"IndividualEnrolmentForm for ACP 360 2012"
Enrolment Form for Individuals* Name Job Title and Specialty Please choose a version of ACP 360: General Adult Child & Adolescent Learning Disability 270 version (ACP 360 without service user feedback for those with limitied patient contact) Address Telephone Email (essential) Please use a personal email address to which we can send your completed confidential report. Your assessment pack will also be sent electronically to this address. The ACP 360 assessment uses questionnaires which elicit numerical responses, and colleagues are invited to provide free-text comments about what they perceive to be your strengths and areas for development. These free-text comments are only sent to your appraiser so that they may be discussed in a supportive way. For this reason it is important that you supple the name and email address of the person in your Trust to whom we can send the free-text comments (e.g. your line manager, or the person responsible for your annual appraisal). This person will then feedback the comments to you when you discuss your ACP 360 report. Name _________________________________________________________________________ Tel. ___________________________________ Email___________________________________ Your instruction pack will be sent via email after you have enrolled to guide to you through the process (how to activate your online survey, invite colleagues to complete a questionnaire and provide feedback, and invite service users to complete a questionnaire. I wish to pay my registration fee of £110 + VAT (£132) Cheque (payable to ‘The Royal College of Psychiatrists’) Credit/Debit card (please note that we do not accept AMEX) Card no. - - - Cardholder Name Start Date (MM/YY)__________ Expiry Date (MM/YY) Issue no. _________ I confirm my enrolment in ACP 360 Signature *For enrolment of 10 or more psychiatrists, the cost of ACP 360 is reduced to £99.00 + VAT. Please complete the multiple enrolment form if you would like to enrol more than one psychiatrist. Please email or send this completed form to: ACP360@cru.rcpsych.ac.uk or to ACP 360, Royal College of Psychiatrists’ Research and Training Unit, 4th Floor Standon House, 21 Mansell Street, London, E1 8AA. Charity registration no. 228636