IP Self nomination form

IP Self nomination form

Please complete this form if you wish to nominate yourself to instruct on an ALSG provider course.
Name

First NameLast Name
Email address you use to access the ALSG website
Clinical role/job
Area of work
e.g. ED, anaesthetics, paediatrics, obstetrics, psychiatry
ALSG course for which you wish to nominate yourself to be an instructor?
- Which centre did you do your APLS recertification course at?
- What was the date of the course?
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Who was the course director?
- How much of your clinical role is predominantly seeing paediatric patients?
  
  Other
- How much acute paediatrics (illness or trauma) do you see in this role?
- Have you already done a GIC course?
- Do you already teach on another ALSG course?
- If so, which course(s) do you currently teach on?
  Control and click to select multiple courses
- And are you a full instructor or an instructor candidate?
- Which centre did you do your CPRR course at?
  (if already attended or observed)
- What was the date of the course?
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Who was the course director?
- Please confirm you are ST7 or above
- Please confirm you are a Named or Designated Safeguarding Nurse
- Thank you for applying to be a CPRR instructor, however at this time you are not eligible to self-nominate to be an instructor. For more information email kflaherty@alsg.org
- I have included the name, email address and role of the senior colleague or CPRR working group member who is recommending you for CPRR instructor training
- Thank you for applying to be a CPRR instructor, however at this time you are not eligible to self-nominate to be an instructor. For more information email kflaherty@alsg.org
- Name, email address and role of senior colleague or CPRR working group member who is recommending me for CPRR instructor training
- Please confirm that you have experience in child protection work
- Please outline your experience in child protection work?
- Please confirm that you have level 3 training of CPiP / equivalent (e.g., greater than CPRR course)
- Please detail what the level 3 training was?
- Have you already done a GIC course?
- Do you already teach on another ALSG course?
- If so, which course(s) do you currently teach on?
  Control and click to select multiple courses
- And are you a full instructor or an instructor candidate?
- Do you already teach on an RCUK course?
- Which RCUK course(s) do you teach? Please indicate if you are a full instructor or an instructor candidate
- Do you already teach on ATLS?
- If so, are you a full instructor or an instructor candidate?
- Do you already teach on ETC?
- If so, are you a full instructor or an instructor candidate?
- In a couple of paragraphs please can you tell us about why you want to become an instructor and what you would bring to the community of ALSG instructors?
- Please add any additional information here that you feel will be helpful for us to consider your application:
- Thank you for completing this form.
  
  Someone from ALSG will be in touch with you about your application.
  
  Please allow 2 weeks for this response.
- Should be Empty: