WMS Nominee Form

Please complete and submit the form below if you wish to be considered for an Honorary Association. Part 3 should be completely only, if you wish to be considered for an association as an Honorary Associate Clinical Professor.

Is your application a:

Part 1 Personal Details

Title

First Name

Surname

Date of Birth

Legal Gender

Nationality

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

Home Address

Post Code

Preferred email address

Telephone No.

Link to your professional website (e.g. your personal page on a university website, linked-in page etc. Not Facebook or informal social page):

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

Current substantive employer (the organisation paying your salary):

yes

Other

If yes, name and contact details of your Clinical Line Manager or Clinical Director, with whom you have discussed your application:

Role:

Name:

Telehpone No:

Email:

If :'yes', name and contact details of your Trust Medical Director or equivalent:

Name:

Role:

Telephone No:

Email:

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

Other

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.

Please select one of the following (required)

I currently receive payment for work undertaken on behalf of WMS

I used to receive payment for work undertaken on behalf of WMS

I have never received payment for work undertaken on behalf of WMS

If you answered ‘Yes’ to ‘currently receive payment’ or ‘used to receive payment’ please give brief details

Name of your proposer at Warwick Medical School (This must be an academic employee of WMS): (required)

Do you hold any honorary academic titles elsewhere? If yes, please provide details.

Please upload your: a. Head and shoulders photo for use on the Medical School website. b. Recent Curriculum Vitae (required)

Attach file

No files are currently attached.

a. I have uploaded my photo (required)

yes

b. I have uploaded my CV (required)

yes

Part 2 Interests Describe your interests under at least one of sections 1, 2 and 3. If you are applying for a renewal, please indicate briefly what you have done in the course of your previous association with WMS, as well as your proposed activities for a future term. Please do not exceed 150 words per section.

1. Area of clinical practice (if relevant)

2. Area of teaching interest/expertise (if relevant)

2a. Teaching qualifications achieved (eg, Fellowship of the Higher Education Academy, PGCE, completed modules; such as Essentials of Medical Education) (if relevant)

2b. Teaching-related training courses undertaken (dates and duration), (if relevant):

3. Area of research interest (if relevant):

4. Any pre-exisiting relationships with Warwick Medical School:

5. Please provide up to 10 key words or phrases that describe your PROFESSIONAL interests (each word or phrase to be comma separated). These words should reflect the areas in which you would be positioned to contribute to research or provide student support and should be as specific as possible e.g. functional gastrointestinal disorders, assessment in medical education, placement of dental implants. (required)

Part 3 Applicants for the title "Honorary Associate Clinical Professor"

ONLY COMPLETE THIS SECTION IF YOU WISH TO APPLY FOR THE TITLE OF HONORARY ASSOCIATE CLINICAL PROFESSOR for Honorary Associate Clinical Professor To undertake a role in curriculum design and development and / or to make a significant contribution to research complementary to the research programme of Warwick Medical School. For Honorary Clinical appointments: To work to academic objectives that will be agreed annually as part of a joint NHS / University appraisal using Follett principles.

I am applying for the title of Honorary Associate Clinical Professor. (required)

yes

No

If No, proceed to section 4

Part 4 Applicants for the title "Honorary Professor"

ONLY COMPLETE THIS SECTION IF YOU WISH TO APPLY FOR THE TITLE OF HONORARY PROFESSOR Criteria for Honorary Professor Experience at a level equivalent to that of a professor Expected to make a significant contribution to the development of WMS Meeting at least one of the following requirements: - An international reputation for outstanding research and teaching in a specialist field - Evidence of academic leadership, knowledge development and innovation in research and teaching - An eminent professional practitioner or recognised authority in a specialist field who will provide strategic input into WMS and as an advocate for the University.

I am applying for the title of Honorary Professor (required)

Yes

No

If Yes, I confirm I will work with my proposer to list measurable academic outcomes for the period, with timescales. I understand that these should be added to my personal development plan to be assessed at my annual joint clinical appraisal.

yes

If Yes, please be aware that you should already have made informal contact with the Dean of WMS and provided an indicative CV. References may be required; if so you will be asked to provide the names of up to 3 referees who must have given explicit consent for you to share their personal data with the University of Warwick. Your application will be reviewed by the Honorary and Visiting Professor Appointments Panel at WMS before a recommendation is made. The panel meets termly.

If No, proceed to section 5

Part 5 Conflicts of Interest

Do you have any conflicts of interest to declare in relation to your proposer or the potential honorary role? (required)

No

yes

If ‘Yes’. I wish to declare the following potential or actual conflicts of interest:

You will be required to complete the Universitys FP1a form to declare conflicts of interest if the honorary association goes ahead.

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

On some occasions we may request details of three referees. We will contact you if this is the case.

Disclaimers

Disclaimer 1 (required)

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

Disclaimer 2 (required)

(if employed) I have discussed this Honorary Association with my substantive employer who is supportive.

Disclaimer 3 (required)

I agree to participate in laboratory induction and occupational health checks if required to do so.

Disclaimer 4 (required)

I agree to comply with all relevant research governance processes.

Disclaimer 5 (required)

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

Disclaimer 6 (required)

I agree that the information provided in Part 1 of the form, including my photograph, can be used by Warwick Medical School on its website and in promotional material

Other

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, professional links, job title, place of work, clinical practice, teaching interest/expertise, research interests and key words will be placed on the University webpage. The legal basis for placing this personal data on the website is that it is necessary for the performance of services.

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 this information and is committed to protecting the rights of individuals in line with Data Protection Legislation. Please visit the Information Commissioner’s Office’s webpages for further information in relation to your rights and the University’s Data Protection webpages for further information about how the University processes your personal data. The University’s Data Protection Officer can be contacted through infocompliance@warwick.ac.uk and any requests or complaints should be made in writing to the University’s Data Protection Officer.

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.

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