Application Form

Proposal for consideration of funding by the School of Medicines Optimisation (staff working across Yorkshire & the Humber)

Section A: About the Applicant(s) and their proposal

A1 / Name of Your Organisation
Job Title: / Pharmacist / Pharmacy Technician
Y/N / Y/N
A2 / Your Name
Address / Address Line 1
Address line 2
Town
County
Postcode
A3 / Telephone Contact
E-mail contact
A4 / Please indicate on what basis you wish the School to consider your application (tick only one)
I am an INDIVIDUAL making an application to HEE for funding for a programme of post-registration study / I am applying on behalf of an ORGANISATION for funding on behalf of a staff memberfor a programme of post-registration study
You should now complete section B to E in full before returning the form / You should now complete sections B to E in full before returning the form

Section B: For individual propsals for postgraduate funding

B1 / Name of the course applied for
Academic Level of the programme / Level 8 / Doctoral Study
Level 7 / Masters
PGCE
PGDip
PGCert
Bsc
Graduate Certificate
Graduate Diploma
Level 6
Other
B2 / The cost of this programme of study:
B3 / Proposed start date: / Please note- only start dates in the current financial year are considered
B4 / If a programme of study over multiple academic years: which year of study are you making your application for?
(NB: we may only guarantee one years funding dependant on programme/funding availability) / First Year /
Second Year /
Third Year /
Fourth Year /
Other /
B5 / Name of University or Educational Institution:
B6 / Please tick the following statements to confirm that as the person/ representative making the application to HEE, you understand that:
For higher education course approval, final confirmation of attendance will be usually be required 6 weeks prior to the programme commencing
Only once confirmation has been received, will the place be confirmed with the University/FE Institution
In the event of subsequent failure to complete the year of study, HEE will be notified by the provider
In the event of subsequent failure to complete the year of study, and in the absence of exceptional circumstances, further applications for the same individual will not be considered for a 5 year period
Now please complete section G before returning your application form to HEE

Section C: How this proposal links to learning needs

C1 / This proposal specifically references a national initiative (e.g. clinical training, dementia training, genomics education etc.) / Yes / / No /
Please state the initiative(s) below:
C2 / This proposal specifically references a local initiative (e.g. a serious untoward incident or investigation etc.) / Yes / / No /
Please state the initiative(s) below:
C3 / Please explain how this proposal places an emphasis on enhancing personal learning needs/ or patient safety:

Section D: Proposed Evaluation

D1 / There is a clear evaluation process intended for this proposal / Yes / / No /
Please describe it here:
D2 / Is there a clear mechanism for providing a suitable progress report (e.g. student monitoring report of progress evaluationetc.) / Yes / / No /
To what forum will this feedback be presented?
D3 / Is there a clear criterion for the assessment of return on investment? / Yes / / No /
Please describe it here:

Section E: Supporting Evidence and Declaration

E1 / Do you have further evidence to submit regarding the particular appropriateness of you or your organisation to make this proposal? / Yes / / No /
If so, you may write it here:
E2 / Do you have further evidence to submit regarding particular considerations we should make at this time e.g. particular workforce needs or vulnerabilities that you think we should know about? / Yes / / No /
If so, you may write it here:
E3 / Do you have anything further to add to support your application to HEE overall at this time?
If so, you may write it here:
E4 / I can confirm that I have authorisation to apply on behalf of myself and/or of the organisation named to apply to Health Education England (HEE) within Yorkshire & the Humber via School of Medicines Optimisation for consideration of this proposal.
Name:
Position/Role:
Signature:

HEE (Yorkshire & the Humber) School of Medicines Optimisation - Application form 2016