HEEoE TRAINEE STUDY LEAVE APPLICATION FORM
This form is to be completed and authorised according to the HEEoE Study Leave Policy & Guidelines
which can be downloaded from the PGME Website: https://nanime.nnuh.nhs.uk/induction/
Trainee to:
1. Discuss your request with your Educational Supervisor and departmental rota coordinator
2. Open PDF form and select ‘Fill & Sign’. Complete all Yellow areas of the form (Sections A-D)
3. Save your form and email to your Educational/Clinical Supervisor for approval (Section E).
Please give six weeks’ notice for study leave. Retrospective applications cannot be accepted.
Authoriser to: Complete all Green areas (Section E) and email to [email protected]
A. APPLICANT DETAILS
Full Name: GMC/GDC Number:
Grade: Trust Contract Start Date:
Specialty: Trust Contract End Date:
Email Address: Full Time/Part Time:
Payroll Number: %WTE if Part Time:
B. PERIOD OF LEAVE REQUESTED
Date of event: From: To:
Actual no. of days leave taken:
Event Title & Organiser:
Event location & postcode:
Purpose of Leave: Course ☐ Exam ☐ Exam Course ☐ Conference ☐ Private Study ☐
C. EXPENSE DETAILS
You must submit a TPD approved HEE Additional Funding Request Form alongside this NNUH Study Leave Application Form
for all Aspirational Activity and all applications in excess of £600.00.
Full details can be found on the HEEoE website: Study Leave Homepage | East of England (hee.nhs.uk)
Mode of Transport Estimated Costs
Car (56p per mile) ☐ Course Fee:
Train ☐ Travel:
Bus/Coach ☐ Accommodation:
Air ☐ Subsistence: Total:
D. APPLICANT DECLARATION
☐ I confirm I have liaised with my rota-coordinator and it has been agreed that cover is/will be arranged
☐ I confirm the benefits of this study leave have been discussed with my supervisor
Signature of Applicant: Date:
E. AUTHORISATION
☐ I regard this application relevant for continuing professional development
☐ I regard this course/activity as beneficial to the individual/Trust
☐ I confirm that I approve leave in respect of the above individual for the dates specified
Signature of Approver: Date:
PGME ADMINISTRATOR USE ONLY
Amount of funding approved:
Authorised Signature: Date:
Comments:
