MB ChB Nominee Form

Congratulations on your nomination for honorary association with the University of Warwick. To complete the nomination process please complete the form below. The personal data provided is required to create a record in our HR systems. We also ask you to indicate your areas of expertise or research interests to allow us to connect you with academic educators at WMS.

Details of the criteria and types of honorary associations can be found in the Honorary Associations criteria document with examples of suitable clinical educators who would be invited to apply.

Please note this form is for MB ChB education teams only.

MB ChB Honorary Associations Flowchart and Process

Is your application a:

Part 1 Personal Details

Title

First Name

Surname

Date of Birth

GMC/GDC/HCPC/NMC Registration Number (if not applicable, enter N/A):

Home Address

Post Code

Work email address

Telephone No.

Current substantive employer (the organisation paying your salary):

Current substantive post (this is your main job and it is external to WMS):

I currently have an employment contract with the University of Warwick

I used to have an employment contract with the University of Warwick

I have never been employed by the University of Warwick

If you answered ‘Yes’, to ‘currently employed’ or ‘have been employed in the past’ give brief details:

Please note that an Honorary Association cannot be made in connection with work that is paid for.

Part 2 Associate Details

Association Title (Please refer to Appendix A for guidance) (required)

Honorary Clinical Teaching Fellow

Honorary Clinical Lecturer

Honorary Associate Clinical Professor

2. Area of clinical practice/teaching interest/expertise

2a. Teaching qualifications achieved (eg, Fellowship of the Higher Education Academy, PGCE, completed modules; such as Essentials of Medical Education), recent and relevant training (relating to teaching)

3. Area of research interest (optional):

Part 3, Employment Status

Nationality (required)

I hold a UK immigration status which permits me to work in the UK (if 'other' please state immigration/visa status)

Immigration Status (required)

UK/Irish National

Other

Professional Conduct (required)

I am not currently under investigation for misconduct or have any disciplinary outcomes pending

Part 4, Conflicts of Interest

Do you have any conflicts of interest to declare in relation to your application for honorary association? (required)

No

Yes

If yes, you will be required to complete the University's FP1a form to declare conflicts of interest upon receiving your honorary association.

You will be given the option to receive an email copy of your submitted information when you press SUBMIT.

Disclaimers

Disclaimer 1

I am aware than an Honorary Association, if awarded, is unpaid and does not constitute a contract of employment.

Disclaimer 2

(for all healthcare professionals) I hold professional registration and appropriate insurance or indemnity, and I agree to inform Warwick Medical School if I cease to hold professional registration or appropriate insurance or indemnity.

Disclaimer 3

I consent to WMS contacting me regarding my disclosed interests/area of expertise, in relation to academic contribution to medical education activities

Part 5, Diversity, Inclusion and Statutory Monitoring Information

The University is committed to ensuring Warwick is a fully inclusive community, which recruits and retains talented staff from all sectors of society equally. We believe that every individual should be treated fairly with dignity and respect and be part of a working and learning environment that is free from barriers and that we do not inadvertently make decisions or have processes that treat you less favourably on the basis of your age, race, gender or disability.

Information that we collect in this section will be held on our HR systems and may be used by the University to generate anonymised and aggregated statistics. It will never be shared, reported or published in a form that allows individuals to be identified.

Gender:

What is your sex?

Female

Male

Prefer not to say

How would you describe your gender identify?

Male

Female

Non-binary

In another way

Prefer not to say

Do you identify as transsexual?

Yes

No

Prefer not to say

Do you identify as intersex?

Yes

No

Prefer not to say

Sexual orientation

How would you describe your sexual orientation?

Bisexual

Gay man

Gay woman / lesbian

Heterosexual / Straight

Other

Prefer not to say

Disability

Do you have an impairment, health condition or learning difference that has a substantial or long-term impact on your ability to carry out day-to-day activities?

Yes

No

Prefer not to say

If yes, what is the nature of your disability? Please tick the appropriate box. If your disability does not fit any of these types, please select the last but one option. If you experience more than one type of impairment, please select the last option.

Neurodiverse, specific learning differences such as dyslexia, dyspraxia or ADHD

General learning disability such as Down syndrome

Neurodevelopmental, Social, Communication differences such as Autism Spectrum, Asperger’s

A long standing physical illness or health condition such as ME/chronic fatigue, epilepsy, diabetes, digestive conditions or HIV

A mental health condition, such as depression, anxiety, OCD, or schizophrenia

A physical or mobility issue, use of mobility aids or difficulty using arms

Deaf, other hearing issues or conditions

Blind or a serious visual condition uncorrected by glasses

A disability or medical condition that is not listed above, such as speech difficulties/stammer

Two or more disabilities or medical conditions

Ethnicity: How would you describe your ethnicity or ethnic background?

White

Mixed: White and Black Caribbean

Mixed: White and Black African

Mixed: White and Asian

Mixed: Other mixed background

Asian or Asian British: Indian

Asian or Asian British: Pakistani

Asian or Asian British: Bangladeshi

Asian or Asian British: Chinese

Asian or Asian British: Other Asian background

Black or Black British: Caribbean

Black or Black British: African

Black or Black British: Other Black background

Arab

Gypsy or Traveller

Other Ethnic Group

Prefer not to say

Religious beliefs:

What are your religious beliefs?

No religion

Buddhist

Christian

Hindu

Jewish

Muslim

Sikh

Spiritual

Any other religion or belief

Prefer not to say

Privacy notice

The University of Warwick will process your personal data provided in this online application form for the purposes of administering and considering your application as an honorary associate. The information provided on the application form will also be used to contact you with relevant information in relation to progress of your application and if successful, your honorary appointment.

The legal basis for processing this personal data is that it is necessary for the performance of services.

Your application may be shared with your employer, whose approval will be sought for your holding an Honorary Association at Warwick together with your substantive employment.

Your first name and surname, job title, place of work, clinical practice, teaching interest/expertise, research interests will be placed on an internal database. If you have indicated consent above, WMS may contact you in relation to academic or research interests.

Your personal data will not be transferred outside of the EEA, will be kept securely by the University of Warwick and will be retained for a period of seven years after the expiry of your honorary association unless your application is unsuccessful, at which point your personal data will be kept for six months from the point your application is unsuccessful.

The University of Warwick is the Data Controller of any information you have entered on this form and is committed to protecting the rights of individuals in line with Data Protection Legislation. The University's Data Protection webpages provide further information on your rights and how the University processes personal data. If you wish to submit a data subjects rights request, make a complaint or report a suspected personal data breach, please contact the University’s Data Protection Officer by email at infocompliance@warwick.ac.uk.

Spam prevention

Failure to load reCAPTCHA

reCAPTCHA is a utility used to verify you're not a robot filling out this form. Unfortunately this has failed to load correctly.

Please try reloading the page. If the problem persists, or if you are in a country which blocks Google products, please contact us by using the ‘page contact’ link at the foot of this page.