Clinical Technologist Training Scheme supervisor application

Consent for storing submitted data *

Yes, I give permission to store and process my data

Accredited training Centre/Consortium name *

If accredited as part of a consortium, name all the participating Departments and Hospitals

Give the full address of the co-ordinating Department *

Subject areas accredited *

Nuclear Medicine

Radiotherapy Physics

Radiation Physics

Medical Engineering

Radiation Engineering

Rehabilitation Engineering

Proposed new supervisor details - Supervisors must be an IPEM Full Member or Fellow; OR registered on the RCT as a Clinical Technologist in a Medical Physics or Clinical Engineering role

First name *

Surname *

Date of birth *

Job title *

Department *

Hospital *

Telephone number *

Email address *

Staff/Job grade *

Relevant experience in SUBJECT AREA applying for and in a TRAINING *

How much time will you spend with trainees whilst they are working in your subject area? *

Number of other registered technologist or equivalent supporting this area. (At least 2 others are required) *

Qualifications

Relevant qualification 1 - Name *

Relevant qualification 1 - Where obtained *

Relevant qualification 1 - Date obtained *

Relevant qualification 2 - Name *

Relevant qualification 2 - Where obtained *

Relevant qualification 2 - When obtained *

Other relevant qualifications

List name, where obtained and date obtained

Employment history

	Post held	Employer	Dates
1.
2.
3.

Professional Membership/Registration details

IPEM membership grade (i.e. Full, Associate)
IPEM membership number
RCT registration number (CT number)

Supervisors for the training scheme must be an IPEM Fellow or Full Member working as a Clinical Technologist, or as a Clinical Scientist in a Medical Physics or Clinical Engineering role and familiar with the Technologist Training Scheme; OR registered on the RCT as a Clinical Technologist in a Medical Physics or Clinical Engineering role.

Training Coordinator details

Training Coordinator name *

Training Coordinator job title *

Training Coordinator department *

Training Coordinator hospital *

Training Coordinator address (including post code)

If different from address of the accredited training centre

Training Coordinator telephone number *

Training Coordinator email *

Training Coordinator statement of support for new supervisor *

If your Training Coordinator is not available to complete the statement above, add N/A in the box above and upload a previously prepared and signed statement from them here.

Declaration

I wish to apply to become a Supervisor to deliver the IPEM Clinical Technologist Training Scheme. I declare that the information I have given in this application is, to the best of my knowledge, accurate and true and that my Head of Department and Training Coordinator for my Centre/Consortium are in full support of my application. *

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