Florence Nightingale Foundation and HEE Education Scholarship and Fellowship Application Form

Part 1 - Personal details

Scholarship/Fellowship Applying For

Your Name

Title

First Name

Last Name

Professional Registration

Professional Registration Number (NMC, HCPC, GOsC)

Professional registration

Year Qualified

Professional Registration Document

Home Postal Address

Street Address

Town/City

Postcode

Country

Personal Details

Personal Email

Personal Mobile

Date of Birth

DD/MM/YYYY

Twitter Handle

Linkedin Profile

Professional and Higher Education - click 'Add another response' to add multiple

Qualification

Institution Name

Institution City

Institution Country


Date Commenced	Month Year
Date Completed	Month Year

Major field of study

Emergency Contact Details

Emergency Contact Name

Relationship to you

Emergency Contact Phone

Emergency Contact Mobile

Special Requirements

Do you have a disability?

Please provide details

How did you hear about our scholarships?

How did you hear about us?

Please specify

Part 2 - Employment details

Job Title

Full job title

Please write in full without abbreviations

NHS pay band/grade or equivalent seniority

If you are not employed by the NHS please input the band that your salary equates to

Employing Organisation Details

Employing Organisation (Hospitals)

Employing Organisation (if other)

Please write in full without abbreviations (e.g. GSTT)

NHS Trust/CCG/ICS/STP Team

NHS Trust/CCG/Area Team (if other)

Please write in full without abbreviations (e.g. GSTT)

Work Street Address

Work Town/City

Postcode

Work location by NHS Region or equivalent

Work Country

Work Contact Details

Work Phone

Work Mobile

Work Email

Part 3 - Supporting information

Nominator Details - Chief Nurse/ Director of Nursing/ and/or Chief AHPS

First Name

Last Name

Work Email

Work Phone

Nominator Details - Key Line Manager

First Name

Last Name

Work Email

Work Phone

Organisation Information

Please specify the sector of your NHS Provider/Commissioners

Please specify

The size of your organisation's workforce

Part 4 - Personal leadership

Briefly outline your current role, highlighting any specific operational and strategic responsibilities

Tell us about your role and your team

Briefly describe the leadership responsibilities involved in your role and identify any strategic responsibilities. Include information on the nature of your team including areas such as the number of people you currently lead and the budget that you manage.

Discuss the key features of your approach to leadership

Give examples of how you have applied your approach to leadership in practice and the impact this has had on outcomes.

What are your personal goals and leadership aspirations?
Identify your short, medium and long term goals over the next five years. Outline what outcomes you hope to influence and how will you know if you have made that impact.

How will an FNF Scholarship/Fellowship specifically enable you to achieve these goals and have that impact?

Consider the difference the FNF scholarship will make to you, people who use health and social care services, the general public, policy makers, colleagues and senior leaders.

Our definition of education improvement draws on broader definitions of healthcare improvement. It includes the use of evidence and systematic approaches that build and embed knowledge within systems to improve practice learning capacity and quality. This academic field draws on a range of disciplines (e.g. psychology and behaviour change) in combination with the insights of those engaging with practice learning. It has a strong translational component – with those who research, manage, provide and access practice education working together to create impact.

If you are applying for a Fellowship please tell us what your clinical education improvement project would focus on and the anticipated outcomes/benefits. If you are applying for a Learning Environment Improvement Scholarship: Please propose a quality improvement project which will:

1. Increase placement capacity whilst maintaining quality

2. Support providers to focus on quality improvement, reducing unwarranted variation and adopt innovation 3. Support workforce transformation through improving the learning environment.

You should show evidence of how this builds on good practice and has been discussed with key stakeholders within your system

Please indicate which HEI you would like to build links with to support your ongoing clinical academic career, and why.

How did you hear about this opportunity?

Part 5 - Programme administration

In order to stimulate the networking process for participants, we ask that you send us a short biography

Please note: Biographies and answers will be edited for consistency and style. Include information on your current and previous roles and interests. Write in the third person. Clarify any abbreviations used.

