MEDICAL SCIENCES DIVISION Level – 3, Medical Sciences Office, John Radcliffe Hospital, Headington, Oxford OX3 9DU

ACADEMIC CLINICAL LECTURERSHIP

The closing date for this application is 30 November 2012 at 12 Noon. Please make sure that your completed form along with your CV reaches us by this date, preferably by email, or by post (the email ID and postal address are listed in the Further Particulars in the ‘Applications’ section).

To gain a better understanding of your career to date, we would like you to answer the following questions. If there are any that you cannot answer, please insert n/a or leave them blank. Please do not cross-reference to an attached CV unless the section says so; we need the completed form for consistency in presentation to the selection board.

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SPECIALITY APPLIED FOR: ______

Part 1

Personal details

MALE/FEMALE (Please circle) The University is an Equal Opportunities Employer. This information is only used for monitoring the policy; it is not always clear from names.

TITLE: Dr/Mr/Miss/Mrs/Ms (Please circle)

SURNAME:

FIRST NAME(S): MIDDLE NAME(S):

ADDRESS: TEL NO: Home:

Work:

Email:

DATE OF BIRTH: PLACE OF BIRTH:

NATIONALITY: 2. Clinical status

(a) What level of clinical contract do you currently hold? If ‘Other’, please specify.

(b) Name of Health Authority or Hospital Trust:

(c) Date current contract expires:

(d) Please state your chosen clinical specialty

(e) How many years of specialist training have you completed?

(f) Please give your General Medical Council (GMC) number:

(g) i) Do you hold a National Training Number (NTN)?

ii) If yes, state NTN and date awarded:

iii) If no, when do you intend to apply for a NTN?

iv) In which postgraduate deanery is your NTN held, or will be held?

(h) i) Do you hold a Certificate of Completion of Training (CCT)?

ii) If yes, state date awarded:

iii) If no, what date would you currently expect to receive your CCT,? (mm/yy)

3. Details of current position Title of current post (If unemployed or in temporary employment, please give details of last appropriate post):

Date of appointment/Start date of last appropriate post:

Expected date of termination/End date of last appropriate post: With whom do you have a contract of employment? What is your notice period?

Current/last appropriate salary details Salary grade: Source of personal salary support (If ‘Other’, please specify): Please also be specific if salary is funded from more than one source. 4. Previous posts held: (most recent first)

Date from Date to Position Department University/ Institution

5. Referees: We require the names, addresses, telephone numbers and if possible email addresses of two people who can provide references. One of them should be your last or present employer. We require one of your referees to have been associated with your academic work.

(1) Name: (2) Name:

Address: Address:

Tel: Tel:

Email: Email:

Relationship: Relationship:

May we approach your referees without further reference to yourself? Please indicate by circling.

YES/NO YES/NO

6. Interview arrangements

Is there any provision you require if invited for interview? ………………….………….…….

……………………………………………………………………………….……………………..

Are there any dates when you are NOT available for interview? …..……………………….

………………..…………………………………………………………………………………….

From which publication or source did you learn of the vacancy? ………………….…….….

..…………….………………………………………………………………………………………. 7. General information:

Have you ever been dismissed from a post because of misconduct, or resigned whilst disciplinary action has been taken against you? YES/NO

Please declare any unspent criminal conviction. (You may be dismissed summarily should your application prove to contain any material falsehoods or omissions.)

Are you eligible to work in the UK? YES / NO

If you hold a work permit please furnish the following information:

Work permit number ……….…………………….. Date of expiry ..………………………….....

I declare that the information given on this application is to the best of my knowledge true and complete.

SIGNED ...... ………... DATE ...... (Please type your name / add electronic signature) Part 2 (Please complete) refer to guidance notes at the end of this document SUPPLEMENTARY QUESTIONS FOR CANDIDATES APPLYING FOR A CLINICAL LECTURESHIP AS PART OF INTEGRATED ACADEMIC TRAINING

Academic Achievement and Professional qualifications University (ies) attended. Please also indicate the Department or School. Dates

Shortlisted candidates will be required to bring original certificates to the interviews Degree/Diploma (include BSc, BDS, Awarding Body Date of Qualification BChD, MBBS, MSc, MB/PhD, PhD, MD or equivalent) – state class of degree awarded, where appropriate.

Prizes and other academic Awarding Body Date of Award distinctions

Key and Relevant Academic Achievements Prizes or other academic distinctions. Please provide any relevant additional information to that provided above. Describe your MD/PhD/DPhil research. Include a brief description of your main findings and their impact and the research methods you used (up to 750 words).

