sas doctors and dentists professional development fund application form v1 3 by w23Bxsc5

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									SAS Doctors’ and Dentists’ Professional
Development Fund


                                     APPLICATION FOR FUNDING
This form should be used for all applications to be considered for funding from NES SAS Doctors’ and
Dentists’ Professional Development Fund. Please read the guidance notes before completing the form.

                                                           Guidance Notes
All SAS doctors and dentists working within the NHS in Scotland are eligible to apply. This new funding
source is additional to the normal study leave funding, provided by employers. Any courses which would be
expected to be covered by study leave, or that would be considered to be mandatory training by employers,
should continue to be applied for in the usual way.

The purpose of the SAS Doctors’ and Dentists’ Professional Development Fund is to provide individual special
financial assistance to individuals by way of a contribution towards the cost of carrying out a course of study or
project, for the purpose of meeting a specific aim. The cost of travel and other approved expenses will be
considered for inclusion but funding for this must not be assumed. Applicants need to be aware that
requests for payment for exam preparation courses and professional examination fees will not be
considered.

Applications for reimbursement from the Fund should relate to projects or courses of study which can clearly
be demonstrated to directly link to an individual’s Personal Development Plan (PDP), broaden educational
development and enlarge the professional knowledge of the recipient. These projects or courses of study
should ideally lead to an increased contribution by the recipient to the NHS, both in general and locally.

Applications worthy of support will need to demonstrate the following:
1.   A clear connection between the proposed project or course of study and delivery of relevant service(s) in
     the NHS in Scotland.
2.   A clear connection between the proposed project or course of study and the applicant’s PDP, which has
     been agreed as part of the NHS Appraisal process.
3.   Evidence to support the choice of project or study course and travel destination.
4.   Clarity in their objectives for seeking support and funding.

The level of funding available for successful applicants will be dependent on the number of applications
received as there is a finite budget to support this development. Priority will have to be given to those
applications that demonstrate a clear link to service and professional development in their current role.

The Application Form should be fully completed, including sponsoring support from Clinical Lead and DME.
Any incomplete applications will be returned to the applicant resulting in an inevitable delay in
processing.

Applications will be considered by a national panel of representatives from the Project Implementation Group
which includes staff from NHS Education for Scotland, the DME Group and the BMA. This panel meets
quarterly to decide on funding applications and applicants will be informed of the outcome as soon as possible
after the panel meetings.

Successful applicants will be required to submit a brief written report to the sponsoring DME and
Clinical Lead following completion of their project or course of study.

     Data Protection:
     NES uses the personal data you provide for purposes associated with administering the SAS Doctors’ and Dentists’ Professional Development
     Fund. NES may also use this data for purposes associated with our responsibilities for health workforce development, including the
     administration of courses, monitoring training programmes and circulating information relating to relevant development opportunities. For more
     information see www.nes.scot.nhs.uk/privacy-and-data-protection.aspx. Personal data will be retained in line with our records retention policies.

For Office                 Reference No:                                    Received:                                    Panel Date:
Use Only:
1. APPLICANT DETAILS

Personal Details
Title:                             Mr     Mrs      Miss        Ms   Dr    Prof    Other
First Name:
Surname:
Job Title:

Correspondence Address:



Work E-mail Address:
Daytime Telephone No.:
Mobile Telephone No.:
Age:
Gender:                                           Male                            Female

Employment Details
Current Employer:
Current Grade:
Specialty:
Full or Part Time:                              Full Time                        Part Time
Date appointed to current post:
Length of time in current post:
Main place of work:

Registration / Qualifications
Are you on the Specialist Register?                                 Yes                    No
Have you applied to the GMC for a CESR?                             Yes                    No
Have you considered applying to the GMC for a CESR?                 Yes                    No
Have you considered re-entering specialty training?                 Yes                    No
Qualifications in addition to primary medical degree:




Postgraduate qualifications:




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Career Details
Please provide a brief description of your career progress to date:




Please outline any relevant development activities you have undertaken during your career to date:




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2. APPLICATION DETAILS

Professional Development Activity

2.1 Please briefly describe the activity that you are seeking funding for, including reasons why you wish to
    study this subject and the aims and objectives you expect to achieve.




2.2 Is this reflected in your Personal Development Plan?              Yes                        No
2.3 Please provide further details regarding the form of learning you plan to use, e.g. distance learning:




2.4 If you are planning to undertake a learning opportunity with a HEI, College or other training organisation,
    please provide the name and contact details of the provider:

   Course Name:

   Name and Address
   of provider:



   Tel / Email:
2.5 In what way(s) would the experience and/or knowledge gained from this activity…

 (a) benefit the NHS
     generally?




 (b) help you contribute
     to your department
     / service?




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Funding Details
2.6 Please indicate the total funds you are requesting, including a breakdown of costings:
    Total Funds Requested:

    Breakdown of Costings
    (Full estimates required, including
    annual split if relevant)




2.7 If allocated, how do you plan to use the funds?




2.8 Will you be requesting study
                                                      Study Leave                              Secondment*
    leave or secondment?

    *If secondment, how will your clinical work be covered? Are there any associated costs?



2.10 Please indicate the level of funds required for activities to be
     undertaken in this financial year, i.e. before end of March 2013

2.11 Please provide details of any additional sources of funding/contributions to the overall costs of this
     activity, including source and amounts of funding already received and details of any other financial
     support you have or intend to apply for in relation to this activity.




Declaration
I declare that the information given in support of my application, including information on this form and any appendices, is
to the best of my knowledge and belief true and complete. I understand that if it is subsequently discovered that any
statement is false or misleading, or that I have withheld relevant information, particularly on additional funding received,
any funding approved by the SAS Doctors’ and Dentists’ Professional Development Funding Panel may be withdrawn.


    Signed:

    Date:



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3. AUTHORISATION         (To be completed by your Clinical Lead and your DME)

(a) Service Approval – Head of Service / Clinical Director
   I fully support this application because:




   Priority Level:                         High                   Medium                 Low

   Signed:

   Print Name:
   Date:
   Title:

   Department Address:


(b) Educational Approval – DME
   I fully support this application because:




   Priority Level:                         High                   Medium                 Low

   Signed:

   Print Name:
   Date:
   Title:

   Department Address:


Please return fully completed application forms to:

                                  NHS Education for Scotland – East Deanery
                                  Postgraduate Medical Office
                                  Level 7, Ninewells Hospital & Medical School
                                  Dundee DD1 9SY
                                  Tel: 01382 496516

SAS CPD Funding Panel Outcome:
              Outcome:           Approved:            Not Approved:              Date:
For Office    Reason for
Use Only:     non approval:



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