Less Than Full Time Training Scheme

APPLICATION FORM

Prior to completing the application form, please ensure that you have read the relevant information sheets and the BMA guidance on pay. Once the application form is completed please return it to the Specialty PA/Administrator, together with an up to date copy of your CV.

PART 1: APPLICANT DETAILS
Surname / First Name
Maiden Name (if used in training) / Preferred name
Title / Gender
Date of Birth
GMC Number / Renewal Date / Do you have a licence to practice:
Yes No
Country of Birth / Nationality
Address for Correspondence
Home Tel. No. / Work Tel. No. / Bleep/Ext.
Mobile No. / E-mail Address
Marital Status / Dependants / YesNo
Next of Kin Name / Next of Kin Contact No.
Employment Details Please attach an up to date Curriculum Vitae
Country of Qualification
Qualifications(Include medical degree and medical school, date qualification attained, any postgraduate diplomas / degrees and any College membership).
Current Post
Grade and Year / NTN/VTN
Specialty / Trust
Start date / Anticipated end date
CCT Date / Hours of work
CT/ST Rotation? / Yes No / Rotation/Scheme End Date
GP VTS Scheme? / Yes No
Long term career aim
PART 2: APPLICATION FOR ELIGIBILITY
CATEGORY 1 APPLICATIONS
(a) / Disability
Please give a brief outline and your last dates of GP, Occupational Health and hospital consultant review. (A letter of confirmation from Occupational Health/GP/Consultant/Medical Specialist must be included if you wish to work Less Than Full Time for disability)
(b) / Health related reasons
Please give a brief outline and your last dates of GP, Occupational Health and hospital consultant review. (A letter of confirmation from Occupational Health/GP/Consultant/Medical Specialist must be included if you wish to work Less Than Full Time for health reasons)
(c) / Responsibility for caring for children (Continue on a separate sheet if necessary)
Name/s of Children
(optional at application stage, but information may be required at a later date which may include copies of birth certificates) / Date of Birth
(mandatory at application stage) / Age
Are you pregnant? Yes No / If yes, state expected date of delivery
Is your partner / spouse a LTFT trainee? Yes No
If yes, we may request further information at a later date.
Please add any comments that are relevant to your current situation (please include family support, spouse occupation, home situation)
(d) / Responsibility for caring for ill/disabled partner, relative or other dependant.
(Continue on a separate sheet if necessary)
Supporting documentation is required from the medical specialist involved in the care of your partner/relative/dependant. This must be on letter-headed paper or from an official email address which can be validated. The details should include the level of care which the specialist anticipates you will need to provide to the partner/relative/dependant and the level of time commitment that will be required. To avoid communication of sensitive personal data, broad terms, e.g. personal care, should be used rather than personal details relating to the level of care which will be provided.
Name/s and relationship of dependant/s / Date of Birth
Is your partner / spouse a LTFT trainee? Yes No
If yes, we may request further information at a later date.
CATEGORY 2 APPLICATIONS
Please outline your reason for applying for part time training (if not Category 1)
You must include supporting documentation which evidence the opportunity that you are applying for.
PART 3: LESS THAN FULL TIME TRAINING PLANS

Please provide details of your intended training plans. Please note that there is no guarantee that these can necessarily be met.

Anticipated start date / Reason this date was chosen
Anticipated End Date / Anticipated Trust
Proposed Grade / Proposed Specialty
In accordance with the new pay arrangements for LTFT training please indicate your anticipated actual hours of work:
May we discuss your application with your relevant training advisors e.g. Programme Director / Lead Consultant / GP Programme Organiser?
If no, please provide reason: / Yes No
PART 4: DECLARATION
a) I have read the Deanery information on LTFT training.
b) I have seen and read the website documents relating to the principles and pay arrangements for LTFT training dated April 2005 (joint BMA/NHS Employers Agreement).
c)In accordance with the new pay arrangements I understand that I will normally be expected to move between posts and rotations on the same basis as a full time trainee in the same specialty.
d) I agree that information provided on this form may be entered into a computerised system and may be passed to my employing Trust. I also agree that there may occasionally be a need to use my details for trainee mailings, but will only be used by those closely connected with my training.
e) I agree not to exceed the Out of Hours equivalent of my Full Time colleagues in accordance with my pro rata basic hours.
fI agree that the information given in this application is accurate to the best of my knowledge and belief.
Signature / ...... / Date
Print Name
PART 5: CONFIRMATION OF ELIGIBILITY – FOR DEANERY USE ONLY
Date Application Received by Deanery
Date acknowledgement letter sent to trainee
Recommendation of Programme Manager:
Category 1 a / Category 2 a / Not Eligible
Category 1 b / Category 2 b / If not eligible please give reason:
Category 1 c / Category 2 c
Category 1 d
Signature ...... / Date ......
Print Name ......
Associate Dean Decision
Proceed / Interview Needed / Not Eligible
If not eligible please give reason:
Signature ......
Print Name ...... / Date ......