Clinical Scientist Guided Training Scheme supervisor application form

Consent for storing submitted data *

Yes, I give permission to store and process my data

First name *

Surname *

Date of birth *

Gender *

Male

Female

Other

IPEM membership number (if applicable)

Membership reference 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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3.

Relevant qualifications

	Qualification	Where obtained	Date obtained
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2
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4

Employment history

	Post held	Employer	Date from	Date to
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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. *

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