The Strategic Peer Support Programme
Supporting senior clinical leaders to strengthen their leadership capabilities
and deliver lasting quality improvement
Application Form
Please complete the following information to apply to join the Strategic Peer Support (SPS)
Programme. Further details of the programme can be found at:
www.fmlm.ac.uk/the-strategic-peer-support-programme
Please indicate which role you wish to apply for:
Mentee [for Quality Improvement support and guidance]

Mentor / ‘Expert’ Peer [to provide Quality Improvement support and guidance]

Section 1: Personal Information
1. Title
2. First Name
3. Last Name
4. Address
Address Line 1
Address Line 2
Address Line 3
City/Town
Postcode
Country
5. Contact email
6. Telephone number
7. Mobile number
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Section 2: Professional Information
7.
Current organisation
8.
Job title
9.
GMC number (or other Professional
Registration number)
10. Specialty (please see Appendix 1)
11. Management Position: please tick
which role(s) you currently hold.
Clinician in a management or leadership
position at Directorate or board level?
Clinical Director
Medical Director
Chief Executive
Other (please specify below)
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Region: please indicate which region
England – South
you currently work in below.
England – North
England – Midlands and East
London
Scotland
Wales
Northern Ireland
Armed Forces
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Section 3: Supporting Details
13. Please provide us with a short personal biography (300 words max)
14. Please provide us with your motivations for applying for the SPS Programme and your
expectations from the SPS Programme (300 words max)
15. What if any, previous experience do you have of mentoring or coaching, either as a
coach/mentor or a mentee/coachee (100 words max)
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16. Commitment: The programme commences in January through to September 2015. To
fully realise the benefits of the SPS Programme, you will be required to participate in the
following:
Please confirm your availability by ticking each box.

Desirable: Virtual orientation session on the 28th January 2:00pm – 3:30pm

Desirable: Formal launch event at the FMLM conference in Manchester on 23rd
February 2015

Essential: Three essential development days on the 18th March (London), 8th July
(Leeds) and 16th September (Midlands/South) 2015

Essential: Six to eight (face to face or virtual) one to one sessions, two to three hours
per session
17. Organisational Support
Please ask your direct report or CEO or Chair to sign your application form before submitting
Name.............................................................................................
Signature ……………………………………….............................................
Date ……………………………………………….............................................
18. How did you hear about the SPS
programme?
NHS IQ website
FMLM website
SPS programme leaflet
SPS programme email
Recommendation from a mentor/mentee
Recommendation from your supervisor
Through your organisation
NHS IQ or FMLM Twitter
For any queries or questions relating to the SPS programme, please contact the
FMLM on 0203 075 1377 or Liz Maddocks-Brown, NHS IQ Senior Manager on 07734
756980.
Thank you for your interest in the SPS Programme.
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Please return your application by Wednesday 14th January 2015, midnight to
keenda.sisouphanh@fmlm.ac.uk or by post (marked confidential) to:
FMLM NHS Improving Quality Strategic Peer Support Programme
c/o Keenda Sisouphanh
Faculty of Medical Leadership and Management
2nd Floor
6 St Andrews Place
London
NW1 4LB
Confidentiality Policy
The information you provide will be treated with the utmost confidence.
Disclosures of personal data are only made in accordance with the provisions of the Data
Protection Act 1998 and only to staff within the Service who need the information to carry out
their duties. Data subject rights are maintained at all times.
Equal Opportunities Form: Strategic Peer Support Programme
This will be separated from your application and will only be used for monitoring purposes
only to help us achieve our equality and diversity objectives.
1. Gender
Male
Female
Prefer not to say
2. Age Group
Under 30
30-40
41-50
51-60
over 60
Prefer not to say
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3. Ethnicity
White – English
White – Irish
White – Scottish
White – Welsh
White – other
Mixed – White and Black Caribbean
Mixed – White and Black African
Black / Black British – African
Black / Black British – Other
Asian / Asian British – Indian
Asian / Asian British – Bangladeshi
Asian / Asian British – Chinese
Asian / Asian British - Other
Mixed – White and Asian
Black / Black British – Caribbean
Mixed – Other
Other Ethnic – Other
Prefer not to say
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Appendix 1: List of Specialties
Specialty
Medical Ophthalmology
Acute Internal Medicine
Medical Virology
Allergy
Neurology
Anaesthetics
Neurosurgery
Audiological Medicine
Nuclear Medicine
Cardiology
Obstetrics and Gynaecology
Cardiothoracic Surgery
Occupational Medicine
Chemical Pathology
Old Age Psychiatry
Child and Adolescent Psychiatry
Ophthalmology
Clinical Genetics
Oral and Maxillofacial Surgery
Clinical Neurophysiology
Otolaryngology
Clinical Oncology
Paediatric Cardiology
Clinical Pharmacology and Therapeutics
Paediatric Emergency Medicine
Clinical Radiology
Community Sexual and Reproductive
Health
Paediatric Surgery
Dental Surgery
Dermatology
Emergency Medicine
Endocrinology and Diabetes Mellitus
Forensic Psychiatry
Gastroenterology
General (Internal) Medicine
General Practice
General Psychiatry
General Surgery
Genito-urinary Medicine
Geriatric Medicine
Haematology
Histopathology
Immunology
Infectious Diseases
Paediatrics
Palliative Medicine
Pharmaceutical Medicine
Plastic Surgery
Psychiatry of Learning Disability
Psychotherapy
Public Health Medicine
Rehabilitation Medicine
Renal Medicine
Respiratory Medicine
Rheumatology
Sport and Exercise Medicine
Stroke Medicine
Trauma and Orthopaedic Surgery
Tropical Medicine
Urology
Other
Intensive Care Medicine
Medical Microbiology
Medical Microbiology and Virology
Medical Oncology
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