S TUDY LEAVE APPLICATION FORM FOR DOCTORS IN TRAINING
Please read notes overleaf before completion. These notes are to be read in conjunction with the NES Study Leave Policy and Operational Guide. Please complete this form in BLOCK CAPITALS. All sections of this application must be completed in full or it will be returned to the applicant, resulting in an inevitable delay in processing.
SECTION 1 - PERSONAL DETAILS OF APPLICANT
|
|
|
FULL NAME:
|
|
|
|
HOME ADDRESS:
(see note overleaf)
|
|
|
|
POSTCODE:
|
|
|
|
CONTACT PHONE:
|
|
EMAIL ADDRESS:
|
|
|
|
GMC/GDC No:
|
|
GRADE/LEVEL:
|
|
SPECIALTY:
|
|
|
|
PLACE OF WORK: (at time of proposed leave)
|
HOSPITAL:
|
|
WARD:
|
|
|
|
SECTION 2 - STUDY LEAVE DETAILS (Please attach a copy of all relevant course/conference registration details - see note overleaf)
|
|
|
DESCRIPTION/TITLE OF ACTIVITY:
|
|
|
|
LOCATION:
|
|
PROVIDER:
|
|
|
|
DATES: FROM:
|
|
am/pm
|
UNTIL:
|
|
am/pm
|
NO. OF DAYS REQUESTED:
|
|
(see note overleaf)
|
|
|
(see note overleaf)
|
I wish to apply for study leave: (please tick)
|
WITH EXPENSES
|
ESTIMATED COSTS APPLIED FOR: £
|
NB - “Expenses” includes course/activity fee.
|
WITHOUT EXPENSES
|
(see note overleaf) FEE
|
|
|
|
TRAVEL
|
|
How is Study Leave being funded: (please tick)
|
SELF
|
NES
|
SUBSISTENCE
|
|
|
OTHER (please detail below)
|
TOTAL
|
0.00
|
|
|
|
|
|
|
DECLARATION:
| -
I shall ensure that my colleagues are fully aware of my absence and that my clinical responsibilities will be covered.
-
I have read the NES Study Leave Operational Guide and the Notes on the back of this form and will abide by the conditions laid down in the “Terms & Conditions” of service.
-
I have provided all the information required for this application to be considered in full.
-
I shall submit all relevant receipts within 3 months of the date of the study leave event.
|
SIGNATURE OF APPLICANT:
|
|
DATE:
|
|
|
|
|
PLEASE ENSURE THAT THIS APPLICATION IS FULLY COMPLETED BEFORE SEEKING APPROPRIATE SERVICE LEAVE OF ABSENCE APPROVAL.
|
SECTION 3 – SERVICE LEAVE OF ABSENCE APPROVAL (by Clinical Director, Supervising Consultant or Head of Department)
|
I have considered the implications of this application on the service(s) for which I am responsible.
|
This application is: (please tick)
|
SUPPORTED NOT SUPPORTED
|
Reason:
|
|
|
|
SIGNATURE:
|
|
DATE:
|
|
|
|
PLEASE NOTE THAT THE ARRANGEMENT AND PROVISION OF ANY LOCUM COVER IS A SERVICE RESPONSIBILITY.
|
SECTION 4 – TRAINING PROGRAMME APPROVAL
|
|
|
This application is: (please tick)
|
APPROVED, WITH FUNDING
|
If APPROVED, up to a maximum of:
|
£
|
|
APPROVED, WITHOUT FUNDING
|
|
|
NOT APPROVED
|
|
|
|
If NOT APPROVED, reason is:
|
NOT WITHIN BUDGET PLAN
|
SIMILAR COURSE AVAILABLE LOCALLY
|
(please tick)
|
INAPPROPRIATE EDUCATION
|
APPLICATION RECEIVED TOO LATE
|
|
POOR VALUE FOR MONEY
|
OTHER REASON: (please specify below)
|
|
|
|
SIGNATURE:
|
|
|
|
|
|
PRINT NAME:
|
|
DATE:
|
|
|
|
|
PLEASE FORWARD THIS APPLICATION FORM TO YOUR LOCAL DEANERY OFFICE, EVEN IF NOT SUPPORTED OR APPROVED.
