FORM D 20__

CLINICAL EXCELLENCE AWARDS SCHEME – OPTIONAL FORM TO ACCOMPANY NEW APPLICATION
Supplementary CV QUESTIONNAIRE for assessment of RESEARCH and INNOVATION by consultants in the NHS Clinical Excellence Awards Scheme 20__
	
Surname:
     	Title:
(Prof/Mr/Dr/
Miss)

     	Address for correspondence:
     

Telephone Number:
     
		
Forename(s):
     				
Statement setting out the relevance of your work to the needs of the NHS and its potential impact.  Indicate collaborations where appropriate. (Box limited to 1350 characters).
     	

Lists of grants obtained in the last five years for which you were/remain the lead or co-applicant (please specify) indicating date of grant, granting body, amount and duration. (Box limited to 1350 characters).
     	

Description of other leadership roles in research, eg officer of learned society, invited lectures, visiting professorships, local, national or international posts held in relation to medical science, indicating what has been achieved (Box limited to 1350 characters).
     	
Contribution to research through training of others such as PhD, MD, MSC or MPhil students; indicate whether lead or co-supervisor (Box limited to 1350 characters).
     	

The full citation of 10 most significant peer-reviewed original research publications::
     	

Full citation of up to 5 other publications such as reviews and text books:
     	
I declare that to the best of my belief, this information is accurate and I am not aware of any disciplinary or professional conduct and performance issues against me.

Name:                                                                 Date: