Application for Level 3 - ASGBI Supported Events
For: Partnership events with external organisations requesting ASGBI involvement (e.g. faculty, promotional support, branding)
Section 1: Event Overview
1. Event name
*
2. External partner organisation(s)
*
First Name
Last Name
3. Main contact name
4. Email address
*
example@example.com
5. Phone number
*
Please enter a valid phone number.
Format: 00000000000.
6. Proposed event date(s)
*
7. Format
*
In person
Online
Hybrid
8. Location (if applicable)
9. Expected number of participants
*
10. Is this a recurring event?
*
Yes
No
11. If yes, attach a summary of previous feedback/evaluation
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Section 2: Role of ASGBI in event
12. What involvement is requested from ASGBI? (tick all that apply)
*
Faculty contribution
Promotional Support (e.g. newsletter, social media)
Branding (ASGBI logo on materials)
Other
13. Proposed ASGBI faculty (if any/applicable):
14. Do you require CPD points via ASGBI?
*
Yes
No
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Section 3: Educational Content
15. Brief description of the event
*
16. Learning objectives
*
17. Target audience
*
Consultant or equivalent
ST3 - ST8 or equivalent
CT1 - CT2 or equivalent
FY1 - FY2 or equivalent
Other
18. Pre-requisites (if any)
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Section 4: Programme Details
Attachments required
19. Please attach a full programme, including named faculty
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20. If you are unable to provide a full programme document, outline the details below
21. Details of any commercial or industry support / sponsorship
22. Conflict of interest summary (for all speakers/faculty)
*
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Section 5: Good Practice Checklist
23. 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
24. Patient Data & Imaging Declaration. Please tick one option:
*
I confirm that this educational activityincludes patient data and/or patient images, and that all such materialcomplies with relevant consent, confidentiality, and data protectionregulations
I confirm that this educational activity does not include any patient data or patient images
25. 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 is subject to review by the Director of Education
I understand that this application must be submitted at least four months before the event
26. Please use this space to include any further details you would like to include in support of your application
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