ACCEA FORM A  (Application Form)                                                                                                                             20__  Round    
CLINICAL EXCELLENCE AWARDS SCHEME – APPLICATION FORM 
	
It is the consultant’s responsibility to ensure that this form is fully completed – all boxes to be completed
Part 1 to be completed by the applicant
Surname:
     	Forename:
     	Professional Title:
     	Application type:
	Level applying for:
	
Employer(s) name(s) with number of sessions per employer
(Lead NHS employer first)
     
	List of consultant appointments in date order
     	Accredited Specialties (main first)
     
	
		Year appointed to the consultant grade
     	
		Primary Medical Qualification (Date and Institution)
     

Subsequent Qualifications
(Date and Institution)
     	
Current level

Year awarded
     			
Ethnic origin

		Preferred address for correspondence
     

	
GMC/GDC Reg No.
     	Work tel (Direct Line)
     	Email
     
		
You cannot fill this form out without using the Guide to the Scheme, to which you must adhere strictly

PERSONAL STATEMENT
Give up to four examples that summarise your achievements.  These should be since your last award. (Box limited to 1350 characters).
     
	
JOB PLAN
List total number of agreed programmed or other activities relevant to the NHS and any academic / university programmed activities.  Please itemise the number of remunerated direct clinical care PAs, the number of remunerated supporting PAs (SPAs), and the number of other remunerated sessions / PAs for activities described in this application with a description of what these are. Also list unremunerated activities. 

If you receive any income from wider roles that may be relevant to the evidence provided in your application, please provide details here. For example, this may include editorial payments, roles or shareholdings in private companies (e.g. non-executive roles or senior positions in spin off companies between academia/Trusts and the private sector), consultancy fees or lecture fees. (Box limited to1800 characters).
     

	
Domains

If you are applying for levels 1-9 you can include additional information for Domain 3 OR Domain 4 OR Domain 5.  
Please provide additional information for one domain only. 

DOMAIN 1: DELIVERING A HIGH QUALITY SERVICE (see Guide)  (Box limited to 1350 characters).
     

DOMAIN 2: DEVELOPING A HIGH QUALITY SERVICE (see Guide)  (Box limited to 1350 characters)
     

DOMAIN 3: MANAGING AND LEADING A HIGH QUALITY SERVICE (see Guide) (Box limited to 1350 characters)
If a candidate at any national level completes form F to illustrate their leadership and management achievement it is not necessary to fill in domain 3; simply enter “see form F”.
     

DOMAIN 4: CONTRIBUTING TO THE NHS THROUGH RESEARCH AND INNOVATION (see Guide)  (Box limited to 1350 characters)

If a candidate at any national level completes form D to illustrate their research achievement it is not necessary to fill in domain 4; simply enter “see form D”.
     

Within the last 5 years, indicate how many publications you have had, how many of these were in peer reviewed journals and list the 3 most important ones. No other text is allowed. (Text limit 1350 characters)

     	

DOMAIN 5: CONTRIBUTING TO THE NHS THROUGH TEACHING AND TRAINING (see Guide)
(Box limited to 1350 characters)
If a candidate at any national level completes form E to illustrate their teaching and training achievement it is not necessary to fill in domain 5; simply enter “see form E”.
     	
Verification of Completion

I declare that to the best of my belief this information is accurate.

Full Name

Signature :    
	
     

(The applicant needs to print a hard copy, which needs to be signed and retained.)