CASC Examiner Application Form

Please complete this form by 2 March.

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* 1. If shortlisted, you will be required to attend a Training and Assessment Day on one of the following dates: 14 May (Manchester), 18 May (London), 20 May (London). Are you available?

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* 2. Forename

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* 3. Surname

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* 4. Date of birth

Date

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* 5. Sex

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* 6. Ethnicity

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* 7. Email address

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* 8. Correspondence address

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* 9. RCPsych number

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* 10. GMC number

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* 11. Membership status

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* 12. Year membership started

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* 13. Degrees and qualifications (include year of graduation)

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* 14. Job title

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* 15. Present employer

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* 16. Date of appointment

Date

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* 17. If present employment is less than 3 years, please enter previous employment details. What was your previous job title?

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* 18. Previous employer

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* 19. Dates of appointment (from-to)

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* 20. Do you hold (or have recently held) any of the following educational roles? (please select all that apply)

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* 21. Please outline your expertise and experience in Medical Education, including your current roles and responsibilities and time served where appropriate. Examples include clinical and educational supervision, teaching (postgraduate and undergraduate) educational CPD (conferences, supervisor training) and postgraduate qualifications in medical education.

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* 22. Please outline your expertise and experience in examinations (including medical school). e.g. item writing, examiner training, participating in mock exams.

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* 23. Are you subject to any complaint, investigation, disciplinary or professional proceedings?

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* 24. If yes please give details

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* 25. If successful you will be required to examine in the next CASC exam (15-18 September, 21-23 September). Are you available?

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* 26. I declare that to the best of my belief the information provided by me on this form is accurate. I understand that the information given in this form may be provided to members of the Examinations Sub-Committee of the Royal College of Psychiatrists, in strictest confidence, for the purpose of appointing to the Board of Examiners. I consent to the College processing the information I have provided, by any means, and its use as described for the purpose of appointing to the Board of Examiners.

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