FIRST TIME APPLICATION This form should be used by first time applicants to the UCD Clinical Pathway. Applicants are not required to propose an academic rank. This will be determined by the Review Panel. Please complete this form fully to ensure that the Review Panel has all relevant information on which to make a decision. Detailed curricula vitae, testimonies or personal references will not be considered. Please submit completed application form by email to the relevant Section Leader (see page 6) who will verify content and will submit to the Review Panel The Section Leader will keep you informed about the progress of your application and will provide feedback on the outcome.
PERSONAL & CONTACT DETAILS
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E-mail:	Click here to enter text.	* if applicable

ACADEMIC & PROFESSIONAL QUALIFICATIONS
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EMPLOYMENT SUMMARY
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HONOURS & AWARDS
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1. RESEARCH SCHOLARSHIP & INNOVATION Candidates will be assessed on the extent of national and international recognition as a leading clinical researcher and scholar in the chosen field.

Research Interests (Briefly list key research interests clearly distinguishing current research from previous activity)
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Current Research Team (Enter numbers not individual names)	Supervisory Experience (Enter numbers not individual names)
Level	Full-Time	Part-Time	Level	Ongoing	Completed
MSc Students	MSc Students
MD Students	MD Students
PhD Students	PhD Students
Post-Doctoral Fellow	Post-Doctoral Fellow
Other (Specify)	Other (Specify)
Total	Total

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Research Grants & Awards – Current Funding (If award was part of a collaboration, please indicate your relative contribution here*)
Date / Time Period	Amount (€)	Funding Agency	%Contribution*	UCD R-Account Ref.
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Research Grants & Awards – Recent Funding (5- 10 years) (If award was part of a collaboration, please indicate your relative contribution here *)
Date / Time Period	Amount (€)	Funding Agency	%Contribution*	UCD R-Account Ref.
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Publication Record – Summary
Time Period	Total No. of Publications	No. of Peer-Reviewed Publications
2010 – 2015
2005 – 2010
Prior to 2005
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Five Most Recent Publications (Please provide full publication details including PMID if possible)	PMID
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Five Most Significant Other Publications (Please provide full publication details including PMID if possible)	PMID
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Other Research Outputs (Briefly list other research outputs arising from your research e.g. patents, major licensing arrangements, NewCo., etc.)
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2. CLINICAL & ACADEMIC LEADERSHIP Candidates will be assessed on their competency within a clinical specialty, their commitment to excellence in patient care and their academic leadership within their chosen field. Please provide detail (where relevant) which demonstrates this clinical and academic leadership.

Clinical Appointment (Briefly describe qualification, registration and appointment showing extent of service, breadth of experience and clinical caseload)
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Clinical Training (Briefly describe internationally recognised and accredited training programmes (including CPD) completed post qualification as a clinician)
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Service Leadership (Briefly describe any appointments as a senior clinical leader, management of clinical programmes, departments or specialist service)
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Profession Leadership (List membership of internationally recognised professional organisations within area of clinical specialty. Document substantial contributions made to and/or election to key positions within national and international bodies and societies.)
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National Leadership List membership of government advisory bodies, committees of enquiry and international delegations relevant to clinical experience. Provide details of the organisation, hosting and chairing of nationally and internationally recognised academic and clinical conferences. Contribution to public awareness of clinical specialty through participation in media exchanges (press, radio, television, etc ).
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International Recognition (List invitations to deliver keynote lectures and addresses at national and international conferences. Describe invitations to serve as external examiner, clinical expert or visiting academic in academic or clinical centres of international repute.)
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3. TEACHING, LEARNING & ASSESSMENT Candidates will be expected to contribute strongly to the teaching, learning and assessment of undergraduate, postgraduate and CPD students. They will be expected to have shown sustained, high quality contribution to medical education and pedagogic research within area of clinical specialty.

UCD Teaching Experience (Briefly describe your contribution to teaching and clinical training within UCD undergraduate and postgraduate programmes.)
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UCD Examiner Experience (Briefly describe your contribution to examinations and assessments within UCD educational programmes.)
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Other Teaching Experience (Briefly describe your contribution to teaching or assessment within programmes delivered by institutions other than UCD.)
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Teaching Awards & Recognition (Evidence of your performance as a teacher through awards and/or peer review recognition of teaching excellence.)
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Educational Leadership (Briefly describe your role in the development of new programmes, improvement in existing programmes, and authoring of textbooks, computer-based or other education resources.)
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Submission of Application

Please submit completed application form by email to the relevant Section Leader (see page 6) who will verify content and will submit to the Review Panel. The Section Leader will keep you informed about the progress of your application and will provide feedback on the outcome.

APPLICATION VERIFICATION and STATEMENT OF SUPPORT

All applicants are required to submit their application form to the relevant Academic Section Leader for verification of the information presented. Candidates are advised to engage early with their Section Leader as these individuals are familiar with the review process and will be able to offer helpful advice.

Section Leaders are required to verify the information presented above and provide a short statement of support. It is not necessary to re-iterate information presented by the candidate. Section Leaders may be required to defend their statement of support with additional evidence if requested by the Review Panel.

All academic and adjunct staff within the School are appointed to one of six academic sections. These Sections integrate across multiple clinical sites. Your Section Leader may not be based at your clinical site

Current Academic Sections and Section Leaders are:

Academic Section	Section Leader	Email Contact
Biomedical Sciences	Prof Paul McLoughlin	paul.mcloughlin@ucd.ie
General Practice and Forensic & Legal Medicine	Prof Denis Cusack	denis.cusack@ucd.ie
Radiography & Diagnostic Imaging	Dr Louise Rainford	louise.rainford@ucd.ie
Medicine & Medical Specialties	Prof Michael Keane	michael.p.keane@ucd.ie
Surgery & Surgical Specialties	Prof Ronan O’Connell	ronan.oconnell@ucd.ie
Women’s & Children’s Health	Prof Fionnuala McAuliffe	fionnuala.mcauliffe@ucd.ie

Comment by Section Leader Please provide any relevant context or background information on the contribution of the applicant to academic or clinical activities in the domains of:
Research, Scholarship & Innovation
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Clinical & Academic Leadership
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Teaching, Learning & Assessment
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Summary Relative strength of contribution in each area.
Research, Scholarship & Innovation Modest ☐ Normal ☐ Strong ☐ Very Strong ☐
Clinical & Academic Leadership Modest ☐ Normal ☐ Strong ☐ Very Strong ☐
Teaching, Learning & Assessment Modest ☐ Normal ☐ Strong ☐ Very Strong ☐

I verify that the information provided above by the applicant is, to the best of my knowledge, correct. I support this application and will be willing to provide any further information required by the Review Panel.

Name: Click here to enter text.
Title: Click here to enter text.