo-facial surgery

Paediatric surgery

Plastic surgery

Trauma and Orthopaedic surgery

Urology

Royal College of Obstetricians and Gynaecologists

Obstetrics and Gynaecology

Community Sexual and Reproductive Health

Faculty of Occupational Medicine

Occupational Medicine

Royal College of Ophthalmologists

Ophthalmology

Royal College of Paediatrics and Child Health

Paediatrics

Royal College of Pathologists

Pathology Specialties:

Chemical Pathology

Histopathology

Medical Microbiology and Virology

Medical Microbiology

Medical Virology

Royal College of Psychiatrists

Psychiatry Specialties:

General Psychiatry

Child and Adolescent Psychiatry

Forensic Psychiatry

Old Age Psychiatry

Psychiatry of Learning Disability

Psychotherapy

Faculty of Public Health

Public Health Medicine

Sub-specialties

Emergency Medicine Paediatric Emergency Medicine

Cardiology Stroke Medicine

Chemical Pathology Metabolic Medicine

Clinical Pharmacology andTherapeutics Stroke Medicine

Clinical Radiology Interventional Radiology

Gastroenterology Hepatology

General (Internal) Medicine Acute Medicine

Metabolic Medicine

Stroke Medicine

Geriatric Medicine Stroke Medicine

Histopathology Cytopathology

Forensic Pathology

Neuropathology

Paediatric Pathology

Neurology Stroke Medicine

Obstetrics and Gynaecology Gynaecological Oncology

Maternal and Fetal Medicine

Reproductive Medicine

Sexual and Reproductive Health (previously known as Community Gynaecology)

Urogynaecology

Paediatrics Community Child Health

Neonatal Medicine

Paediatric Clinical Pharmacology andTherapeutics

Paediatric Diabetes and Endocrinology

Paediatric Gastroenterology, Hepatology and Nutrition

Paediatric Immunology, Infectious Diseases and Allergy

Paediatric Inherited Metabolic Medicine

Paediatric Intensive Care Medicine

Paediatric Nephrology

C:\Documents and Settings\bradlowa\Local Settings\Temporary Internet Files\OLK245\Updated General Application form from March 10.doc