Participant on the Medical Appraiser Courses (Phase 3)
APPLICATION FORM
Before completing this application form please refer to the
covering letter. You are advised to read carefully the role
description / personal specification criteria. Please ensure all
relevant areas of the application form have been completed
(complete the grey boxes) otherwise we will not be able to
process your application.
Electronic applications are required and should be returned
to [email protected] using email attachments.
3-step guide to completing this application form:
1)
2)
3)
Save this form (using “Save As”) to your
computer (e.g. My Documents, Desk top), and
rename the file to your name.
Proceed to filling out the form (all the grey
boxes) - when finished, Save and Close the
document.
Email Joyce and attach the application from
where you had saved it (from step 1).
The closing date for applications is three months before the date of the earliest course you have chosen to
attend (see below for details), with the exception of the NHS Highland course on 20 and 28 October 2011
where the closing date is 2 months. However, late applications will be considered if places are available.
1)
Your details
Title:
First or Given Name:
Last Name:
Contact Address:
Line 2
Line 3
City:
Post Code:
Email Address:
Phone Number:
Alternative Number
Health Board: Please choose:
If “Other”, please specify
Specialty:
If you are a GP, please tick this box:
Current Clinical Role:
GMC Number:
The name and contact details of your Line Manager/Appraisal Lead (Secondary Care) or Local Appraisal Adviser
(LAA) (Primary Care) for your role as a Medical Appraiser:
Name:
Address:
Line 2
Line 3
City:
Post Code:
E-mail:
Phone:
Do you have the support of your Line Manager/Appraisal Lead (Secondary Care) or
LAA (Primary Care) to undertake the course?
By ticking this box, you are stating that your manager/appraisal lead or LAA is aware of
your application and is supportive of it.
(single-click on the grey
box to tick)
Please ensure provide your availability on either page 4 or 5, then finish by signing the Declaration on page 6.
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Your answers to the questions below should give examples that draw on your own experience and are
directly relevant to the Appraiser Role and personal specification criteria.
2) About You
(The grey boxes will expand as you type into them)
Experience as an Appraiser:
Please describe your experience as an appraiser/appraisee and any challenges you have encountered. Please tell
us how many appraisals you have undertaken in the last two years. If you are new to the appraiser role tell us why
you wish to be an appraiser and what you anticipate may be your strengths and weaknesses in this role.
Understanding of the principles of medical revalidation:
Please describe your understanding of the role of appraisal in medical revalidation.
Please tell us what you hope to learn through participation in this training:
We hope to develop the training progressively. We have ideas about what we think will be useful for appraisers to
learn but we want to meet the participants’ learning needs. What outcomes/changes would you hope to have as a
result of participating in this training? How will you know that you have learnt what you need to learn?
Any other information/experience relevant to your application not included above:
All participants will be informed of the outcome of their application as soon as possible and whenever possible
three months before the commencement date of the training. [This is dependent on NES receiving timely
applications from potential participants and the Health Boards providing venues on the relevant date(s).]
For GP participants only, please note that you will be required to undergo an interview before proceeding
to a New Appraiser Training course because, if you are successful at the training course, you will be
recommended for appointment with the relevant Health Board. All secondary care participants are already
employees with their Health Board.
Please ensure provide your availability on either page 4 or 5, then finish by signing the Declaration on page 6.
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Participant on the Medical Appraisers Courses (Secondary Care)
3) Your Availability
Before providing us with your availability, you must determine if you wish to apply to the New Appraiser Training
or the Experienced Appraiser Training course. You can attend either course but NOT both.
If you wish to apply for the New Appraiser Training, please give your availability on page 4.
If you wish to apply for the Experienced Appraiser Training, please give your availability on page 5.
When providing your availability, please select up to 3 courses from the list provided, and rank your preference
accordingly.
Priority will be given to those applying within their home Health Board, however some places will be available for
participants from external Health Boards on each course.
After completing the availability, please sign off the Declaration on page 6.
Please ensure provide your availability on either page 4 or 5, then finish by signing the Declaration on page 6.
