Please complete and submit by midnight on 22/03/21.

For each answer, please provide dates wherever possible and avoid using acronyms unless the organisation is very well known (e.g. NHS). Full guidelines regarding criteria and how to fill in your application (including example answers) can be found on our website.

Question Title

* 1. These details will be removed from your application before it is sent to the assessment panel. Your application will be anonymous, but could be identifiable via any specific experiences you describe or reference to publications that you provide.
Please let us know your name, contact email and telephone number

Question Title

* 2. Degrees and other relevant professional qualifications

Question Title

* 3. Primary professional register

Question Title

* 4. Professional registration number

Question Title

* 5. Current role(s)

Question Title

* 6. Previous roles

Question Title

* 7. Please attach scanned copies of documents that confirm both your professional registration and qualifications

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

Question Title

* 8. If needed, please upload any further documents

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

Question Title

* 9. If needed, please upload any further document

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

Question Title

* 10. Please describe your clinical informatics experience in the workplace (including start and finish dates). [recommended maximum of 500 words]

Question Title

* 11. Please provide details of your leadership roles and/or recognition in the field of clinical informatics at a local, national, and international level. [recommended maximum of 500 words]

Question Title

* 12. Please describe your commitment to the advancement of clinical informatics as a professional discipline. This should include details of contributions that you have made both in your main role and/or any other projects you have worked on. [recommended maximum of 500 words]

Question Title

* 13. Declaration: I understand that if elected as an International Member I will be required to contribute an annual fee to the Faculty of Clinical Informatics. This is currently set at £102 per annum. Other pricing options are available based on income.

Question Title

* 14. Signed :

Question Title

* 15. Date:

Date
0 of 15 answered
 

T