Health Education East of England

Extension to Out of Programme (OOP) Application Form

Please complete ALL sections of this form for all requests to extend previously agreed time out of programme, if incomplete the form will be returned and not processed.

Section 1

Full Name
Training Number
GMC Number
Specialty
Date of Birth
Email Address
Contact Telephone Number
Start Date of OOP
Anticipated return date*

*While every effort will be made to allow you to return on your chosen date, the placement and timing will have to be negotiated with your Training Programme Director

Title & Location of OOP

Section 2

Health Education East of England requires extension to out of programme applications and supporting information to be submitted at least six months prior to the original planned end date. (Exceptions will only be agreed by the Postgraduate Dean).

What type of OOP are you currently undertaking?
(Please tick) / Out of Programme for Clinical Training (OOPT) (please use the CN18 form)
Out of Programme for Research (OOPR)
Out of Programme for Clinical Experience (OOPE)
Out of Programme for Career Break (OOPC)
Please submit the following: / Please tick
Educational Supervisor’s Report of Progress to support application
Statement detailing reasons for applying for an extension

Without the above documentation, your application will not be processed

I am requesting approval from the Postgraduate Dean’s Office to continue on my current OOP whist retaining my training number. I understand that:
·  Three years out of my clinical programme will normally be the maximum time allowed out of programme. Extensions to this will only be allowed in exceptional circumstances and will need further written approval from the Postgraduate Dean.
·  I will need to liaise closely with my Training Programme Director so that my re-entry into the clinical programme can be facilitated. I am aware that at least six months notice must be given of the date that I intend on returning to the clinical programme, and that the placement will depend on availability at that time. I understand that I may have to wait for a placement.
·  I will return an annual out of programme report each year that I am out of programme for consideration but the annual review panel. This will need to be accompanied by an Educational Supervisor’s report of progress and a formal statement detailing my progress made during my time out of programme. Failure to do this could result in the loss of my training number.
Signed
Date

TRAINING PROGRAMME DIRECTOR’S APPROVAL

I confirm that I approve this period out of programme

Signature of Training Programme Director
Name
TPD Email Address
Date

HEALTH EDUCATION EAST OF ENGLAND APPROVAL

Signature of Deputy Postgraduate Dean / Head of School
Name
Date

Please send the completed form to:

Out of Programme Coordinator

Email:

Confirmation of authorisation will be sent to you via email

Please contact us if you have any queries