Application for Level 2 - ASGBI Educational Events
For: ASGBI-led events by committees, working groups, regional representatives or members
Section 1: Event Overview
1. Event name
*
2. Organiser / convenor name
*
First Name
Last Name
3. ASGBI committee / region / working group (where applicable)
4. Email address
*
example@example.com
5. Phone number
*
Please enter a valid phone number.
Format: 00000000000.
6. Proposed event date(s)
*
7. Duration (hours per day, excl. breaks)
*
8. Location and format (in-person / online / hybrid)
*
9. Expected number of participants
*
10. Faculty-to-participant ratio (if applicable)
11. Is this a recurring event?
*
Yes
No
12. If yes, attach a summary of previous feedback/evaluation
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Section 2: Educational Objectives
13. Aims of the event
*
14. Learning outcomes
*
15. Target audience
*
Consultant or equivalent
ST3 - ST8 or equivalent
CT1 - CT2 or equivalent
FY1 - FY2 or equivalent
Other
16. Pre-requisites (if any)
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Section 3: Programme Details
Attachments required
17. Please attach a full programme, including named faculty
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18. If you are unable to provide a full programme document, outline the details below
19. Outline of topics and structure
*
20. Details of commercial support
21. Conflict of interest summary (for all speakers/faculty)
*
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Section 4: Budget and Sponsorship
Attachments required
22. Will the event charge a registration fee? Please note that if yes, registration management must go through ASGBI Secretariat
*
Yes
No
23. Please provide a budget summary
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24. If you are unable to provide a full budget summary document, outline the details below
25. Details of confirmed sponsorship
26. Please attach a copy of your industry prospectus (if applicable)
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Section 5: Good Practice Checklist
27. Please indicate below that the following event best practices have been considered
*
Rows
Yes
No
Diversity of faculty representation
Accessibility for attendees
Parent/child facilities available/nearby
Dietary/religious/medical requirements catered for
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Section 6: Declaration
28. Patient Data & Imaging Declaration. Please tick one option:
*
I confirm that this educational activity includes patientdata and/or patient images, and that all such material complies with relevantconsent, confidentiality, and data protection regulations
I confirm that this educational activity does not include any patient data or patient images
29. Tick to acknowledge the following
*
I confirm that the information provided is accurate and complete
I confirm that all relevant conflicts of interest have been declared
I understand that this application must be submitted at least four months before the event
30. I request ASGBI endorsement and CPD allocation for this event
*
Yes
No
31. Please use this space to include any further details you would like to include in support of your application
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