116103740
NIHR INTEGRATED ACADEMIC TRAINING RECRUITMENT MONITORING FORM
A copy of this form must be completed for each newly selected / recruited ACF and CL and returned together
with the Quarterly Monitoring Form.
TRAINEE DETAILS
Surname
First Names
Phone No
E-mail
Address
NTN (a)
ST /Grade
GMC/GDC No.
Date of
Birth
Expected CCT
date
Lead NHS
Trust
Gender
Male
Female
EDUCATION
Intercalated BSc
YES
NO
MBPhD
YES
NO
PhD
YES
NO
MD
YES
NO
POST DETAILS
Please indicate if this is an ACF or CL
Please indicate how this post is funded
ACF
NIHR funded
CL
Locally Funded (NIHR recognised)
Locally Funded (unrecognised)
GMC Approved Speciality:
Post profile date (year allocated to partnership (refer to SLA))
a)
Is the post a refill?
YES
NO
b)
Is the post deferred from a previous year’s allocation?
YES
NO
YES
NO
If you answered yes to a) or b), was NIHR Trainees CC approval
obtained?
Proposed start date
Is the post approved by GMC (please state GMC ref)?
YES
NO
GMC Ref:
PROGRAMME LEAD
Name of Academic Programme Lead
Phone No
Address
Email Address
Post Code
LOCAL HEE DETAILS
Name of HEE local Team:
Address
Post Code
I confirm that the information provided above is accurate and that consent has been given for the use of personal information.
Name of Postgraduate Dean: .....................................................................................................
Signature: ......................................................................
Date: ................................
Please return a signed hard copy of this form to: Recruitment Monitoring, Integrated Academic Training, NIHR Trainees
CC, Leeds Innovation Centre, 103 Clarendon Road, LEEDS, LS2 9DF.
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