Candidate:

North West London Hospitals NHS Trust

APPLICATION FORM

FELLOWSHIP IN MEDICAL EDUCATION

Intake
August – October 2011 (start date negotiable)


Candidate:

Please complete this application form carefully. CVs and additional pages will not be accepted.

North West London Hospitals NHS Trust

APPLICATION FORM

FELLOWSHIP IN MEDICAL EDUCATION

Section A - Personal details
Last Name / First Names
Title / If previously known by another name, please specify
Home Address / Address for correspondence
Home telephone number
Home fax number
Home email address
Mobile phone number / Work telephone number
Work fax number
Work email address
NB: Communications about FME applications will be conducted by email unless stated otherwise
Date available to start if offered the post
Section B - General Medical Council registration
Type of registration / GMC Number / Renewal date / Name in which you are registered
If not registered with the GMC at time of application, will you be eligible for registration by the time of appointment? Please give details below.


Candidate:

Section C – Immigration status

PLEASE COMPLETE THIS SECTION FULLY – FAILURE TO DO SO WILL RESULT IN YOUR APPLICATION BEING REJECTED

1 / Are you a United Kingdom (UK), European Community (EC) or European Economic Area (EEA) national? (Please indicate as appropriate) / YES / NO
2 / If not, do you have evidence of entitlement to enter and work permanently in the United Kingdom i.e. settled status? (Please indicate as appropriate) / YES / NO
If you have indicated no to both of the above sections please tick those boxes that relate to your immigration status as at 6 August 2010:
Tick / Status / Start Date / Expiry date
Tier 1 Visa
Highly Skilled Migrant Programme
Permit Free Training / Post Graduate Doctor Visa
Refugee
Work Permit / Tier 2 Visa
Any other – please specify:
Residence Permit valid until:

Note 1: If short listed for interview you will be asked to provide a copy of your residence permit to the application form

Section D – Entry criteria
Training number (NTN)
Name of run-through training programme
Eg. Psychiatry specialist training
By the post start date how many months’ experience at SHO, SpR or StR level in this specialty will you have? (DO NOT include time spent in Foundation modules)
By the post end date how many months’ experience at SHO, SpR or StR level in this specialty will you have left to undertake?

Note 2: If offered an FME opportunity you will soon be asked to provide a completed Out of Programme Experience form as evidence that your OOPE is supported. You are strongly advised to start discussing this with your Educational Supervisor and Training Programme Director at the time of applying. The relevant OOPE paperwork can be found on the London Deanery website at http://www.londondeanery.ac.uk/var/career-planning-personal-development/out-of-programme

What evidence of achievement of satisfactory progress will you provide? / YES / NO
Evidence of satisfactory RITA, ARCP or VTR2 reviews
Other – please specify below.
Other evidence of achievement of specialty training competences. (Only complete this if you have selected ‘Other’ above. Please explain why RITA or ARCP outcome forms are not available)


Candidate:

Section E – (1) Additional experience, training and courses
Please give details of any other clinical experience, training or courses you have undertaken.
Activity / Location / Date from / Date to
Section E – (2) – Extracurricular activities/achievements relevant to your specialty
Please give details of any other relevant activities you have undertaken.
Activity / Location / Date from / Date to
Section F – Present employment
Employer/NHS Trust Name:
Address:
Telephone number:
Current position
Specialty / Grade / Date appointed / Length of contract / Length of notice required


Candidate:

Section G – Previous appointments/clinical experience

Please list posts in chronological order and state if locum/temporary/substantive posts.

Specialty, Hospital or Trust, Consultant / Grade (state if Locum[L],Temporary([T], or Substantive [S] post / From / To / Months in Post


Candidate:

Section H – Professional qualifications
Medical School/University / Dates

Note 3: Short listed candidates will be required to bring original certificates to the interviews

Basic Medical Degree / Awarding Body / Date of Qualification
Other degrees done as part of the medical course (e.g. BSc, MD). State class of degree awarded
Degree/Class / Awarding Body / Date of Qualification
Other degrees or diplomas (e.g MSc, PhD, MD (by thesis))
Degree / Diploma / Awarding Body / Date of Qualification
Section I – Academic achievements
(A) Prizes or other Academic Distinctions
Prize/Distinction / Subject Area / Date of Award / Who was this awarded by?

