APPLICATION FORM

GP Post-CCTQuality Improvement Fellowships

Closing date for applications: 17.00 on Monday 6th April 2014

Interviews will be held at:Health EducationWessex (Southern House, Otterbourne) on TBC (Late April or early May 2015)

Please see the Job Description and Person Specification before completing this form. If you require further information on this opportunity, please contact: Johnny Lyon-Maris who leads on GP Quality Improvement projects – ; or the Wessex recruitment team

Title: / First Name: / Surname:
Correspondence Address:
Post Code:
Contact Telephone Number: / Email:
(This will be for all future correspondence) / GMC Number:
Please give Programme Area
Current Workplace (Name of Employer):
This appointment is a Post CCT appointment for GP Trainee’s completing their
training programme on or about August 2015
  • Date of expected CCT:
  • Name of GP Associate Dean:
(please provide evidence that your Programme Director knows of this application)
Declaration of support from GP Trainer:
I confirm support for the application of this candidate for one of the Quality Improvement Fellowships, including senior level engagement in the project.
Signature:
Name and Job Title:
Date:
Signature of GP Patch Associate Dean:
Date:
I confirm support for the application of the candidate for one of the Quality Improvement Fellowships
(NB: successful applicants will still need to apply for OOP experience.
Personal Statement:
(Please tell us about yourself, including why you are applying for the Fellowship, what relevant skills and experience you will be bringing, and what you hope to gain from the Fellowship. Max 300 words.
Making a difference:
Please tell us about an example of where you have made a difference (does not have to be work related). What did you do to make this happen? Max 200 words
The School of Quality Improvement invites applicants to consider work on a current Wessex LETB health priorities:
______
Outline of Project:
Please identify the education or health issue you would like to investigate, and its local relevance to quality improvement. Please give a brief background and introduction to the project, a brief description of how you might approach this work, what resources are needed, who needs to be involved, what are the expected outcomes and benefits to both patients and staff.
Evidence that you have worked with your employer/sponsor to prepare this proposal will strengthen your application. (Please note at this stage only a draft outline is required) Max 500 words.

Signature …………………………………….…………… Date …………………………………………..

Return completed form to the Recruitment Team at