INFORMATION REQUIRED TO ACCOMPANY
APPLICATION FOR REQUEST FOR
UNPAID LEAVE
Updated September 2010
The following must be included with your application for unpaid leave from your Specialist
Registrar/Specialist Trainee training programme. Without the details below the Postgraduate
Dean and the GMC* will not be able to consider your request:PMETB cannot accept applications from individual trainees or Colleges/SACs/Faculties
Please tick
boxes below
Name
Specialty
Current contact address
Training number
GMC Number*
Current CCT date
Current placement
Proposed leave - dates
Written details of research/ clinical training
location
source of funding
Written Support from
Consultant Supervisor
Programme Director
Head of School
If you require your time out of programme to count towards your
CCT written College confirmation of educational credit for
proposed time to be spent out of programme MUST
ACCOMPANY THIS APPLICATION. Please attach a copy of
the correspondence from the College confirming they approve
your Out of Programme time.*
A signed “provisionally agreed” copy of the OOPE form will
only be provided for those Colleges who require a Deanery
signed form before they can produce a College letter of
support.
Both Deanery and College approval must have been given in writing before Specialist
Registrar/Specialist Trainee can leave the programme.
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OXFORD PGMDE
Request for Unpaid Leave (At least THREE MONTHS notice must be given)
Out of Programme Clinical Experience (OOPE)
Out of Programme Experience for Training (OOPT)
Out of Programme Experience for Research (OOPR)
Out of Programme for Career Break (OOPC)

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
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Please indicate clearly which option
1.
TRAINEE:
Name: .................…………………………………………………………………...……
Date of Birth: ………………………………
GMC No: ………………………..
NTN No: …………………………………...
ACF*: YES / NO
Speciality: ….………………………………
Hospital: ………………....……...
Contact address: ……………………...………………………………………………...
…………………………………………………………………………………………...
Work: Tel. No/Bleep No: ………………………
Email: …………………………...
Training Number (NTN/VTN) …………………. CCT date: …………..…………..
Mobile Number: ………………………………………………………………………..
I hereby request unpaid leave for the period:
Start date: …........…(day)/…….........….(month)/ …...........…(year)
End date: ….......….(day)/…........…… (month)/ .............……(year)
Please state clearly if this period of OOPE/OOPT/OOPR is to count towards your CCT
this now requires GMC approval
YES
NO
If YES the trainee MUST obtain a College letter of support to accompany this request to
the Deanery for OOPE. The Deanery will be unable to make an application to the GMC
without it.
Please indicate the length of time this request for Out of Programme is to count towards your
CCT
………………………………………………………………………………………………
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I have completed the section overleaf indicating how I intend to spend the period of
unpaid leave and attach written College/Regional Adviser approval.
Trainee Signature: ……………………………………… Date: ……………….
2.
CONSULTANT SUPERVISOR:
I DO/DO NOT SUPPORT* this request (* please delete as appropriate)
Name in BLOCK Capitals: ……………………………………………………………..
Signature: …………………………………………….…. Date: ……….………
3.
STC/PROGRAMME DIRECTOR:
I DO/DO NOT SUPPORT* this request (* please delete as appropriate)
Name in BLOCK Capitals: ……………………………………………………………..
Please provide the reason(s) for your decision on a separate sheet.
If supported, please indicate:
(i)
Whether the post will remain vacant/be filled with a LAT/Returning
Researcher/Other
…………………………………………………………………………………..
(ii)
How much of the period of leave will count towards accreditation ………………
(iii)
Whether the original CCT date is unchanged/postponed by: ………….. months
Signature: …………………………………………….…. Date: ……….………
4.
HEAD OF SPECIALTY SCHOOL:
I DO / DO NOT SUPPORT* this request ( * please delete as appropriate)
Name in BLOCK Capitals: .........................................................................……..…..
Signature: ..........................................................................
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Date: .................
5.
CONTACT DETAILS WHILST OUT OF PROGRAMME:
Address:
……………………………………………………………………………………
…………………………………………………………………………………….
Telephone:
……………………………………. Email Address: …………………….
(if different from overleaf)
Mobile Number: …………………………………………………………………………………
SOURCE OF FUNDING CONFIRMED AS:
………………………………………………………………………………………………………
………………………………………………………………………………………………………
6.
POSTGRADUATE DEAN
I APPROVE/NOT APPROVE * this request (* please delete as appropriate)
Signature:
7.
………………………………………..