Candidate:

(b) Publications
(c) Presentations/posters at conferences
Title of presentation/poster / Where presented? / Date of presentation

Candidate:

Section J – Educational experience and career Plans
(a) Please give brief details of previous experience or roles undertaken in medical education e.g. undergraduate teaching. Indicate your level of involvement and role (up to 150 words).
(b)  Please describe in more detail one of the initiatives/roles above (up to 150 words)


Candidate:

(c) Please say why you want this particular Fellowship, indicating your career goals in relation to medical education (up to 150 words)


Candidate:

Section L – Referees
1
Telephone Number
Fax Number
Email address / 2
Telephone Number
Fax Number
Email address
Note 4: Name, job title and address of two referees, ideally from the last two years of employment (references to be written using the separate reference template form provided). One of the referees must be your present or most recent Consultant/Educational supervisor. The second must be a senior educationalist e.g. clinical tutor, training programme director who is willing to comment on your strengths and weaknesses, and potential for development of a career in medical education. Referees should be able to comment, from experience, on your ability and suitability for the post.
Section N - Notes
1 / Children and Vulnerable Adults
Where the appointment involves substantial access to children and /or vulnerable adults, the appointment is subject to a police check. The Criminal Records Bureau will be asked to verify that you have no convictions and cautions or pending prosecutions, convictions, cautions and bind-over orders. This will include local police force records in addition to checks with the Police National Computer and the government department lists held by the Department of Health and Department for Education and Employment, where appropriate.
2 / Declaration
If you are related to a member or Senior Officer/Manager of the Deaneries/Trusts/Universities involved in the training programme, you must disclose such a relationship. You are also required to declare any involvement, either directly or indirectly, with any firm, company or organisation which has a contract with Deaneries/Trusts/Universities involved in the training programme. Failure to declare any information on these matters may result in your application being rejected or, if it is discovered after appointment that such information has been withheld, then this may lead to dismissal. Please note canvassing of a Senior Officer/Manager shall disqualify an applicant. Please state any disclosure/declaration related to the above on a separate sheet.

Section O - Equal Opportunities

NHS employers are committed to equal opportunities. No applicants will be discriminated against on the grounds of colour, race, ethnic origin, nationality, age, disability, gender, sexual orientation, marital status, religion, or politics

Section P – Accepting an Appointment

You must take up any post, including a locum post, you have formally accepted unless the employer has adequate time to make other arrangements. (Good Medical Practice published by the General Medical Council 2009). Failure to comply with this requirement may result in a complaint to the GMC.

Section Q – Fitness to Practice & Criminal Investigations Declaration

The North West London Hospitals NHS Trust and London Deanery aim to promote equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of race, gender, marital status, religion, disability, sexual orientation or age. We undertake not to discriminate unfairly against applicants on the basis of criminal conviction or other information declared.

Prior to making a final decision concerning your application, we shall discuss with you any information declared by you that we believe has a bearing on your suitability for the position. If we do not raise this information with you, this is because we do not believe that it should be taken into account. In that event, you still remain free, should you wish, to discuss the matter with the interviewing panel. As part of assessing your application, we will only take into account relevant criminal record and other information declared.

The Data Protection Act 1998 requires us to provide you with certain information and to obtain your consent before processing sensitive data about you. Processing includes: obtaining, recording, holding, disclosing destruction and retaining information. Sensitive personal data includes any of the following information: criminal offences, criminal convictions, criminal proceedings, disposal or sentence.

The information that you provide in this Declaration Form will be processed in accordance with the Data Protection Act 1998. It will be used for the purpose of determining your application for this position. It will also be used for purposes for enquiries in relation to the prevention and detection of fraud. Once a decision has been made concerning your appointment, we will not retain this Declaration Form longer than is necessary (i.e. until you leave your post/programme or the recruitment episode in closed).

This Declaration Form will be kept in securely and in confidence, and access to it will be restricted to designated persons within North West London Hospitals NHS Trust and the Faculty Development Unit of the London Deanery and other persons who need to see it as part of the selection process and who are authorised to do so. The information may be passed to your employing trusts.