3
Availability for New Appraiser Training
For continuity of training, you must attend both days of delivery of the New Appraiser course when you are a
participant.
Review the list of courses in the table below, choose up to THREE that match up with your availability, and rank
your preferences accordingly at the bottom of the page using the dropdown menus provided.
ID
Course
Dates
NHS Board
Venue
N1
New Appraiser Training (pt1)
New Appraiser Training (pt2)
20th October 2011
28th October 2011
NHS Highland
TBA by hosting
Health Board
N2
New Appraiser Training (pt1)
New Appraiser Training (pt2)
9th February 2012
17th February 2012
Golden Jubilee Hospital
TBA by hosting
Health Board
N3
New Appraiser Training (pt1)
New Appraiser Training (pt2)
15th March 2012
23rd March 2012
NHS Ayrshire & Arran
TBA by hosting
Health Board
N4
New Appraiser Training (pt1)
New Appraiser Training (pt2)
19th April 2012
27th April 2012
NHS Tayside
TBA by hosting
Health Board
N5
New Appraiser Training (pt1)
New Appraiser Training (pt2)
10th May 2012
18th May 2012
NHS Forth Valley
TBA by hosting
Health Board
N6
New Appraiser Training (pt1)
New Appraiser Training (pt2)
7th June 2012
15th June 2012
NHS Lothian
TBA by hosting
Health Board
N7
New Appraiser Training (pt1)
New Appraiser Training (pt2)
23rd August 2012
31st August 2012
NHS Greater Glasgow & Clyde
TBA by hosting
Health Board
N8
New Appraiser Training (pt1)
New Appraiser Training (pt2)
18th October 2012
26th October 2012
NHS Fife
TBA by hosting
Health Board
N9
New Appraiser Training (pt1)
New Appraiser Training (pt2)
8th November 2012
23rd November 2012
NHS Greater Glasgow & Clyde
TBA by hosting
Health Board
N10
New Appraiser Training (pt1)
New Appraiser Training (pt2)
7th February 2013
15th February 2013
NHS Greater Glasgow & Clyde
TBA by hosting
Health Board
N11
New Appraiser Training (pt1)
New Appraiser Training (pt2)
11th April 2013
18th April 2013
NHS Lanarkshire
TBA by hosting
Health Board
N12
New Appraiser Training (pt1)
New Appraiser Training (pt2)
9th May 2013
17th May 2013
NHS Grampian
TBA by hosting
Health Board
N13
New Appraiser Training (pt1)
New Appraiser Training (pt2)
6th June 2013
14th June 2013
NHS Lothian
TBA by hosting
Health Board
Using the dropdown menu, please select your three courses that suit your availability in order of
preference:
1st Choice
2nd Choice
3rd Choice
Please choose:
Please choose:
Please choose:
Please proceed to page 6 to complete the Declaration to finish.
Please ensure provide your availability on either page 4 or 5, then finish by signing the Declaration on page 6.
4
Availability for Experienced Appraiser Training
Please be aware for the Experienced Training courses, video equipment will be used to record the sessions for
your review. It is NOT mandatory, but we do need your consent. Should you wish to opt out of this, please
remember to indicate this at the training event.
Review the list of courses in the table below, choose up to THREE that match up with your availability, and rank
your preferences accordingly at the bottom of the page using the dropdown menus provided.
