FORM F 20__

CLINICAL EXCELLENCE AWARDS SCHEME – OPTIONAL FORM TO ACCOMPANY NEW APPLICATION

Supplementary questionnaire for assessment of medical leadership and managing a high quality service by consultants in the NHS Clinical Excellence Awards Scheme 20__

	
Surname:     
     	Title: 	Address for correspondence:     
     
Telephone number:      		
Forenames:     
     				
Statement on overall contribution to medical leadership and management (1350 characters)
     
	
Statements for the following domains (1-6) can be completed in conjunction with attached guidance 
1. Statement demonstrating achievements “over and above” (not core contributions) in COMMUNICATION (900 characters)
     
	
2.  Statement demonstrating achievements “over and above” (not core contributions) in MANAGING AND DEVELOPING PEOPLE AND TEAMS (900 characters)
     	
3.  Statement demonstrating achievements “over and above” (not core contributions) in DEVELOPING THE SERVICE (900 characters)
     
	
4. Statement demonstrating achievements “over and above” (not core contributions) in DEVELOPING ONESELF (900 characters)
     
	
5. Statement demonstrating achievements “over and above” (not core contributions) in THE WIDER CONTEXT OF THE NHS (900 characters)
     	
6. Statement demonstrating achievements “over and above” (not core contributions) in QUALITY IMPROVEMENT (900 characters)
     
	
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: