Coaching For Improvement 2023 – South East Leadership Academy

It is essential that applicants can make all the training days. Are you available to attend all 3 dates of this programme?

Yes

No

The dates are Module 1- 12.10.23 from 09:30am finishing at 16:15pm. Module 2-15.11.23 from 09:30am finishing at 16:15pm. Module 3-07.12.23 from 09:30am finishing at 16:15pm. The sessions are not standalone and you need to be available for all the dates to be considered for a place on this programme.

First Name*

Surname*

E-mail Address*

Please state what NHS Region you are from*

If you selected Other, please specify:*

Please select your job role from the list below:*

If you selected Other, please specify:*

What is your occupational group?*

What is your occupational group? (AHPs / Healthcare Scientists / Scientific and Technical)*

What is your occupational group? (Medical and Dental)*

What is your occupational group? (Ambulance/ operational)*

What is your occupational Group/ (Registered Nurses and Midwives)*

What is your occupational group? (Social Care)*

What is your occupational group? (Wider Healthcare Team)*

What is your occupational group? (Other, please specify)*

Do you work or is your primary role in the following area of care:*

Primary

Secondary

Voluntary, community and social enterprise (VCSE) sector care

I do not wish to disclose

Unknown

Do you have face-to-face contact with patients / service users are part of your day job?*

Yes, frequently

Yes, occasionally

No

For NHS and Social Care staff – please select your Agenda for change band*

If you selected Other, please specify:*

For non-NHS – please specify your organisation/career grading i.e. Administration/clerical, Management, Senior management, Board member, or Other/ Do not wish to disclose*

Organisation*

If you selected Other, please specify:*

Please select the ICS your organisation is in*

If you selected Other, please specify:*

What are your experience of managing change in the workplace?*

Thinking about your motivations, please identify one objective which you hope to achieve in attending this programme and why?*

I confirm that I have my line manager’s support to attend this event.*

Yes

No (your form will not be accepted)

Please provide your line manager’s email address:*

This session may be recorded. Please confirm that you are in agreement with this?*

Yes

No

This event is funded by the South East Leadership Academy (SELA). By completing and submitting this form:*

Yes, I agree to these terms and conditions

No, I do not agree to these terms and conditions (your form will not be accepted)

*I hereby give SELA consent to keep a record of my name, job role, organisation, band, telephone number and email address on their secure alumni register and contacts database for management information and communication purposes.
*I am fully committed to attend and participate in this event. If my application is successful, I realise the importance of attendance and completing any preparatory coursework (if applicable).
*I understand that if asked, I will participate in post-event follow up and evaluation.

If you are successful and accept your place on this event, we will share:
your application details, in line with information governance and data protection guidelines, with the event provider and/or facilitator to allow them to understand participant thinking and adapt the event accordingly if required. your email address with your cohort participants and may also share it with the members of other relevant SELA networks to aid communication, sharing of good practice and support.
Please see our Privacy Notice. You can opt-out of these arrangements at any point by contacting us at nhsi.selll@nhs.net

Important Notice – Cancellation Policy*

Yes, I agree to the cancellation policy

No, I do not agree to the cancellation policy (your form will not be accepted)

In order to demonstrate best value to patients, the NHS and taxpayers, we need to ensure maximum attendance on leadership development opportunities and events.
The South East Leadership Academy and your employing organisation will expect full attendance by employees who take up places.
As this event has been organised with an external provider, there will be a non-attendance charge to your employer/organisation should you secure a place and subsequently fail to meet any of these commitments. Workforce pressures are not a justifiable reason for failing to meet these commitments:
Please note: Funding of places on this event does not include backfill. [Primary Care only]
– where cancellation is made with less than 1-week’s notice
– non-attendance
– cancellation without a justifiable reason (extenuating circumstances are treated compassionately)
In these circumstances, we will contact you to ask you to arrange with your finance department a Purchase Order (PO) number to cover the cost of your place.

How did you hear about this development opportunity? Please select any that apply.*

If you selected Other, please specify:*

I would like to receive the Leadership Dispatch with information about current programmes and courses offered by the South East Leadership Academy.*

Yes

No

I already receive Leadership Dispatch

Would you be happy for us to contact you for further information?*

Yes

No

Coaching for Improvement Programme Form (1)