Medical Education Centre

Clinical Attachment Scheme

Application Form

Please return completed form together with your CV to:

Please complete this application form in black ink or typescript

PERSONAL DETAILS
Title: Mr/Mrs/Ms/Miss/Dr etc: ……………………………………………………………………….
Surname/Family Name: …………………………………………………………………………..
Forenames: ………………………………………………………………………………………..

UK Address: ……………………………………………………………………………………..

……………………………………………………………………………………………………
…………………………………………………………………………………………………….
Postcode: ………………………………………………………………………………………….
E-Mail Address : …………………………………………………………………………………
Home Telephone No: …………………………………………………………………………….
Work Telephone No: ……………………………………………………………………………..
Mobile No: ……………………………………………………………………………………….
HOSPITAL & AREAS OF CLINICAL INTEREST
Where would you ideally like to do your clinical attachment?
Please indicate 3 specialties that you would be interested in:
1.  ………………………………………………………………………………………
2  .……………………………………………………………………………………..
3. ……………………………………………………………………………………….

REFUGEE/OVERSEAS STATUS

How long have you lived in the UK? Date From:…………………..

Date To: …………………


Do you have ILR status? Yes No

Do you have ELR status? Yes No
Do you have humanitarian protected status? Yes No

Do you have discretionary leave status? Yes No

Please list details of all full-time and part-time work even if it was carried out overseas.

Previous Employment
ORGANISATION OR
INSTITUTION
/ SPECIALITY & CONSUTLANT / DATE / COMMENTS
TO / FROM

Please list colleges and universities etc attended. You will be require to produce the originals of all examination certificates, professional qualifications certificates and professional registration details

Education & Training
Place of Study
/ Qualification and Subject / DATE / COMMENTS
TO / FROM
PLAB STATUS
EXAM
/ DATE / DATE TO BE TAKEN / ORGANISATION OR
INSTITUTION
TO
/ FROM
PLAB 1
PLAB 2
PREVIOUS CLINICAL ATTACHMENT HISTORY
ORGANISATION OR
INSTITUTION
/ SPECIALITY & CONSUTLANT / DATE / COMMENTS
TO / FROM
HEALTH & REHABILITATION OF OFFENDERS
If you were accepted onto the clinical attachment scheme, it would be subject to successful occupational health screening.
Please provide details of any criminal convictions or police cautions you have received in the space below (this information will be treated as confidential)
………………………………………………………………………………………………………..
………………………………………………………………………………………………………..
LEARNING NEEDS
Please identify what you feel to be your 3 main learning needs.
2.  ………………………………………………………………………………………
2  .……………………………………………………………………………………..
3. ……………………………………………………………………………………….
Provide a brief outline of how you feel this scheme will help to meet your learning needs:
…………………………………………………………………………………………………….
……………………………………………………………………………………………………..
…………………………………………………………………………………………………….
Signature: ………………………………….. Date: ………………………………

Equal Opportunities Monitoring Data

The Trust has an equal opportunity policy which aims to ensure that no applicant receives less favourable treatment on the grounds of ethnic group, nationality, gender, marital status, age, parenthood, sexual orientation, religion or disability. In order to assess the effectiveness of the policy and to assist in its development we would be grateful if you would please complete this form.

Do you consider that you have a disability? Yes □ No □
Ethnic Origin ( Please indicate by a tick in the appropriate box)
White Mixed
□ British □ White and Caribbean
□ Irish □ White and Black African
□ Any other white background □ White and Asian
□ Any other mixed background
Asian or Asian British Black or Black British
□ Indian □ Caribbean
□ Pakistani □ African
□ Bangladeshi □ Any other Black background
□ Any other Asian Background
Other Ethnic Groups
□ Chinese □ Any other ethnic group
Gender
□ Male □ Female
Marital Status
□ Single □ Married □ Divorced
□ widowed □ Common Law Partnership □ other
Date of Birth:………………………….. Place of Birth:………………………………………..
How did you become aware of this programme: …………………………………………..
Forenames:…………………………………… Surname:……………………………………
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