ID
Course
Dates
NHS Board
Venue
E1
Experienced Appraiser
Training
11th November 2011
NHS Grampian
TBA by hosting
Health Board
E2
Experienced Appraiser
Training
18th November 2011
NHS Lanarkshire
TBA by hosting
Health Board
E3
Experienced Appraiser
Training
2nd December 2011
NHS Borders
TBA by hosting
Health Board
E4
Experienced Appraiser
Training
20th January 2012
NHS Greater Glasgow & Clyde
TBA by hosting
Health Board
E5
Experienced Appraiser
Training
7th September 2012
NHS Grampian
TBA by hosting
Health Board
E6
Experienced Appraiser
Training
27th September 2012
NHS Tayside
TBA by hosting
Health Board
E7
Experienced Appraiser
Training
7th December 2012
NHS Tayside
TBA by hosting
Health Board
E8
Experienced Appraiser
Training
25th January 2013
NHS Greater Glasgow & Clyde
TBA by hosting
Health Board
E9
Experienced Appraiser
Training
1st March 2013
NHS Lothian
TBA by hosting
Health Board
E10
Experienced Appraiser
Training
15th March 2013
NHS Greater Glasgow & Clyde
TBA by hosting
Health Board
E10a
Experienced Appraiser
Training
9th May 2013
NHS Grampian
TBA by hosting
Health Board
E10b
Experienced Appraiser
Training
23rd May 2013
NHS Greater Glasgow & Clyde
TBA by hosting
Health Board
E11
Experienced Appraiser
Training
23rd August 2013
NHS Dumfries & Galloway
(TBC)
TBA by hosting
Health Board
E12
Experienced Appraiser
Training
6th September 2013
NHS Lothian
TBA by hosting
Health Board
Using the dropdown menu, please select your three courses that suit your availability in order of
preference:
1st Choice
2nd Choice
3rd Choice
Please choose:
Please choose:
Please choose:
Please proceed to page 6 to complete the Declaration to finish.
Please ensure provide your availability on either page 4 or 5, then finish by signing the Declaration on page 6.
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DECLARATION
I declare that if I am successful with my application to be a participant in the Medical Appraisers Courses Training, I
can attend the training days indicated above. If I am unsuccessful on this occasion I understand that my name will
be kept for future training days and I may be contacted in the future.
Please click on the grey boxes to confirm the following statements:
I declare that the information I have given in this application form is, to the best of
my knowledge and belief, true and complete.
I am currently practising in my specialty and intend to do so for the next 2 years.
I am currently practising in my specialty (Primary Care).
Type Name/Electronic Signature:
Date:
(dd/mm/yyyy)
Please complete the Equal Opportunity Monitoring Form and return it along with your completed application.
Please ensure provide your availability on either page 4 or 5, then finish by signing the Declaration on page 6.
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Timetable for Delivery 2011 - 2013
Sep 11
Oct 11
Nov 11
Dec 11
Jan 12
Feb 12
Mar 12
Course
Tutor
Training/Selection
Event
New
Exp
Exp
Exp
Exp
New
New
Health
Boards
NES - Beardmore
Hotel
Highland
Grampian
Lanarkshire
Borders
Glasgow
Golden
Jubilee
Hospital
Ayrshire
and Arran
Dates
15 Sep
20 & 28
Oct
11 Nov
18 Nov
2 Dec
20 Jan
9 &17 Feb
15 & 23
Mar
Apr 12
Course
New
May 12
Jun 12
Jul 12
Aug 12
Sep 12
Oct 12
Nov 12
Dec 12
Jan 13
Feb 13
Mar 13
New
New
No
Course
New
Exp
Exp
New
New
Exp
Exp
New
Exp
Exp
Health
Boards
Tayside
Forth Valley
Lothian
Glasgow
Grampian
Tayside
Fife
Glasgow
Tayside
Glasgow
Glasgow
Lothian
Glasgow
Dates
19 & 27
Apr
10 & 18 May
7 & 15
Jun
23 & 31
Aug
7 Sep
27 Sep
18 & 26
Oct
8 & 23
Nov
7 Dec
25 Jan
7&15
Feb
1 Mar
15 Mar
Apr 13
May 13
May 13
Jun 13
Jul 13
Aug 13
Sept 13
Course
New
No New APR
Course
Exp
New
No Course
Exp
Exp
Health
Boards
Lanarkshire
Glasgow
Lothian
Lothian
Dates
11 & 18
Apr
23 May
6 & 14
Jun
Dumfries
&
Galloway
23 Aug
6 Sep
Please ensure provide your availability on either page 4 or 5, then finish by signing the Declaration on page 6.
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