Application form

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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
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