Please describe any research training that you have received to date, for example, training courses in research methods (up to 250 words). Publications (short-listed candidates will be asked to bring copies of all peer-reviewed publications to the interview).

Presentations/posters at national or international conferences (indicate whether national or international). Other Relevant Experience Please provide a brief description of any teaching experience you have had. You may include experience gained outside of medicine.

Please give examples and brief details of experience you have had of management or leadership.

Aims, Career Objectives, and Commitment to a career in Academic Medicine Please indicate your medium and long-term career goals in relation to an academic career. If you are successful in gaining an Academic Clinical Lectureship, please describe how you will manage the completion of your clinical training.

Please explain how the hosting research department will support your research aims and career objectives.

Any further information relevant to an application for an Academic Clinical Lectureship

Please provide any further information that you feel is relevant to this application, in particular, areas that have not been covered elsewhere. Please state what skills and attributes you will bring to this position and how you meet the selection criteria. Guidance Notes for completion of the Part 2 “Supplementary Questions for candidates applying for a Clinical Lectureship as part of Integrated Academic Training” These Guidance Notes are for candidates applying for an NIHR Clinical Lectureship. In addition to the application form please ensure that you meet the criteria in the Person Specification for a Clinical Lectureship and the eligibility criteria outlined in the paper ‘Academic Clinical Fellowships and Clinical Lectureships: Entry, Eligibility, and Exit Points from April 2012’ which can be downloaded from the NIHR Trainee’s Co-ordinating Centre (NIHR TCC) website at http://www.nihrtcc.nhs.uk/.

Academic Achievement and Professional Qualifications

University (ies) attended Please provide the name of the university or universities that you have attended with dates where you gained your professional or academic qualifications. For each, please name the Department or School where you were based for your study.

Degree/Diplomas Please provide all the qualifications that you have achieved which you feel are relevant to your application for a Clinical Lectureship. Where a class or grade was associated with your qualification, please provide this information. The date and awarding body of your qualification(s) should also be provided. Please note that original certificates will be requested at interview.

Prizes or other academic distinctions Please list any prizes or academic distinctions (maximum of six) which you have gained and provide the date of award and the awarding body for each.

Key and Relevant Academic Achievement

Prizes and other academic distinctions This section gives you the opportunity to provide further detail about the prizes or distinctions you have achieved. Please select those that are relevant to your application for a Clinical Lectureship and briefly describe what you did in order to be recognised with a prize or distinction.

Describe your MD/PhD/DPhil research This section gives you the opportunity to describe the research you completed for your higher degree. Please include a brief description of your main findings and the impact these have had. Examples of impact could include:-

 Contribution of research to practice, diagnosis, treatment or management of patients;

 Contribution of research to the understanding of a disease process;

 Changes to a service (e.g. a referral pathway); and

 Translation of a research finding or development into clinical practice (e.g. a diagnostic tool).

Please also give details of the research methods that you used. Please do not exceed the 750 word limit.

One other significant research project This section provides you with the opportunity to give details about one other significant research project that you have been involved in, other than your higher degree. You only have 250 words, but please give brief details about the project, the methods you used and your exact role in, and contribution to, the project overall. Publications Please list all your publications. Please note that short-listed candidates will be required to provide copies of their peer-reviewed publications at interview.

Presentations/posters Please provide details of any posters or presentations you have given at both national and international conferences. Please make it clear which ones are national and which ones are international.

Other Relevant Experience

Teaching experience Please describe any experience you have of teaching, and indicate where this is relevant to research. You may also include examples outside of medicine.

Management or leadership Please give examples and brief details of the experience you have had of developing your management or leadership skills.

Aims, Career Objectives and Commitment to a Career in Academic Medicine

Medium and long-term career goals Please indicate your medium and long-term goals in relation to academic medicine. You might wish to say what you are aiming to be doing in 5 and 10 years time.

Managing completion of clinical training Please use this section to describe how you will manage the completion of your clinical training alongside your academic development. Please provide a timetable of your plans.

Support from Host Department Please explain how the host department offering the Academic Clinical Lectureship you have chosen will support your research aims and career objectives.

Any further information Please use this section to provide information which might support your application that has not been covered elsewhere on the form. Please describe the skills and attributes that you feel you have which make you a suitable candidate for an Academic Clinical Lectureship.