HONORARY APPOINTMENTS FOR 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):
Form AF - Page 1 of 2
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?
http://www.ucl.ac.uk/hr/docs/criminal_record.php
Yes / NO (delete as appropriate)
Please attach your CV and teaching portfolio or teaching statement with evidence from NHS job plan (ecopies preferred). Those seeking renewal of their title must submit evidence of continuing research
activity and/or their teaching portfolio and NHS Job Plan.
See Section 3, 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
Site Sub Dean, Community Sub Dean 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 Divisional Staffing
Administrator (Vicky Cooper – v.cooper@ucl.ac.uk) to update local records and seek UCLMS approval
Divisional Director Authorisation
Print Name:
Email:
Signature:
Date:
Tel:
Once UCLMS authorisation is received the forms should be returned to the Divisional Staffing Assistant
Administrator for 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:
Form AF - Page 2 of 2