Clinical Scientist Guided Training Scheme supervisor application form

Consent for storing submitted data *

Yes, I give permission to store and process my data

Sharing your details

As an approved Supervisor we will need to share your name and email address with other IPEM approved Supervisors and External Advisors. To continue with your application, please confirm that you agree to this requirement.

First name *

Surname *

Date of birth *

Gender *

Male

Female

Other

IPEM membership number (if applicable)

Work details

Employer *

Work department *

Workplace name *

Work address *

Work post code *

Work telephone number/mobile *

Work email *

Job title *

Date appointed *

Work Band/Grade *

Specialist area *

HCPC registration number *

Please note that applicants should have at least three years post registration experience before applying to become a Supervisor for trainees on the Clinical Scientist Guided Training Scheme.

Year of HCPC registration *

List the Clinical Scientist Guided Training Scheme trainee/s (first name, last name) whom you are supervising (if applicable)

Other relevant registrations

	Professional body	Registration number	Date registered from
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2.
3.

Relevant qualifications

	Qualification	Where obtained	Date obtained
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2
3
4

Employment history

	Post held	Employer	Date from	Date to
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2
3
4

Relevant work experience and supervisory experience *

Overview of previous experience in a supervisory role or examples of mentoring:

Head of department

Head of department first name *

Head of department surname *

Head of department email *

Declaration

I wish to apply to become a Supervisor to deliver the IPEM Clinical Scientist Guided Training Scheme. I declare that the information I have given in this application is, to the best of my knowledge, accurate and true and that my Head of Department is in full support of my application. *

How do we use your data?

All information collected is treated in strict compliance with the Data Protection Act. You can read our Privacy Policy here.