Imperial College Faculty of Medicine
Honorary Academic Titles
Honorary Lecturer or Honorary Senior Lecturer for Medical NHS Staff
Honorary Lecturer, Honorary Senior Lecturer, Honorary Teaching Associate or Honorary Senior
Teaching Associate for Non-Medical NHS Staff (the word Clinical may be added to all of the titles).
Please complete legibly, preferably typed.
Please ensure a copy of your CV is attached to this form.
Last Name (s):
Title:
(required by
College to issue
ID number)
First Name(s):
Qualifications:
Present NHS Appointment(s):
Employing Trust /authority:
Department within Trust:
Academic Line Manager’s name
or Head of Department:
Contract WTE% [or PAs]:
Date
of
appointment:
Appointment end date
(not normally less than
3 years):
Trust employee
number:
Proposed School, Institute or Department affiliation (please tick)
Institute of Clinical Sciences
Department of Medicine
National Heart and Lung Institute
School of Public Health
Department of Surgery and Cancer
Faculty Education Office
x
Proposed Division/Department within SID: ______________________________________
Proposed Section within Division/Department: ___________________________________
Correspondence Address:
Email Address:
Work Telephone Number:
Date of Birth:
Please give details of your current ongoing activities relating to UNDERGRADUATE teaching at Imperial College
London (note teaching to non IC students e.g., nurses, physiotherapists should not be included). Please specify
the number and frequency of teaching sessions and the type of teaching. [Only dedicated teaching sessions
should be included. Service activities, e.g., business clinics and ward rounds should not be listed].
Year group / Theme
Type of teaching
Duration / Frequency
Number of
students
Teaching
(e.g., lectures,
clinical teaching,
teaching ward
rounds, etc.).
Academic Leadership /
Curriculum
Development (e.g. Site
Coordinator, Course
Leader).
Examinations (e.g.
question setting,
examining).
Education
Committees/groups.
Please give details of your current ongoing activities relating to teaching postgraduate students at Imperial
College London. Please specify the number and frequency of teaching sessions and the type of teaching (note.
only teaching to postgraduate students should be included; not teaching to doctors (e.g., F1s and F2s) or
healthcare professionals).
Year group / Theme
Teaching
(e.g., lectures,
clinical teaching,
teaching ward
rounds, etc.).
Academic Leadership /
Curriculum
Development (e.g. Site
Coordinator, Course
Leader).
Type of teaching
Duration / Frequency
Number of
students
Examinations (e.g.
question setting,
examining).
Education
Committees/groups.
Other Academic activities related to undergraduate or postgraduate medical education with details and dates (over the last
three years).
Training
Courses
attended
i Imperial
ii HEA
iii Other (NHS
CPD, Royal
College)
Name of Course
Date / Duration
Course Provider
Participation in
training courses as a
trainer
OTHER CONTRIBUTIONS to undergraduate/postgraduate medical education not within the above categories e.g.,
participation in educational research programmes.
RESEARCH ACTIVITIES
Please give details of your activities relating to RESEARCH relating to the past three years, with details and
dates. Please ensure you give details of publications and grants received. [You may attach additional pages if
necessary].
Full name
………………………………………………………………………………………………………..
Signature
...........................................................................................
Date
..............................
DATA PROTECTION ACT notice: The information supplied on this form will be held on a database kept in
compliance with the Data Protection Act 1998.
Please note: For administrative purposes applications will be dealt with via one route only, research or teaching,
below. For applicants who have combined research and teaching experience, please choose the route on the
basis of the most significant activity that contributes to the College.
Research Applications:
School, Institute or Department Head (or delegate e.g. Head of Division) to complete, for both medical and nonmedical applications.
Proposed Title:
Is this:
(i) a new title?
(ii) a routine review?
Y/N
Y/N
Yes/ No
Do you support this application?
[comment if appropriate]
Name:
(print)
Date:
Signed:
Email:
Telephone number:
The Trust R&D Director (for non-medical NHS applications only) to complete
Do you support this application?
Yes/ No
[comment if appropriate]
Name:
(print)
Signed:
Email:
Telephone number:
Date:
Teaching Applications:
Relevant NHS Trust Director of Clinical Studies (DCS) to complete for medical NHS applications.
The Trust Director of Education or site equivalent (e.g. Education Lead for the profession concerned) to
complete for non-medical NHS applications.
Do you support this application?
Yes/ No
[comment if appropriate]
Name:
(print)
Date:
Signed:
Email:
Telephone number:
School, Institute or Department Head (or delegate e.g. Head of Division) to complete
Do you support this application?
Yes / No
[comment if appropriate]
If No, please explain reasons for rejection:
Name:
Date:
Signed:
Imperial College London Director of Education (or delegate) to complete
Proposed Title:
Is this:
Do you support this application?
(i) a new title?
(ii) a routine review?
Y/N
Y/N
Yes/ No
[comment if appropriate]
Name:
Signed:
Date:
For Both Teaching and Research Applications:
For completion after consideration by the School, Institute or Department / Faculty Education Office (FEO), as
recommendation to Human Resources. This is completed by the FEO Office Administrator for teaching applications and
the School, Institute Manager for research applications.
Title agreed:
Host School,
Institute or
Department,
Division and
Section:
SID: _________________________________________
Division/Dept: _________________________________
Section: ______________________________________
Start date:
Review date:
For HR Use
Date Agreed:
Title granted
Allocated CID
number:
Please ensure the applicant’s CV is attached.
Letter sent:
Trust/FEO informed: