ࡱ> JMIC fbjbj 04hh dd8F<<h%"$$$$$$$$') %W*WW %J"%###Wv$#W$##J#htOB#$8%0h%#**#*#> ,#L$p % %"h%WWWW*dX : SALISBURY Ӱ FOUNDATION TRUST SENIOR MEDICAL STAFF (CONSULTANT AND SAS DOCTORS) STUDY LEAVE APPLICATION Note: Study Leave will ONLY be approved if it aligns to your Personal Development Plan, agreed at your Appraisal, and if your Mandatory Training is up to date. Please ensure that this Form is submitted at least 6 weeks before the intended leave. Retrospective applications will only be approved in exceptional circumstances Name: ------------------------------------------------------------------------------------------------------- Address: ------------------------------------------------------------------------------------------------------- Grade: --------------- Specialty: ------------------------------------------- PAs : ------------ Directorate: ---------------- Last appraisal date:--------------------------------- Details of Study Leave (give full details and attach a meeting outline or programme) Meeting or Course Title ----------------------------------------------------------------------------------------- Location ------------------------------------------------------------------------------------------------------------- Period of leave: From ________________to________________ No of days ______ Approved for CME: Yes/No/applied for (delete as appropriate) If Yes, how many Credits?------------------------------ Cover Arrangements for Leave Outpatient clinics cancelled? Y/ N /NA If N name of doctor covering ---------------------------- Please list cancellations Theatre lists cancelled? Y/ N /NA If N name of doctor covering -------------------------- Please list cancellations Other fixed sessions cancelled? Y/ N/ NA If N name of doctor covering ---------------------------- Please list cancellations Name of doctor covering emergencies or inpatients ------------------------------------------------------------ ______________________________________________________________________________ Is funding required? No (please forward to Clinical Director) Yes (please complete next section) Expenses requested NB Travel costs to destinations outside the UK will not be funded Registration, course fees etc Travel Air (economy/tourist) Train (second class) Car (public transport rate: miles Passenger miles Other (no taxis) Subsistence (meals etc day rate) Accommodation (append details) Other expenses (append details) Sponsorship: Please indicate if you are receiving any support or sponsorship, by whom and to cover what aspect of the costs Attachments 1. Copy of your PDP agreement If a new PDP requirement has emerged since your Appraisal please add this to your original Plan, signed by your Appraiser or Clinical Director. 2. Course outline or programme _________________________________________________________________________ Signatures and approval Applicant ------------------------------- Date ---------------------------------------- Clinical Director ----------------------- Date -----------------------------------------  I approve this study leave application (please forward to Medical HR. (Medical HR to send copy to finance where reimbursement of expenses is indicated) OR  I do not approve this study leave application (please forward to Medical Director) Comment: _______________________________________________________________________ Medical Director ----------------------- Date -----------------------------------------  I approve this study leave application (forward to Medical HR) OR  I do not approve this study leave application (return to originator) Comment:     APPENDIX A PAGE  PAGE 1 Author: Dr Christine Blanshard MEDICAL DIRECTOR DATE OF NEXT REVIEW: September 2018 Version: 2sTUDY LEAVE POLICY  5QRSjklr   ? _ c ! " # +  L M N O [ \ a e u Ϳꭠh6^>hKWh6^>h?}5 h6^>5h$(?h$(?hKW5 h/5 h$(?5 h\L5h/h?}5h?}hKWhKW56hKWh6^>56 hKW56 hI56 h?}5 hKW5h?}h,5h?}h?}55 RSkl  " # M N O   &dPgdKW$a$gd/    ! : Y Z v w x RlmNZ[\л hKW5h/hKW5hXhX5 hX5h/|5hXhAO7h|h h|h| h?}5hKWhKW5h?}h PheJyh6^>hKWh$(?? ! 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B S  ?H0(  H I Hf/ktSktktctktctZC[C\C]CPPg RRg9*urn:schemas-microsoft-com:office:smarttagsplace8*urn:schemas-microsoft-com:office:smarttagsCityB*urn:schemas-microsoft-com:office:smarttagscountry-region (,WXdg&L2X^k"_e3 8  D ;GWXdg33333333333333333333  !!""##$$%%&&''(())**++,,--..//00112233445566778899::;;klllF H I I D D X X RSWgllX X ,78SWXdg@=l 5 liIJA"./ 13c5/|5AO7j76^>$(?HA MzoNHWKW]XThQQlq+mztxeJyRHrR/$vkW5/,kE]|=T' P?}BjQDNn4x^-kka\LX j !{&J)PH_@5f@UnknownG.[x Times New Roman5Symbol3. .[x Arial5. .[`)TahomaC.,.{$ Calibri Light7..{$ CalibriA$BCambria Math"hxx/t /t !203q@P ?B2!xx%h SALISBURY NHS FOUNDATION TRUST Administrator/GERAGHTY, Mark (SALISBURY NHS FOUNDATION TRUST) Oh+'0 0< \ h t SALISBURY Ӱ FOUNDATION TRUSTAdministratorNormal0GERAGHTY, Mark (SALISBURY Ӱ FOUNDATION TRUST)2Microsoft Office Word@F#@tO@tO/t  ՜.+,D՜.+,\ hp  Ӱ Ӱ Trust SALISBURY Ӱ FOUNDATION TRUST Title([co_NewReviewCycleWinDIP File ID(5f74d3e4-13d9-43ff-ab41-774f3b5db7de  !"$%&'()*+,-./012345678:;<=>?@BCDEFGHKLORoot Entry FжtONData 1Table#*WordDocument 04SummaryInformation(9DocumentSummaryInformation8AMsoDataStoretOhtOM25GZ40IU4Q==2tOhtOItem  PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q