Patient Safety Collaborative Post Graduate Funding

APPLICATION FORM

Please type in your answers using a size 10 font.

PART I: SUMMARY INFORMATION

A. APPLICANT AND COURSE INFORMATION

Name:
Present position:
Department:
Institution/organisation:
Work address:
Home address:
Telephone (daytime):
Mobile:
Email:
Qualification: / Class of degree obtained / College/University: / Date

Professional qualifications:

B. SUMMARY STATEMENT

Please provide a brief statement describing how the postgraduate qualification chosen will support you in your future career (no more than half a page)

C. COURSE INFORMATION AND ELIGABILITY

Please attach a copy of the course acceptance letter or official confirmation with the application.

Patient safety course title:
University (eg.University of Hertfordshire):
Please confirm the duration of the course and whether you have applied for full or part time:
Please confirm the cost of the course:
I confirm I meet the requirements for home student statusYes / No (please delete as applicable)

D. EMPLOYERS LETTER OF REFERENCE AND PROFESSIONAL REFERENCEINFORMATION

Please give the names and contact details of two referees below.

Name of employers Chief Executive/Executive Director:

Referee 1, should provide your employers letter of reference and organisational support, should be someone who can legitimately authorise release from work for the period of study required, e.g. your Chief Executive or Executive Director.

Name:
Position:
Organisation:
Work address:
Work telephone:
Work email:

2. Professional Referee

Referee 2 should be an individual able to provide a professional reference for you. Professional referees need to address the following:

-The period of time the referee has known the applicant and in what capacity;

-The calibre of the applicant’s work and relevance topatient safety and quality improvement;

-Qualifications or reasons why the applicant should be selected to be funded for a postgraduate qualification.

Name:
Position:
Organisation:
Work address:
Telephone:
Email:

Patient Safety Collaborative Post Graduate Funding

APPLICATION FORM

PART 2: STATEMENT OF PROFESSIONAL OBJECTIVES

Please type your responses into the boxes using a size 10 font. Maximum 200 words for each question.

A. Please describe your interest in improving the quality and safety of healthcare services.
B. Please provide a brief outline of how you have engaged with theEastern AHSN Action on Frailty Patient Safety Collaborative. (eg. attendance at QI training days; PSC learning events).
C Please describe your professional accomplishments and/or experience that you feel best demonstrate your potential to take advantage of the postgraduate funding opportunity.
Application checklist
  1. application form (submitted by applicant)

  1. CV (submitted by applicant)

  1. course offer letter or confirmation (submitted by applicant)

  1. employers letter of reference and organisational support (submitted by referee 1)

  1. professional letter of reference (submitted by referee 2)

Please email completed application paperwork to Emma Dickerson, Programme Manager, Eastern Academic Health Science Network

1

August 2017