SPSP Fellowship Application FormYR 4v1 by 4v4x0P4

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									                Scottish Patient Safety Programme
                                   Fellowship
                                     Cohort 4

Application form – Part 1

Section 1: Contact details of applicant
  Name (and title)

  Profession

  Job title

  Address

  Telephone

  Email



Section 2: Organisation details
2.1    Name of department in which you are employed



2.2    Name of head of department



2.3    Name and job title of individual (if other than departmental head) within the department
       to whom you are directly accountable



2.4    Name of organisational sponsor (this should be the chief executive, medical or nurse
       director).



2.5    Telephone




File name : 4f57dca2-0b92-42d7-b14b-2984e2c8a48c.doc                Version 0.1             09/03/2011
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Scottish Patient Safety Programme
2.6      Email




2.7      Designation/Relationship of applicant to organisational sponsor




Section 3: Curriculum Vitae of Applicant

3.1               Surname
3.2               Forenames
3.3               Qualifications (Degrees, Diplomas, etc.)

    Subject                         Qualification & Class    College/University    Date




3.4               Current post

    Job title

    Department

    Institution

    Date of appointment

    Is your post permanent?

                                    If not, please indicate the type of contract


                                    If other, please provide details
                                    Date of termination of contract



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Scottish Patient Safety Programme


3.5           Previous posts held (full or part time)

    Dates                        Position                       Institution




Section 4: About the applicant

4.1 Provide a brief statement outlining your current role and explaining why you are applying
    for this fellowship. (Maximum 200 words)




4.2 How do you see the role of leadership in clinical safety programmes? (Maximum 200
    words)




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Scottish Patient Safety Programme



4.3 How do you plan to build upon your fellowship experience and what would you like to
    achieve in the medium to longer term? (Maximum 200 words)




4.4 What do you consider to be your greatest achievement so far in terms of improving the
    quality and/or safety of patient care? Please clearly state your reasons. (Maximum 200
    words)




4.5 What do you consider to be your greatest challenge or dilemma in terms of improving the
   quality and safety of care? What is your strategy for dealing with challenges? (Maximum
   200 words)




4.6 What do you do consider to be your leadership for safety development needs? (Maximum
    200 words)




4.7 What are the benefits of investing in you? (Maximum 200 words)




4.8 What experience have you had of developing others? (Maximum 200 words)




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Scottish Patient Safety Programme


Section 5: Statement of Support

Please provide two personal references with the original signed copy of your application.
These should be provided in a separate envelope and signed across the seal by the referee.




Section 6: Declaration

Data Protection Act 1998
To comply with this Act, we require your consent to NHS QIS using personal data supplied by
you in the processing and review of this application and in any other legitimate activity of the
organisation; this includes transfer to and use by such individuals and organisations as the
organisation deems appropriate. NHS QIS requires your further assurance that personal data
about any other individual is supplied to NHS QIS with his/her consent.
The organisation also accepts NHS QIS’s requirements relating to the Data Protection Act
(see above). All signatories below will provide this consent and assurance.


By Applicant

    Signed



    Name

    Date




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Scottish Patient Safety Programme

Organisation Support Form – Part 2

Section 1: Applicant details

1.1   Name of applicant:

1.2   Job title:



Section 2: Sponsor details

2.1   Name:

2.2   Organisation:

2.3   Address:


2.4   Telephone:

2.5   Email:



Section 3: Organisational support

3.1   Please outline the opportunities the applicant will have to implement what they have
      learnt and continue to actively participate in and lead improvements in quality and/or
      safety. (Maximum 200 words)



3.2   In what ways will the organisation ensure the applicant is provided with opportunities
      for leadership? (Maximum 200 words)



3.3   Please describe how the applicant will disseminate their learning to the wider health
      economy and how they will contribute to the Quality Strategy. (Maximum 200 words)




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Scottish Patient Safety Programme



Section 4: Declaration

Declaration by the Chief Executive:

Participants will need the full support of their employing organisation and explicit sponsorship
from the Medical or Nurse Director and the Chief Executive. The programme will not provide
a grant to the employing organisation. However, the programme will cover the teaching and
accommodation costs for the residential component of the fellowship. Fellows will also
receive funding to support their attendance at the International Quality Forum and study visit.



    Signed:



    Name (please print):

    Date:




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Scottish Patient Safety Programme




Checklist for full application form

Please tick the boxes


Application form

    Original application form – single-sided, not stapled or bound

    Electronic copy of application form sent

    Personal references – signed across a sealed envelope

    Declaration – signed

    Original organisational support form completed by Chief Executive



Please submit completed applications to

email kellis3@nhs.net

and one original application form to:

Kirsty Ellis
Senior Project Officer
Scottish Patient Safety Programme
NHS QIS
Edinburgh Office
Elliott House
8 – 10 Hillside Crescent
Edinburgh EH7 5EA.




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