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 1 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) 12 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 2 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) 3 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; Virtual orientation session on the 28th January 2:00pm – 3:30pm Formal launch event at the FMLM conference in Manchester on 24th/25th February 2015 Three essential development days on the 18th March (London), 8th July (Leeds) and 16th September (Midlands/South) 2015 Six to eight (face to face or virtual) one to one sessions, two to three hours per session Please confirm that you are able to meet these requirements, by ticking this box: 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. 4 Please return your application by Monday 15th December 2014, 5pm to thuy.vuong@fmlm.ac.uk or by post (marked confidential) to: FMLM NHS Improving Quality Strategic Peer Support Programme c/o Thuy Vuong 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 5 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 6 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 7