FMLM Five yearly Fellowship Declaration About you Name Prefix * - Select -DrProfMrMrsMissMsAir CommodoreAir Vice-MarshalBaronessBrigadierColonelDameGroup CaptainLieutenant ColonelMajor GeneralProf ColonelProf DameProf SirSirSurgeon CaptainSurgeon CommanderSurgeon CommodoreWing CommanderMxAir MarshallSurgeon Vice AdmiralVice AdmiralSisterLordNurse First Name * Last Name * Phone Number * Email * Street Address * Street Address Line 2 City * Postal Code * Country * United KingdomAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo, Republic Of TheCongo, The Democratic Republic of theCook IslandsCosta RicaCôte d’IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Job Title * Medical career stage * - Select -Medical studentDental studentFoundation year 1 or 2Doctor in trainingConsultant (CCT/CESR)GPDentist in Primary CareDentist in secondary-careMedical ManagerOtherPharmacy studentRetiredStaff and associate specialist doctor Medical career stage - other Non medical career stage - None -Clinical scientistTrainee public health specialistQualified public health specialistOther Non medical career stage - other Doctor in training grade - None -Foundation Year 2Core/Specialty Trainee 1Core/Specialty Trainee 2Core/Specialty Trainee 3Specialty Trainee 4Specialty Trainee 5Specialty Trainee 6Specialty Trainee 7Other Doctor in training grade (other) Expected CCT date Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030 Specialty * - Select -Acute Internal MedicineAllergyAnaestheticsAudiological MedicineAudio Vestibular MedicineCardiologyCardiothoracic SurgeryChemical PathologyChild and Adolescent PsychiatryClinical GeneticsClinical ImmunologyClinical NeurophysiologyClinical OncologyClinical Pharmacology and TherapeuticsClinical RadiologyCommunity Sexual & Reproductive HealthDental SurgeryDermatologyDiagnostic NeuropathologyEmergency MedicineEndocrinology and Diabetes MellitusForensic HistopathologyForensic PsychiatryGastroenterologyGeneral (Internal) MedicineGeneral PracticeGeneral PsychiatryGeneral SurgeryGenito-urinary MedicineGeriatric MedicineHaematologyHistopathologyImmunologyInfectious DiseasesIntensive Care MedicineMedical MicrobiologyMedical Microbiology and VirologyMedical OncologyMedical OphthalmologyMedical PsychotherapyMedical VirologyNeurologyNeurosurgeryNot applicableNuclear MedicineObstetrics and GynaecologyOccupational MedicineOld Age PsychiatryOphthalmologyOral and Maxillofacial SurgeryOtherOtolaryngologyPaediatric and Perinatal PathologyPaediatric CardiologyPaediatric Emergency MedicinePaediatricsPaediatric SurgeryPalliative MedicinePharmaceutical MedicinePlastic SurgeryPsychiatryPsychiatry of Learning DisabilityPsychotherapyPublic Health MedicineRehabilitation MedicineRenal MedicineRespiratory MedicineRheumatologySport and Exercise MedicineStroke MedicineTrauma and Orthopaedic SurgeryTropical MedicineUrologyVascular Surgery Specialty - other If not listed above, enter your primary specialty or other specialties Geographical region * - Select -England - East of EnglandEngland - LondonEngland - MidlandsEngland - North East & YorkshireEngland - North WestEngland - South WestEngland - South EastNorthern IrelandScotlandWalesOverseasOtherArmed Forces Registration status Do you continue to hold a licence to practice with the GMC/GDC? * - Select -YesNo Please provide full details relating to the circumstances of no longer holding a licence? Are you currently in ‘good standing’ with the GMC/GDC? * Good standing refers to any restriction(s) on a doctor or dentists practice in the UK, or any restrictions which are no longer active that might be at odds with the aims and values of FMLM. - Select -YesNo Please provide full details FMLM may request further information from you. If Retired: Were you in ‘good standing’ with the GMC/GDC at the point of retirement? - None -YesNo Have you been subject to any organisational disciplinary procedure, formal or otherwise within the last five years?? * - Select -YesNo Please provide further details All information shared with FMLM will remain confidential and are only accessible to authorised FMLM staff and representatives involved in the assessment of declarations. Have you been subject to a criminal conviction or caution whether successful or unsuccessful within the last five years? * - Select -YesNo Please provide further details All information shared with FMLM will remain confidential and are only accessible to authorised FMLM staff and representatives involved in the assessment of declarations. Have you been subject to any formal investigations or decisions (including restrictions, suspensions or licence revoked) overseen by the GMC or GDC within the past five years? * - Select -YesNo Please provide further details All information shared with FMLM will remain confidential and are only accessible to authorised FMLM staff and representatives involved in the assessment of declarations. Professional activities within the last five yearsThis section relates to activities undertaken during the last five years since you have held fellowship of FMLM Date of last revalidation * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year2014201520162017201820192020202120222023202420252026 Date of last appraisal * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year2014201520162017201820192020202120222023202420252026 Any gaps in annual appraisal within the past five years * - Select -YesNo What was the reason for deferral? Please include any mandatory deferrals due to COVID-19. Do you continue to meet the required level of continuous professional development for your role? * - Select -YesNo How much of your practice is undertaken in the UK? * - Select -I only practise in the UKMost of my practice is in the UKMost of my practice is outside the UKI only practice outside the UK On average, what percentage of your role is leadership and management (non-clinical)? * Please list any training or development programmes in leadership and management you have undertaken within the last five years? * Please list any key achievements and awards in leadership and management gained in the past five years * Please share any other points of note, or feedback for FMLM Associate Fellows/Fellows ONLY - Are you considering applying to Fellowship/Senior Fellowship in the next 12 months? - None -YesNo Why not? Declaration I confirm that the information presented in this declaration is correct to the best of my knowledge and I remain committed to upholding the standards and values of FMLM * I hereby confirm this submission is correct to the best of my knowledge