APPLICATION FORM FOR CURRICULUM/EXAMINATION LEAVE FOR TRAINEES IN HEALTH EDUCATION ENGLAND, ACROSS YORKSHIRE AND THE HUMBER APPLICATION FORM SHOULD BE USED UNLESS YOU ARE INSTRUCTED TO USE A LOCAL FORM IN YOUR LEP PLEASE CONSULT THE CURRICULUM DELIVERY GUIDANCE BEFORE COMPLETING http://www.yorksandhumberdeanery.nhs.uk/pgmde/policies/curriculum_delivery/ PART A STUDY LEAVE DETAILS – Surname: Forenames: Current Employer: Your Address: E-mail: Tel No: Specialty: Acute Medicine GMC: Main Hospital: Department: Post at time of leave if different from above: Leave requested for Professional Development Exam Leave Exam Preparation Other Dates (inclusive of travel) From: To: No of days: Title of course/conference/study day: Location: Exam details: Date of Exam: Number of previous attempts at this exam: Dates taken: The following colleagues have agreed to cover my duties: Name (print): Signed: Name (print) Signed: Residential Costs Travel Other EXPENSES Course Fee Subsistence No of Road Rail (Please specify) Nights ………  Estimated: £ £ £ £ £ Approved: £ £ £ £ £ Signed (Applicant): Date:
APPLICATION FORM FOR CURRICULUM/EXAMINATION LEAVE FOR TRAINEES IN HEALTH EDUCATION ENGLAND, ACROSS YORKSHIRE AND THE HUMBER APPLICATION FORM SHOULD BE USED UNLESS YOU ARE INSTRUCTED TO USE A LOCAL FORM IN YOUR LEP PLEASE CONSULT THE CURRICULUM DELIVERY GUIDANCE BEFORE COMPLETING http://www.yorksandhumberdeanery.nhs.uk/pgmde/policies/curriculum_delivery/ PART A – STUDY LEAVE DETAILS Surname: Forenames: Your Address: Current Employer: E-mail: Tel No: Specialty: Acute Medicine Main Hospital: Post at time of leave if different from above: Department: GMC: Leave requested for Professional Development Exam Leave Exam Preparation Other Dates (inclusive of travel) From: To: No of days: Title of course/conference/study day: Location: Exam details: Date of Exam: Number of previous attempts at this exam: Dates taken: The following colleagues have agreed to cover my duties: Name (print): Signed: Name (print) Signed: EXPENSES Course Fee Residential Costs No of Nights ……… Travel Road  Rail Subsistence Other (Please specify) Estimated: £ £ £ £ £ Approved: £ £ £ £ £ Signed (Applicant): Date:
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