POINTS AWARDED Where appropriate, please enclose certificates of attendance, registration receipts, meeting programmes, name tags, etc Section D: TEACHING COURSES OFFICE USE Date Name of Course Venue Length of Course Postgraduate or ONLY (in hours) Undergraduate? POINTS AWARDED TOTAL POINTS AWARDED IMPORTANT PLEASE RETURN THIS FORM BEFORE 1ST MAY – Declaration: I declare that the information provided in and/or attached to this report is accurate and true. I understand that if I knowingly provide false information this may result in disciplinary action and that I may be liable for prosecution and civil recovery proceedings. I consent to the disclosure of this information from this form for the purpose of verification and the investigation, prevention, detection and prosecution of fraud. Signed (Perfusionist) _________________________________________ Date ______________________ Signed _________________________________________ Date ______________________ (Dept’al Tutor) Signed (Head of Dept) _________________________________________ Date ______________________ Valerie Campbell, Administrator, of , Royal College of Surgeons, 35-43 ’s Inn Fields, London, WC2A 3PE, England Tel: 020 7869 6891 Email: admin@scps.org.uk
POINTS AWARDED Where appropriate, please enclose certificates of attendance, registration receipts, meeting programmes, name tags, etc Section D: TEACHING COURSES Date Name of Course Venue Length of Course (in hours) Postgraduate or Undergraduate? OFFICE USE ONLY POINTS AWARDED TOTAL POINTS AWARDED IMPORTANT – PLEASE RETURN THIS FORM BEFORE 1ST MAY Declaration: I declare that the information provided in and/or attached to this report is accurate and true. I understand that if I knowingly provide false information this may result in disciplinary action and that I may be liable for prosecution and civil recovery proceedings. I consent to the disclosure of this information from this form for the purpose of verification and the investigation, prevention, detection and prosecution of fraud. Signed (Perfusionist) _________________________________________ Date ______________________ Signed (Dept’al Tutor) _________________________________________ Date ______________________ Signed (Head of Dept) _________________________________________ Date ______________________ Valerie Campbell, Administrator, of , Royal College of Surgeons, 35-43 ’s Inn Fields, London, WC2A 3PE, England Tel: 020 7869 6891 Email: admin@scps.org.uk
Academic%20Activity%20report%20form.docx