Before you can be considered for appointment in a position of trust as a trainee on a North West London Hospitals NHS Trust and London Deanery funded placement we need to be satisfied about your character and suitability.
It is vitally important that you read, understand and answer the questions asked in this section – please read the accompanying notes carefully before completing this declaration form.
The position for which you have applied is exempted from the Rehabilitation of Offenders Act 1974. This means that you must declare all criminal convictions, including those that would otherwise be considered “spent”.
Answering “YES” to any of the questions below will not necessarily bar you from appointment. This will depend on the nature of the position for which you are applying and the particular circumstances.
If you would like to discuss what effect any previous convictions, police investigations or fitness to practise proceedings taken or being taken either in the UK or by an overseas licensing or regulatory body might have on your application, you may telephone: Pami Kalia on 020 8869 2192 (Human Resources) in confidence.
1 / Are you currently bound over or have you ever been convicted of any offence by a Court or Court-Martial in the United Kingdom or in any other country? NB You do not need to tell us about parking offences. Please indicate as appropriate. / YES / NO
2 / Have you ever received a police caution, reprimand or final warning? Please indicate as appropriate. / YES / NO
3 / Have you been charged with any offence in the United Kingdom or in any other country that has not yet been disposed of? Please indicate as appropriate.
Please note: you must inform us immediately if you are charged with any offence in the United Kingdom or in any other country after you complete this form and before taking up any position offered to you. You do not need to tell us if you are charged with a parking offence. / YES / NO
4 / Are you aware of any current police investigation in the United Kingdom or in any other country following allegations made against you? Please indicate as appropriate. / YES / NO
5 / Are you aware of any current NHS Counter Fraud and Security Management Service investigation following allegations made against you? Please indicate as appropriate. / YES / NO
6 / Have you ever been investigated by the Police, CFSMS or any other Investigatory Body resulting in a caution, conviction or dismissal from your employment? (Investigatory bodies include Local Authorities, Customs & Excise, Immigration, Passport Agency, Inland Revenue, Department of Trade & Industry, Banks and Building Societies, General Life Insurance Companies – this list is not exhaustive, and you must declare any investigation conducted by an Investigatory Body). Please indicate as appropriate. / YES / NO
7 / Have you ever been dismissed by reason of misconduct from any employment, office or other position previously held by you? Please indicate as appropriate. / YES / NO
8 / Have you ever been disqualified from the practice of a profession or required to practice subject to specified limitations following fitness to practise proceedings by a regulatory or licensing body in the United Kingdom or in any other country? Please indicate as appropriate. / YES / NO
9 / Are you currently the subject of any investigation or fitness to practise proceeding by any licensing or regulatory body in the United Kingdom or any other country? Please indicate as appropriate. / YES / NO
10 / Are you subject to any other prohibition, limitation, or restriction that means we are unable to consider you for the position for which you are applying? Please indicate as appropriate. / YES / NO
If you have answered “YES” to any of the questions, please provide full details on a separate sheet and place in a sealed envelope addressed to Pami Kalia, HR Business Partner, Human Resources, Level 6BB, Northwick Park Hospital, Watford Road, Harrow HA1 3UJ (tel 020 8869 2192). Please indicate clearly the number(s) of the question (s) that you are answering. Please mark the envelope “CONFIDENTIAL”
DECLARATION
I have read the “Guidance Notes for Applicants” that accompanied my application form, and I consent to the information provided in this Declaration Form being used by the North West London Hospitals NHS Trust and London Deanery for the purpose of assessing my application, and for enquiries in relation to the prevention and detection of fraud.
I confirm that the information that I have provided in this Declaration Form is correct and complete. I understand and accept that if I withhold or provide false or misleading information this may result in my application being rejected, or if I am appointed, in my dismissal and I may be liable to prosecution.
Signed : / Date :
Name (please print)
You are reminded that if you are appointed to a training post or programme, you will have a continuing responsibility to inform your employer(s) and the Postgraduate Dean of any new criminal convictions, police investigations or fitness to practise proceedings that arise in the future.
Note: if you wish to withdraw your consent at any time after completing this Declaration Form, please contact Dr Roger Sharpe by email at

Section R - Signature