|
SECTION 5 – DEANERY ADMINISTRATION
|
|
|
ELIGIBLE FOR LEAVE: (please tick)
|
YES NO
|
NO. OF DAYS APPROVED:
|
|
|
|
CURRENT LEAVE PERIOD:
|
FROM:
|
|
TO:
|
|
DATE RECEIVED BY DEANERY:
|
|
|
|
SIGNATURE:
|
|
DATE:
|
|
|
|
|
|
|
|
APPLICATION ID NO:
|
|
RECEIPTS RETURNED:
|
|
|
|
|
Data Protection: NES uses the personal data you provide for purposes associated with our responsibilities for health workforce development, including the administration of courses, monitoring training programmes and circulating information relating to relevant development opportunities. For more information see www.nes.scot.nhs.uk/data protection. Personal data will be retained in line with our records retention policies. We may share your personal data as appropriate and necessary with your employing Health Board and other relevant educational bodies.
|
Version 1.6 03/02/10
|
NHS EDUCATION FOR SCOTLAND
NOTES FOR DOCTORS APPLYING FOR STUDY LEAVE AND FUNDING.
GENERAL
-
ALL applications must reach your local Deanery office at least one month before the planned activity.
-
No retrospective applications will be processed. All subsequent expense claims must be submitted within 3 months of the activity.
-
This form must be completed for ALL training events, even if no funding is required, to ensure appropriate processing and recording of data.
-
All educational activities must be approved by the applicants Training Programme Director (TPD) before any payment can be made.
-
No payment will be made until an associated Claim Form is completed.
-
Receipts should NOT be sent with Applications Forms. They should be retained for inclusion with any subsequent expense claim.
SECTION 1 – PERSONAL DETAILS OF APPLICANT
-
All fields in this section must be fully completed.
-
Home Address details are essential so that any subsequent Claim Forms and payments can be sent to applicants with minimum delay.
SECTION 2 – STUDY LEAVE DETAILS
-
Where applicable, a course/conference registration form/programme must accompany the application. This is necessary to allow the TPD to assess the educational value of the event. If no such information is supplied then the form will be returned to the applicant, resulting in an inevitable delay in processing.
-
Course/activity dates must be fully completed so that the number of days requested can be verified.
-
Number of days requested/recorded will include half-days, weekend days and Annual Leave days where relevant.
-
Estimates of all costs applied for must be provided and should be as accurate as possible. All parts of this section must be completed:
1. Fee - Evidence of the fee should be attached, where relevant. If this application is fully approved then the course/conference fee could be paid directly, on provision of a formal invoice made out to “NHS Education for Scotland”. Responsibility for such invoice requests lies with the applicant.
2. Travel - Please estimate the costs of all potential travel including mileage and parking, if relevant. The cheapest form of travel should be used at all times.
3. Subsistence - This estimate should also include the costs of any accommodation required to attend the study leave activity.
Please note: All travel and subsistence costs subsequently claimed, within the set guidance, must be receipted otherwise no reimbursement will be made.
-
It is the responsibility of the applicant to ensure that their clinical duties are covered to allow them to attend the activity.
SECTION 3 – SERVICE LEAVE OF ABSENCE APPROVAL
-
If the application for study leave is not supported, from a service perspective, then full details of the reason need to be disclosed.
-
Provision of Locum cover, where required, is a service responsibility. As such, all arrangements will be made within the service department(s) affected.
SECTION 4 – TRAINING PROGRAMME APPROVAL
-
In line with NES’ Study Leave Policy, in some instances it may be necessary for a TPD to authorise study leave time for the applicant but without any funding. Similarly, approval may be given up to a maximum sum of funding. In either case, details of maximum approved must be completed.
-
Full details need to be provided for all applications that are not approved at the TPD level.
-
On completion of this section, the application form should be forwarded to the local Deanery office for processing. This includes all forms that have not been supported or approved at Section3 (Service) and Section 4 (TPD).
Dostları ilə paylaş: |
