Study Leave Application Forms - Northern Deanery
Study Leave Application Forms - Northern Deanery
Study Leave Application Forms - Northern Deanery
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NORTHERN DEANERY<br />
ONCOLOGY STUDY LEAVE / INDIVIDUAL LEARNING ACCOUNT PILOT – 2011<br />
STUDY LEAVE APPLICATION FORM<br />
This form must be submitted in duplicate and all sections completed.<br />
<strong>Study</strong> leave and study leave funding will not be agreed retrospectively.<br />
PART 1 – Trainee information and details of proposed study leave<br />
Surname:……………………………………………… First name:……………………………<br />
Full time/Flexible………………………………………………………………………………….<br />
Date of start of training in <strong>Northern</strong> <strong>Deanery</strong>:…………………………………………………..<br />
Current post:……………………………………………………………………………………….<br />
Start date of current post:…………………………... End date of current post:…………….<br />
Educational Supervisor:…………………………………………………………………………..<br />
Consultant/Clinical Supervisor:…………………………………………………………………..<br />
Contact telephone number for Trainee:……………………… ……... Bleep…………….....<br />
E-mail address for Trainee……………………………………………………………………….<br />
Hospital address during episode of requested leave:<br />
<strong>Study</strong> leave experience requested: course / conference / exam leave / private study<br />
Location of event:………………………………………………………………………………….<br />
Dates of event:<br />
from………………………………. to………………………………………<br />
If exam, previous number of attempts:………………………………………………………….<br />
Have you informed your Consultant of this request? Yes / No<br />
Name:……………….............................................................................................................<br />
Has your Head of Department approved this leave?<br />
Have you arranged cover of your duties?<br />
Yes / No<br />
Yes / No<br />
Total number of study days taken (since start of training in <strong>Northern</strong> <strong>Deanery</strong>): ………….<br />
Total number of study leave days requested:………………………………………………….
FUNDING (cannot be agreed retrospectively)<br />
Course fee: £………………………………..<br />
Other expected costs: £………………………<br />
(please specify)<br />
Travel (estimate): £………………………… Subsistence (estimate): £…………………....<br />
Accommodation (estimate): £…………….<br />
Total amount estimated: £…………………<br />
PART 2 – How will this educational experience benefit you?<br />
Aims of the course of study leave experience:<br />
1.<br />
2.<br />
3.<br />
Has this course been classified as mandatory by your STC?<br />
Has this course been classified as desirable by your STC?<br />
Yes / No<br />
Yes / No<br />
Describe how this study leave experience will address your learning needs (refer to your<br />
learning plan / log book / PDP / STC mandatory or desirable courses):<br />
1.<br />
2.<br />
3.<br />
Has this study leave been discussed with your trainer?<br />
Yes / No<br />
Trainee signature:……………………………………………………………… Date:…………<br />
PLEASE SUBMIT THIS FORM TO YOUR STUDY LEAVE COORDINATOR<br />
---------------------------------------------------------------------------------------------------------------------<br />
For <strong>Study</strong> <strong>Leave</strong> Coordinator use only<br />
Date received:………………………...<br />
Approved / Rejected<br />
Reason for rejection:…………………………………………..................................................<br />
Name:…………………………………………. Signature:…………………... Date:…………<br />
----------------------------------------------------------------------------------------------------------------------<br />
For PIMD use only<br />
Logged on spreadsheet (date):…………….. Expenses form sent to Payroll (date):……....<br />
Name:………………………………………… Signature:………………………………………<br />
(Specialty Programme Coordinator)
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