Educational Supervisor Application

Educational Supervisor Application
Please read the Educational Supervisor eligibility criteria before completing the application form. All sections of the application form must be completed and supporting documents uploaded if this is required. An incomplete application form will not be considered.
Full Name*

TitleFirst NameLast Name (as entered on the GMC register)
Main correspondence address*
Main telephone:*
Main email address*
example@example.com

Conditions on becoming an Educational Supervisor
I agree to meet the following conditions:

- undertake induction training before I am fully recognised as an educational supervisor, and then afterwards attend update sessions about every two years or as required;

- be prepared to be an educational supervisor for a trainee, recognising the time commitment that this entails;

- be willing to provide on-going supervising and monitoring of trainees' performan in accordance with the GMC's guidance on Good Medical Practice;

- be willing to attend each annual review - the Annual Review of Competence Progression (ARCP);

- be prepared to prvoide support, if required, for a reasonbale period (e.g. 12 months) after the trainee has been awarded an ARCP outcome 6 to ensure that the trainee is entered on the GMC's specialist register;

- fully engage with the revalidation process.
Applicant's signature:*

Clear
Applicant's name:*

First NameLast Name (as entered on the GMC register)
Date*

DayMonthYear
Date

Introductory workshop
As part of your application to become a recognised Educational Supervisor in pharmaceutical medicine you must attend the Pharmaceutical Medicine Deanery's 'Introductory Workshop for Educational Supervisors and Associate Educational Supervisors'.

You will be booked on to the first available workshop, but you can request an alternative date after your application is processed. The dates of the workshops are listed on the Educational Supervisor webpage.

There is a registration fee of £100 per person.

You are not required to attend the workshop if: 1) you are applying to have your role as a GMC-approved Educational Supervisor reinstated and 2) it has been less than three years after you relinquished the role or the GMC removed the role from your entry on the medical register.
Please indicate to whom the FPM should send the invoice.*

Please send the invoice for £100 to me.Please send the invoice for £100 to my employer.FPM has confirmed I can attend free of charge.I am not required to attend the workshop.
Please enter your employer's full address and the name of the invoice recipient
Terms and conditions: You will receive a full refund of the paid registration fee if you cancel your attendance on the introductory workshop 2 weeks before the workshop. Refunds will made, less a £50 cancellation fee, if you notify us 1 week before the workshop. The FPM reserves the right to change the venue if circumstances arise that require such changes. In the event of cancellation by the FPM, a full refund of the registration fee only will be given; we recommend you take out insurance to cover any travel and accomodation expenses. Your personal details will be used for the purposes of event administration and the Pharmaceutical Medicine Deanery's quality management of approved Educational Supervisors. Please note the FPM's data protection policy.

Educational Supervisors Email Network
The Pharmaceutical Medicine Deanery maintains an email network for educational supervisors (ESs), associate educational supervisors (AESs) and Specialty Advisers (SAs) which is permission based. The deanery will maintain and update a list of email addresses and circulate it to the individuals on the list quaterly. The list will be marked confidential and receipients will be asked not to pass these data on to other parties or to use the list for purposes not related to inter-communication with other ESs, AESs and SAs. Official communications from the deanery or FPM will not be sent via this network.

Please note that the deanery and FPM are unable to accept responsibility for any misuse or onward distribution of these data.
I approve the deanery/FPM adding my email address to the circulation list.I do not approve the deanery/FPM to add my email address to the circulation list.

Data Protection
To comply with the General Data Protection Regulation (GDPR), it is essential that we have your permission to use personal data held on you for FPM and the Pharmaceutical Medicine Deanery to carry out reasonable activities for the efficient administration of their statutory and regulatory obligations regarding the recognition and approval of educational supervisors in pharmaceutical medicine. These data will only be disclosed as part of the process of administering the recognition of educational supervisors with (as appropriate):
- Relevant regional and national training bodies.
- Postgraduate medical deans and their staff.
- Relevant royal colleges and FPM officers, representatives and staff.
- Associate educational supervisors, educational supervisors and Specialty Advisers.
- General Medical Council.
- Specialist and trainee societies and organisations.
- Employing organisations.
Declaration
I declare that the information given on this form is true to the best of my knowledge. I give permission for my personal details to be made available to a third party or parties as required for the purposes of monitoring and assessing my recognition as an Educational Supervisor as explained in the 'Data Protection' section of this application form.
Signature*

Clear
Applicant's name*

First NameLast Name (as entered on the GMC register)
Date*

MonthDayYear
Date
Should be Empty:

Educational Supervisor Application

Eligibility

Conditions on becoming an Educational Supervisor

Introductory workshop

Educational Supervisors Email Network

Data Protection