"SPSP Fellowship Application FormYR 4v1"
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 Produced by: leannem Page 1 Page 1 of 8 Review 03/10/2012 date: None 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 : Page 2 of 8 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) : Page 3 of 8 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) : Page 4 of 8 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 : Page 5 of 8 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) : Page 6 of 8 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: : Page 7 of 8 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 firstname.lastname@example.org 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. : Page 8 of 8