SCTS Ionescu Nursing & Allied Health Professional Fellowship Award Application Form Surname Forename Professional Status & Registration Number (NMC, HCPC etc) SCTS Associate Membership Number Current Place of Work E-mail Address Manager & Consultant Supervisor – please include contact e-mail details Purpose of Planned Placement Proposed Location of Planned Placement Estimate of Travelling Expenses (economy travel, hotel costs, incidentals) £ £ £ £ £ Total Are you receiving funding from any other sources (If yes, please provide details below ) £ No 1 Yes Detailed Proposal of Planned Fellowship Placement ≤ 1000 words 1. What specific learning opportunities are you hoping to gain from the planned fellowship placement? 2. Are there unique features within the clinical establishment that will enhance your own learning opportunities? 3. What additional skills/knowledge do you think you will learn from this fellowship? 4. How do you think your fellowship will impact on the national Nursing & AHP role in developing cardiothoracic surgery in the UK? 2 5. Please describe your proposed aims to implement the fellowship education/training in your department/other hospitals after this fellowship? 6. Please describe your plans for disseminating your new learning skills/knowledge to a broader audience? 7. Why do you think you should be awarded the fellowship? 8. Please include any other relevant information to support this fellowship application? 3 Supporting evidence: References to support this project; at least 2 referees are required: 1. 2. Please provide a separate supporting letter from your supervisor/manager stating that you will be released from clinical work (study leave): Declarations: In completing this, I declare that to the best of my knowledge, the information provided in this fellowship application is true, accurate and complete. I am happy to accept the process by which an application is assessed and agree to abide by the conditions under which an award may be granted. I agree that SCTS Education administrative team may hold and process, by computer or otherwise, personal and other data supplied with this application and, if successful, additional data provided during the award. I understand that the application will be shared with the members of the Expert Review Panel and may be sent for external peer review. Signatories: ---------------------------------------( ) ( Applicant --------------------------------------) ( Manager --------------------------------------) Consultant Supervisor 4