Application for Level 4 - ASGBI Endorsed Events
For: External events seeking ASGBI endorsement only (no ASGBI faculty or delivery role
Section 1: Event Overview
1. Event name
*
2. Event organiser / organisation
*
3. Main contact name
*
First Name
Last 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: Educational Content
12. Brief description of the event
*
13. Learning objectives
*
14. Target audience
*
Consultant or equivalent
ST3 - ST8 or equivalent
CT1 - CT2 or equivalent
FY1 - FY2 or equivalent
Other
15. Pre-requisites (if any)
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Section 4: Programme Details
Attachments required
16. Please attach a full programme, including named faculty
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17. If you are unable to provide a full programme document, outline the details below
18. Details of any commercial or industry support / sponsorship
19. Conflict of interest summary (for all speakers/faculty)
*
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Section 5: Good Practice Checklist
20. 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
21. 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 doesnot include any patient data or patient images
22. 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 request formal endorsement by ASGBI for this event
I understand that this application must be submitted at least six weeks before the event
23. Please use this space to include any further details you would like to include in support of your application
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