Upload headshot

Headshot instructions: head and shoulders only. This photo will be used for your records and will accompany your biography where appropriate.

Part 6 - Diversity form

We are keen to develop diversity in all areas. By completing this form you are helping us to build a picture of those applying and attending our programmes. The information collected is stored in our database and not shared with any third parties. Your responses to this section will not be visible to decision makers during the application process.

Nationality

Ethnicity

Gender

Part 7 - Nominator references and signature

We require information from a nominator.

Please download the nominator form which is to be filled in by your Chief Nurse or Director of Nursing and your immediate line manager.

Please rename your nominator form prior to upload to include the applicant's NMC registration number and name e.g. 'Nominator form - John Smith 12345'

Please note forms are to be filled out electronically. Hand-written submissions will not be accepted.

Chief Nurse/ Chief AHP or Director Nominator form

Line Manager Nominator form

Part 8 - Terms and conditions

Florence Nightingale Foundation Scholarship Application Agreement

Please complete and confirm this is your intention to apply for a scholarship by

ticking and signing this Scholarship Application Agreement.

Failure to complete this agreement in time will result in presumption you do not wish

to apply for a Florence Nightingale Scholarship or no longer require a place on the

leadership programme.

By signing this page I acknowledge and agree to the following terms and conditions:

All applications submitted for the selection process must be accompanied by this completed application form and 2 completed nominator forms signed by my Chief Nurse or Director of Nursing and my line manager giving approval for the release of time to attend all programme dates.
All dates are mandatory. By applying for a place on this scholarship programme I commit to attend all programme days. I agree to partake fully and engage with the programme in its entirety, acknowledging the dates provided are compulsory.
I understand I will be notified of the result of my application 20 working days after the application closing date.
I will become a member of the Florence Nightingale Foundation Alumni Community on completion of the scholarship and will support future, current and past scholars within my area of expertise.
I give permission for my details to be passed to the Florence Nightingale Foundation subcommittees as requested.
If I have a period of sickness or any event that may impact on my ability to attend the Interview I will inform the Foundation as soon as possible to negotiate a new arrangement (subject to availability of dates)
I understand Florence Nightingale Foundation holds all participants' application details in confidence and in line with the requirements of the Data Protection Act 1998 to ensure GDPR compliance.
I give my consent for information and/or images/photographs ("Information") about myself to appear in associated publications from the Foundation.

GDPR* Data Management Statement

We would like to keep in touch with you about the vital work we do at the Foundation

including events and newsletters and we would like you to engage with other

scholars.

We will never sell your data and we promise to keep your details safe and secure.

You can change your mind at any time by emailing admin@florence-nightingale-

foundation.org.uk

'We’ includes the Florence Nightingale Foundation only.

Please tick the boxes below to tell us all the ways you would prefer to hear from us

Yes please, I would like to receive communications by emailYes please, I would like to receive communications by postYes please, I would like to receive communications by phoneI agree for my details and data to be stored and maintained on Salesforce, a secure platform used by the Florence Nightingale Foundation.No thank you, I do not wish to receive communications from the Florence Nightingale Foundation

* GDPR: means (i) unless and until the GDPR is no longer directly applicable in the

UK, the General Data Protection Regulation, Regulation 2016/679/EU, and any

national implementing laws, regulations and secondary legislation, as amended or

updated from time to time, in the UK and then (ii) any successor legislation to the

GDPR or the Data Protection Act 1998.

Please read our privacy policy here on how we manage our data.

Cancellation policy

As a not-for-profit organisation it is crucial that Florence Nightingale Foundation

recover any programme costs in the event of a participant cancellation. Therefore, by

accepting a place on this programme I will commit to attend all programme days.

Agree Terms and conditions

I agree to all the above terms and conditions and I consent to my data being shared

with carefully selected parties as part of the application process.