HONORARY APPOINTMENTSFOR TEACHING IN UCL MEDICAL SCHOOL

FORM AF

Application form for Honorary Titles,for Teaching in UCL Medical School
It is essential that all fields are completed; please put n/a where not applicable
New Request / reappointment (delete as applicable)
Prof/Dr/Mr/Mrs/Ms – circle or indicate other: / Family Name:
Forename(s): / Known as (if different):
Date of Birth: / Gender: Male / Female (delete as appropriate)
Qualifications:
Address for correspondence:
UCL Division or Institute where title will be held - UCL Medical School
Type of title requested (please tick):
* / Hon. Senior Lecturer(Teaching Portfolio) / * / Hon. Clinical Teaching Fellow
* / Hon. Clinical Senior Lecturer(Teaching Portfolio) / * / Hon. Clinical Senior Teaching Fellow
* / Hon. Lecturer(Teaching Statement) / * / Hon. Clinical Principle Teaching Fellow
* / Hon. Clinical Lecturer(Teaching Statement)
Please detail the teaching and research commitment on which basis the honorary title is being requested:
MBBS Teaching
Numbers of additional hours a week:
Duties undertaken:
Main UCL site for these Teaching Activities (please state all if more than one):
Research supervision or research collaboration:
Collaborating with (UCL staff member(s)):
On (details of research):
Other reason:
NHS Trust in which substantive post is held where applicable:
Duration of Appointment- (Maximum of 4 years, renewable if required)
Start date: / End date:
Any other relevant information / or detail any change (other than end date) e.g. where replacing an existing post/title:
Will an IT account be required / YES / NO (delete as appropriate)
Are CRB checks required for this honorary appointment? / Yes / NO (delete as appropriate)

Please attach your CV and teaching portfolio or teaching statementwith evidence from NHS job plan (e-copies preferred). Those seeking renewal of their titlemust submit evidence of continuing research activity and/or their teaching portfolio and NHS Job Plan.

See Section3, How to Apply in the Guidance and Applications Process document; for details on how to submit your application.

If applying for a Clinical Honorary Appointment
SiteSub Dean, Community SubDean or Undergraduate Tutor (DGH) Authorisation
Print Name: / Signature: / Date:
Name of Campus/Trust:
If applying for Non-Clinical Honorary Appointment
Head of Department/ Senior Manager Authorisation
Print Name: / Signature: / Date:
Name of Trust/Institute:

This form, together with the Teaching Statement /Teaching Portfolio (indicated with Honorary Title above), CV and other supporting documentation should now be returned to the UCLMS DivisionalStaffing Administrator (Vicky Cooper – )to update local records and seek UCLMS approval

Divisional DirectorAuthorisation
Print Name: / Signature: / Date:
Email: / Tel:

Once UCLMS authorisation is receivedthe formsshould be returned to the Divisional Staffing Assistant Administratorfor submission of the SiP Form.

Checklist

Application Form completed, required information submitted
Supporting documents provided; Teaching Statement or Portfolio and CV
Criteria met (required qualifications, teaching & research reflected)
Length of appointment (anything up to maximum of 4 years)
Site Sub Dean/ HoD Authorisation provided
Comments: / Action:

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