FORM E 20__

CLINICAL EXCELLENCE AWARDS SCHEME – OPTIONAL FORM TO ACCOMPANY NEW APPLICATION
 Supplementary  CV QUESTIONNAIRE for assessment of  TEACHING AND TRAINING 

	
Surname                                           Forename                                        Institution        

Courses or educational materials developed (Box limited to 1350 characters)
     
	
Developing teaching  skills in others (Box limited to 1350 characters)
     
	
Involvement in examinations or assessment (Box limited to 1350 characters)
     

Contribution to audit or quality assessment of teaching programmes (Box limited to 1350 characters)
     
	
Research into educational methods (Box limited to 1350 characters)
     

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

Full name                                                          Date       

THIS FORM MUST BE SUBMITTED AS A CONTINUATION SHEET OF THE APPLICATION - FORM A. IF IT IS SUBMITTED SEPARATELY IT WILL NOT BE ACCEPTED

Notes.

Give evidence to support your case, such as assessment by participants or awards gained.  

Personal Teaching
Specify to which groups you refer and give any detail of over and above achievements and evidence of their impact 

Courses or educational materials developed. 
Include here, for example, textbooks or chapters written, computer based teaching aids, remote learning initiatives.

Developing teaching skills in others.
Include here evidence of commitment to professional teaching such as educational qualifications gained and  ‘teach the teachers’ initiatives.

Please indicate as appropriate which of the professional groups your work relates to, eg, Medical Undergraduate, Medical Postgraduate, Consultant Peers, Clinical Researchers, Non-Clinical Researchers, Nurses, Other Health Professionals, and Patients and the Public.