Application Form for FOUNDATION MEMBERSHIP / FELLOWSHIP (CLINICIANS WORKING IN SECURE AND DETAINED SETTINGS)

PLEASE NOTE :

This facility is strictly limited to period of three years only and will cease on 31 July 2024.

Information submitted via this form will be used to carry out any reasonable activity related to the administration of the FFLM Foundation Membership /Fellowship process and is held subject to relevant data protection legislation

Criteria

This form is ONLY for Clinicians Working in Secure and Detained Settings applying for either Foundation Membership or Foundation Fellowship of the Faculty.

Failure to complete all sections may result in rejection of the application as the Faculty considers this information is essential to enable the Membership and Fellowship Committee (MFC) to determine whether to recommend to the Board that an individual should be awarded Foundation Status at either category.

The MFC will assess the application based on the information within this form and the information submitted by the nominated referees. Because of the innate variability of the structure and information contained within Curriculum Vitae (CV) the MFC will not consider them. Please DO NOT insert or attach CVs to this form.

Key Points

All applications are reviewed and assessed by the MFC who may take advice at their discretion. It is a thorough but confidential process based on submitted information only and which does not involve the candidates directly.

The application will be reviewed at the MFC. Following this review candidates will be informed of the outcome and the application will be sent to the FFLM Board for ratification. Candidates will then be updated once the board has ratified their application.

If the outcome is unfavourable the applicant may apply again (within the overall limited time frame for Foundation status as noted above). Please note – unsuccessful applicants are not automatically reviewed by the Faculty and so the onus is strictly on an applicant to submit a new application form if they wish to be re-considered by the MFC.

Applications will be considered at the next appropriate meeting of the MFC. The closing dates for completed applications and the dates of the MFC meetings are available on the Faculty website.

Applicant Details

Name(Required)

Prefix First Last

Email (Applicant)(Required)

Phone(Required)

Date of Birth(Required)

Professional Registration Body(Required)

Professional Registration Body Website

Professional Registration Number(Required)

Date Joined Above Register(Required)

Application for Foundation Membership, Fellowship or Affiliate?(Required)

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Fellowships/Memberships of other colleges or societies

Degrees, Qualifications or Honours

Please include the qualification, awarding body and date awarded e.g. MB BCh, Cardiff University, 2010

Current Professional Practice

Role 1 Job Title(Required)

Role 1 Employer(Required)

Year Started Role 1(Required)

Average Hours Per Week in Role 1(Required)

Role 2 Job Title

Role 2 Employer

Year Started Role 2

Average Hours Per Week in Role 2

Role 3 Job Title

Role 3 Employer

Year Started Role 3

Average Hours Per Week in Role 3

Statements

A copy of these statements will be sent to both of your referees on submission of your form.

Personal Statement(Required)

Please provide a brief outline and include any specific examples where the nominee has furthered the objectives of the Faculty in protecting vulnerable people and raising standards in forensic and legal medicine. Your referees should be able to attest to these contributions. (max 1800 characters)

Brief Details of Contributions to the Speciality

Essential only for applications requesting consideration of election to Foundation Fellowship but may be completed by Foundation Membership applicants if they wish to do so. (max 3000 characters)

Appraisal & Revalidation

Revalidation Date (if applicable)

Dates of last 3 appraisals or performance reviews

Appraisal 1

Appraisal 2

Appraisal 3

Appraisal Summary

Please consider uploading your most recent Form 4/Appraisal Summary/Performance Review

Max. file size: 8 MB.

If your employer and regulatory body do not require you to undertake annual appraisal or revalidation please confirm that below

Declaration on Complaints

As part of the application you are asked to declare any pending or upheld formal complaints, disciplinary procedure, litigation or referrals to your regulatory bodies. Please tick yes or no below:

yes/no(Required)

Yes: I DO have outstanding or previously upheld complaints regarding litigation, disciplinary, professional conduct or performance to declare. (please give details IN CONFIDENCE on the Declaration of Complaints form (on the FFLM website) and send to registrar@fflm.ac.uk). Any declarations made will remain strictly confidential and will not be shared beyond the MFC.

No: I DO NOT have any pending complaints or upheld formal complaints to declare. (If this situation should change before the date of the MFC, I undertake to inform the Faculty promptly in writing)

Referees

One of the referees should ideally be a Member or Fellow of the Faculty of Forensic and Legal Medicine however, for the initial stages Foundation status application only, two Senior Colleagues will be acceptable. The referee will be sent a copy of this form and will be required to attest to the achievements described above and to confirm their support of the application for Foundation Membership or Fellowship

Referee 1 Details

Name of Referee 1(Required)

Prefix First Last

Email for Referee 1(Required)

Phone

Role(Required)

Referee 2

Name of Referee 2(Required)

Prefix First Last

Email for Referee 2(Required)

Phone

Role(Required)