Clinical Supervisor Application Form - School of Clinical Medicine

All the data collected will only be used for the purposes of staff development and reviewing the programme. The data complies with all of Cambridge University's data protection policies (https://www.information-compliance.admin.cam.ac.uk/data-protection/general-data).
Terms of Service*
You must check the eligibility and guidelines and confirm that you are eligible to apply for this post
I have read the Clinical Supervisor Guidelines and confirm that I am eligible to apply
- I agree to the Terms of Service
Terms of Service*
I confirm that once I start the role I will commit to undertake the role for a minimum period of 6 months.
- I agree to the Terms of Service
My current hospital location is*
Please choose from the drop-down menu your current hospital location
I will be available to provide supervisions from*
Please choose from the drop-down menu your current hospital location
I will be available to take this position from*
DD slash MM slash YYYY
Terms of Service
I have watched the Recruitment Video before making this application
- I agree to the Terms of Service
Paediatric*
Please choose one from below
- Paediatric
- Non-Paediatric
As you are in Paediatrics at Addenbrookes Hospital please ensure you have chosen 'Addenbrookes Paediatric Department' to the question 'My hospital location from August 2019 will be'. Your application will then go straight to the Addenbrookes Paediatrics Department. They have their own clinical supervisor (undergraduate) processes and they will be able to appoint you to an appropriate group.
I will have a contract with the hospital for 2023-24*
- Yes
- No
I will be at the hospital above until this date*
DD slash MM slash YYYY
If you do not have a contract with Addenbrookes, an Honorary Contract will be required for you to undertake bedside teaching within the hospital. YOU CAN STILL MAKE THIS APPLICATION BUT PLEASE NOTE THAT IT IS YOUR RESPONSIBILITY TO ENSURE THAT YOUR HONORARY CONTRACT IS IN PLACE BEFORE STARTING ANY BEDSIDE TEACHING. IT TAKES 6 WEEKS TO BE PROCESSED FROM WHEN YOU SUBMIT YOUR HONORARY CONTRACT FORM TO ADDENBROOKES MEDICAL STAFFING. Please contact medical.staffing@addenbrookes.nhs.uk for more information and an application form.
If your specialty is Paediatrics we need to know as Paediatric Clinical Supervisor applications are processed directly by the Paediatric Department at Addenbrookes.
Title*
(Miss/Mr/Mrs/Dr)
First name*
(Miss/Mr/Mrs/Dr)
Last name*
(Miss/Mr/Mrs/Dr)
Date of Birth*
DD slash MM slash YYYY
Address*
Street Address Address Line 2 City ZIP / Postal Code
Mobile telephone number*
The WhatsApp group is a group run by the Senior Clinical Supervisors. They are experienced supervisors who can help clinical supervisors with questions and advice. You can opt in at any time by contacting clinicalsupervisors@medschl.cam.ac.uk
WhatsApp group*
- I want to be added to the WhatsApp group
Email*
If you have an CRSid you will have a University of Cambridge e-mail address also known as a Raven login. Please use this e-mail address for correspondence as this will also be your login for Moodle and for CamCORS (if you are Cambridge-based). Please note that if you are Cambridge-based we will use your Raven e-mail address (@cam.ac.uk) for all correspondence about your clinical supervisor role. If you do not yet have a Raven account and you are Cambridge-based, you will be allocated one. Regional and Paediatric applicants - please use the e-mail address you check most frequently.
Enter Email Confirm Email
CRSid
It is important that you tell us if you already have a CRSid. For example, if you have been a Cambridge clinical supervisor previously or if you have studied at University of Cambridge (even on a short course) you may have been allocated one. If you can remember it (even vaguely) please put it here so that we can avoid creating a duplicate record for you. It will be in the format of your initials and then some numbers e.g. ab123. If you have a live and in use CRSid you will be able to log in to CamCORS using your CRSid and your Raven password.
I DO NOT have a CRSid (Raven login). Please tick the box below so that (should it be required) we can request a Raven login for you
- I DO NOT have a CRSid or Raven login. Please request one for me once I am appointed to the role
Current Post*
Clinically or Research based*
- Clinically based
- Research based
Medical School attended*
Qualification*
Date Qualified*
DD slash MM slash YYYY
GMC Registration Number*
I confirm that I am in good standing with the GMC*
- Yes
Do you have any affiliation with a Cambridge College
- Yes
- No
The Cambridge College(s) I have an affiliation with are:
Choose from the list below
Hold down CTRL key to select more than one college
I would prefer a*
- Year 4 group
- Year 5 group
- Year 6 group
- CGC/MBPhd group
- I am happy to be allocated to any year group
Please let us know here about anything else you would like to be taken into account for your application such as any teaching training you have undertaken or any teaching or mentoring experience you have that may be useful for this role. PLEASE ONLY LET US KNOW ABOUT ACTUAL COURSES UNDERTAKEN, NOT COURSES THAT YOU ARE INTERESTED IN TAKING. PLEASE VISIT THE IFME PAGES FOR DETAILS OF THIS PROGRAMME WHICH MUST BE APPLIED FOR SEPARATELY.
Notes
Date
MM slash DD slash YYYY

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