Study Leave Application Form. JUNIOR DOCTORS (In Training) PERSONAL DETAILS DETAILS OF APPLICATION REASONS FOR APPLICATION

Transcription

1 Study Leave Application Form JUNIOR DOCTORS (In Training) External Training/Development Events To be completed by the applicant and submitted at least six weeks before study leave is required. Applicants are advised that until approval has been given by the designated person, study leave cannot commence. Retrospective applications will not be considered for reimbursement of expenses. PERSONAL DETAILS Name:... Dr / Mr / Mrs / Miss / Ms* - Speciality/Department: * (please circle as appropriate) Hospital Start Date:.. Date of commencement in post:.. Termination Date: Job Title:.. Directorate:.. Location:.. Telephone Ext No:... Bleep No:. Mobile No:... DETAILS OF APPLICATION PRESENTATION/COURSE/CONFERENCE TITLE: Venue:.. Dates (inclusive):. Place provisionally booked: Yes / No * Fee:... Inclusive of meals YES / NO / NOT KNOWN * Accommodation Required: YES / NO * Accommodation costs:. (max payable 55 per night) Type of transport:.... (i.e. bus /car/train/plane) Please share transport wherever possible. REASONS FOR APPLICATION Please give below any additional information in support of your application, including why you think you should be considered and how it will benefit the organisation.

2 EXAMINATION LEAVE QUALIFICATION: Venue:.. EXAMINATION LEAVE CONTINUED OVERLEAF STATE NUMBER OF DAYS LEAVE REQUIRED AS FOLLOWS: Dates of Written:.. Dates of Oral:... Dates of Viva:.. Travel dates to/from venue:. NUMBER OF PREVIOUS ATTEMPTS:... TIME OFF FOR PRIVATE STUDY Dates (inclusive): Reason:. DUTY COVER Name of colleague covering duties (if known):... Specific on-call dates:.. SIGNATURE OF APPLICANT Please attach a copy of the course / conference programme. SUPPORT OF APPLICATION When supporting applications, Consultants/Managers are reminded of their responsibility for service provision, and ensuring that leave does not disrupt that provision. Applications must support the individual s personal development plan. LOCUM REQUIRED: YES / NO * Approved / not approved by Consultant/ College Tutor NAME (please print) Approved / not approved by Rota Registrar (if applicable): NAME (please print) Approved / not approved by Directorate General Manager / Clinical Director NAME (please print)

3 PLEASE FORWARD THIS FORM TO THE PERSONNEL DEPARTMENT FOR PERSONNEL DEPARTMENT USE ONLY LOCUM BOOKED: YES / NO * DATES (inclusive):. ORDER NUMBER:. CONFIRMATION OF ENTITLEMENT TO STUDY LEAVE AND EXPENSES To be completed by the Clinical Tutor / Nominee To:. Copy to:. Personnel Department Applicant APPROVAL HAS / HAS NOT* BEEN GIVEN FOR THE ABOVE NAMED APPLICANT TO ATTEND: COURSE TITLE:. VENUE:... DATES (INCLUSVE): EXPENSES ARE APPROVED AS FOLLOWS: Fee:... Subsistence:.. (maximum payable 20 per day) Within Budget Accommodation:.. (maximum payable 55 per night) Within Budget Financial Code: Travel:.. (mileage payable at 24p) Within Budget Financial Code: (Travel) NUMBER OF DAYS STUDY LEAVE TAKEN TO DATE (YEAR/CYCLE): NUMBER OF DAYS REMAINING IN CURRENT LEAVE YEAR/CYCLE):... PLEASE NOTE THAT EXPENSES WILL NOT BE PAID WITHOUT RECEIPTS Signature Lead Clinical Tutor:.. Lead Clinical Tutor Dr Ed Simmonds Clinical Tutors Surgery Medicine Paediatrics & Neonates Obstetrics & Gynaecology Anaesthetics Mr Dan Higman Dr Sailesh Sankar Dr Nigel Coad Mr Laurence Wood Mr Robin Correa

4 BRIEF GUIDELINES ON STUDY LEAVE JUNIOR DOCTORS (In Training) 1. All applications for study leave must be made at least 6 weeks before the date of the leave or course date. Applications may be refused if made within 6 weeks. 2. Study leave allowance is 600 per annum / 300 per six months. This includes subsistence and travel. 3. Retrospective claims for study leave or course expenses will generally not be considered. 4. Revision/Crammer Courses. Any Trainee wishing to attend a revision/crammer course towards an examination will only be reimbursed 50% of the cost of the course, up to a maximum of 250. Only ONE course for each type of examination will be funded, irrespective of whether the candidate is successful in the examination. 5. No payments will be made for exam fees. 6. Funding will not be granted for on-line courses. 7. Contributions towards overseas course fees and expenses (which cover travel, accommodation and subsistence) are in the order of: - Paris, near Europe 150 Mid Europe, Italy, etc 300 India, all the Americas and Canada 450 Australia, New Zealand 500 APPROVAL OF EXPENSES 8. Once study leave has been granted, expenses claims with receipts must be submitted to the Postgraduate Centre within 3 months of the course date. Claims received later than this date will be refused. 9. Expenses will not be paid without receipts. STUDY LEAVE ENTITLEMENT All Junior Doctors are granted 600 per annum / 300 per six months 30 days study leave. In some specialities where there is protected teaching, days and monies will be deducted. Private study entitlement is 10 days per annum (from the 30 total), with 5 being taken at a block.

5 We are an Equal Opportunities Employer Equal Employment Opportunity 1. Gender: Male Female (please tick) 2. Nationality:. 3. Ethnic (Racial) Origin: (please tick appropriate) White UK (inc. Eire) Indian Pakistani White Other Black Caribbean Black African Black Other Chinese Asian Other Bangladeshi Other Ethnic Group 4. Have you a disability which you would like us to know about? Yes No University Hospitals Coventry and Warwickshire NHS Trust as an equal opportunity employer is committed to preventing discrimination and promoting and encouraging equal opportunity in all aspects of employment, including recruitment, training and development, and welcomes applicants regardless of race, nationality, ethnic origin, gender and disability. To facilitate the monitoring of equal opportunities within the Trust, would you please provide the information required in these areas below. This personal information requested for monitoring is intended for the specific purpose of ensuring the effectiveness of the policy and will not be used in the selection process. Ethnic Origin is not synonymous with national origin or with race, but is normally defined in relation to a people or culture with which a person or his/her forebears are most strongly identified. For monitoring/evaluation purposes we use the following classifications:- WHITE/UK INC. EIRE WHITE OTHER BLACK CARIBBEAN BLACK AFRICAN BLACK OTHER BANGLADESHI INDIAN PAKISTANI ASIAN OTHER CHINESE OTHER ETHNIC GROUPS Persons born in or whose recent forebears were born in England, Scotland, Wales or Ireland (including Eire) Persons born in or whose recent forebears were born in Europe, e.g. France, Germany, etc. Persons born in or whose recent forebears were born in the Caribbean Persons born in or whose recent forebears were born in Africa, N.E. Persons of North Africa (Arab) origin should not be included in this group. East African Asians should also be excluded from this group. Persons of Arab origin, East African Asians, or others not included in the above categories. Persons born in or whose recent forebears were born in Bangladesh. Persons born in or whose recent forebears were born in India Persons born in or whose recent forebears were born in Pakistan. Persons born in or whose recent forebears were born in Hong Kong, Malaysia, Singapore, Philippines and all other Far East Countries. Persons born in or whose recent forebears were born in China. Persons born in or originating from countries not included in the above categories. E.g. Americas, Australia, Middle East, Japanese, Vietnamese, etc.