Associate Educational Supervisor Application

Associate Educational Supervisor Application
Please read the Associate 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
Postal address*
Main tel:*
Mobile tel:*
Email*
example@example.com

Eligibility
Do you hold a medical and/or scientific degree (i.e. BSc, MSc, PhD)?*

YesNo
If you selected 'Yes', please upload a copy of your qualification certificate/certificates.

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Are you or have you been a registered health professional?

YesNo
If you selected 'Yes', please upload a copy of your registration certificate.

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Do you have a minimum of five years' experience in the pharmaceutical industry and are you able to demonstrate the necessary breadth of experience in your specialty associated with pharmaceutical medicine?*

YesNo
Upload your CV

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Nominated Educational Supervisor

Please enter the name and email address of your nominated Educational Supervisor.
Full Name*

TitleFirst NameLast Name
Email*
example@example.com

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

- undertake induction training before I am fully recognised as an Associate Educational Supervisor and then attend update sessions about every two years or as required;

- be prepared to be an Associate 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 Good Medical Practice;

- be willing to attend each ARCP;

- be prepared to provide 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; and

- actively undertake continuing professional development (CPD) in the specialty associated with pharmaceutical medicine.
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 Associate 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 Associate Educational Supervisor webpage.

There is a registration fee of £100 per person.
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.I do not need to pay; it has been three years or less since I relinquished my role as an ES.
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 Associate 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, Associate Educational Supervisors and Specialty Advisers 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 the FPM will not be sent via this network.

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

Associate Educational Supervisor Application

Eligibility

Nominated Educational Supervisor

Conditions on becoming an Associated Educational Supervisor

Introductory workshop

Educational Supervisors Email Network

Data Protection