Date: ………………
EXTENSION TO OOPE
Please note any extension of an OOPE should be made in a written request to the
Training Programme Director at least 3 months before the agreed return date and
MUST HAVE the written approval of the Postgraduate Dean.
8.
ACF APPLICANTS
Out of programme time may only be approved for exceptional reasons. The ACF
appointment would cease if a period of research leading to a higher degree is requested.
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REASONS FOR REQUEST
(Section 1)
NB: If you are planning to undertake research during the period of proposed leave, you
must provide the name, contact address, telephone number and email address of your
research supervisor.
If you are planning to undertake clinical training during the period of proposed leave,
please provide details.
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
Please continue on a separate sheet if necessary
When signatures in Sections 1, 2, and 3 have been obtained please forward to
Vicky Beal, P. A. to Postgraduate Dean, Oxford PGMDE,
The Triangle, Roosevelt Drive, Headington, Oxford OX3 7XP.
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PMETB DEFINITIVE LIST OF APPROVED SINGLE SPECIALTIES AND APPROVED
SUB-SPECIALTIES
as at 3 DECEMBER 2009
Royal College of Anaesthetists
Anaesthetics
Royal College of Radiologists
Clinical Oncology
Clinical Radiology
College of Emergency Medicine
Emergency Medicine (also known as Accident and Emergency Medicine)
Royal College of General Practitioners
General Practice
Royal College of Anaesthetists
Intensive Care Medicine
Joint Royal Colleges of Physicians Training Board
Physicianly Specialties:
Acute Internal Medicine
Allergy
Audiological Medicine
Cardiology
Clinical Genetics
Clinical Neurophysiology
Clinical Pharmacology and Therapeutics
Dermatology
Endocrinology and Diabetes Mellitus
Gastroenterology
Genito-urinary Medicine
Geriatric Medicine
General (Internal) Medicine
Haematology
Immunology
Infectious Diseases
Medical Oncology
Medical Ophthalmology
Neurology
Nuclear Medicine
Paediatric Cardiology
Palliative Medicine
Pharmaceutical Medicine
Rehabilitation Medicine
Renal Medicine
Respiratory Medicine
Rheumatology
Sport and Exercise Medicine
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Tropical Medicine
Joint Committee of Surgical Training
Surgical Specialties:
Cardio-thoracic surgery
Otolaryngology
General surgery
Neurosurgery
Oral and maxillo-facial surgery
Paediatric surgery
Plastic surgery
Trauma and Orthopaedic surgery
Urology
Royal College of Obstetricians and Gynaecologists
Obstetrics and Gynaecology
Community Sexual and Reproductive Health
Faculty of Occupational Medicine
Occupational Medicine
Royal College of Ophthalmologists
Ophthalmology
Royal College of Paediatrics and Child Health
Paediatrics
Royal College of Pathologists
Pathology Specialties:
Chemical Pathology
Histopathology
Medical Microbiology and Virology
Medical Microbiology
Medical Virology
Royal College of Psychiatrists
Psychiatry Specialties:
General Psychiatry
Child and Adolescent Psychiatry
Forensic Psychiatry
Old Age Psychiatry
Psychiatry of Learning Disability
Psychotherapy
Faculty of Public Health
Public Health Medicine
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Sub-specialties
Emergency Medicine
Paediatric Emergency Medicine
Cardiology
Stroke Medicine
Chemical Pathology
Metabolic Medicine
Clinical Pharmacology andTherapeutics
Stroke Medicine
Clinical Radiology
Interventional Radiology
Gastroenterology
Hepatology
General (Internal) Medicine
Acute Medicine
Metabolic Medicine
Stroke Medicine
Geriatric Medicine
Stroke Medicine
Histopathology
Cytopathology
Forensic Pathology
Neuropathology
Paediatric Pathology
Neurology
Stroke Medicine
Obstetrics and Gynaecology
Gynaecological Oncology
Maternal and Fetal Medicine
Reproductive Medicine
Sexual and Reproductive Health (previously known as
Community Gynaecology)
Urogynaecology
Paediatrics
Community Child Health
Neonatal Medicine
Paediatric Clinical Pharmacology andTherapeutics
Paediatric Diabetes and Endocrinology
Paediatric Gastroenterology, Hepatology and Nutrition
Paediatric Immunology, Infectious Diseases and Allergy
Paediatric Inherited Metabolic Medicine
Paediatric Intensive Care Medicine
Paediatric Nephrology
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