What's on the Application Form
The registration form is split into 11 pages. Online each page is displayed separately and you can tab between pages to complete them in any order.
Below is a summary of the questions on the form with brief notes about each section. Mandatory questions are marked *. (For full details see the guidance notes.)
*Personal Information
· Title
· Surname or Family name
· Forename(s) or First name(s)
· Name in which qualification(s) where granted if different from your present name
· Address
· Contact Tel
· Mobile
· Email
· Have you made a previous application to register with UKCHIP?
· If yes, when?
· If you were previously registered, please give your registration number
*Qualifications
You should enter details of your highest or most relevant qualification. Level 2 or 3 applications require you to claim points for the qualification (see guidance notes for details.) You can enter more than one qualification if you would like them to be taken into account e.g. if you have separate qualifications in health and informatics.
- School / University/ College / Other
- Qualification Obtained & Major Subject(s)
- Grade / Class
- Equivalent NQ level
- Full / Part Time
- Date from
- Date to
- Points claimed
*Current Employment
Give details of your current or most recent post.
- Employing Organisation
- Department
- Organisation
- Address
- Telephone
- Job Title / Role
- Responsibilities
- When did you start in this role?
- I have been in my current job for at least 10 years? Y/N
- Please give the job title of the person you are directly responsible to
- Please give the number and types of job roles of the people you are responsible for
Current Employment points claimed
Level 2 and 3 applicants allocate themselves points according to their assessment of their current post. (See guidance notes)
Points claimed for Autonomy, Responsibility and Authority
Points for Influence
Points for Job Complexity
Points for Personal Skills
*Employment Experience
You should give details of any previous posts you have held over the last 10 years only. These details can be brief as we will come back to you if we require clarification. However you should highlight all HI experience.
For each post:
- Job Title / Role
- Name of Employing Organisation
- Responsibilities
- Start Date
- Finish Date
Previous experience points
Level 2 and 3 applicants allocate themselves points for their experience in health and informatics (include current and previous posts)
· You claim 5 points for each complete year in either health or informatics
· Years in health informatics can be counted in both the health and informatics totals
· Level 2 registrants can claim a maximum of 25 points (5 years) for health and 25 points (5 years) for informatics
· Level 3 registrants can claim a maximum of 50 points (10 years) for health and 50 points (10 years) for informatics
Using the self assessment Criteria for Registration, please indicate
the number of points you have claimed for Health experience and informatics experience
Other Professional Memberships & Registrations
You should give details of any other professional bodies or organisations you belong to.
For each registration:
- Professional / Registration Body
- Membership Grade / Type of Registration
- Membership / Registration Number
- Date Admitted / Registered
Previous Development
You should give examples of previous development activities you have undertaken which show how you are maintaining and developing your competence in health informatics. These can include taught courses, meetings, conferences, online learning, research, learning at work etc.
For each activity:
- Development Activity
- Area of Health Informatics
- Learning Outcomes
- Date
*Continuing Professional Development (CPD)
You need to pick up to five areas that you intend to develop over the coming year in order to maintain and develop your competence in health informatics. You should be planning at least 40 hours of CPD per year. It can include taught courses, meetings, conferences, online learning, research, learning at work etc. See the CPD section for more information.
For each activity:
- Identified need
- Priority
- Development area
- Topic area
- Activity to be undertaken
- Hours
- Development activity
- Motivation
(Most of these are drop-down lists to select from.)
*Supporting Submission
You should give additional information to support your application. This may include experience, knowledge and competencies not listed elsewhere in your application.
You should also explain why you believe you should be registered with UKCHIP at the level applied for within your chosen Constituency. If, for Level 2 or 3 Registration, you do not meet the minimum points score in any area you should explain here how other areas of your profile compensate for this and why you believe you should be registered at this level.
*Sponsor and Referee
You need to give details of two people who know you well, can confirm your details and support your application. We will send an automatic email to your sponsor when you have submitted your application and paid your registration fee. We will only contact your referee if we need further clarification or verification.
For both Sponsor and Referee:
- Title
- Name
- Address
- Postcode
- Country
- Tel
- Mobile
- Email
- What is your professional relationship with this person?
*Eligibility For Registration
Show which of the areas of informatics you specialise in.
Sector
- NHS
- Private health
- Industry / commercial
- Higher / Further Education
- Other
Constituency
- ICT
- Health Records
- Information Management
- Knowledge Management
- Senior HI Managers / Directors of Services
- Clinical Informatics
- Education, Training & Development
- Research
- Other
*Personal Statement
Are you, or have you ever been, barred or removed from the register of
a professional or regulatory body in the UK or any other country?
Have you had a police caution or have you an unspent criminal
conviction?
*Declaration
You need to agree to the following:
I declare that:
- The information given in this document and all attachments is true and accurate
- I have read, understood and will observe the UKCHIP Code of Conduct
- I accept the provision of the bye-laws and regulations of the Council
I understand that:
- The information given in this document and all attachments is true and accurate
I agree to:
- Undertake appropriate Continuing Professional Development in accordance with UKCHIP recommendations
- Notify UKCHIP in writing of any change of personal details as and when any such change occurs
I will submit:
Equal Opportunities
UKCHIP operates an equal opportunities policy. All applicants will be assessed purely on merit, but to help us monitor this policy please complete this form.
All information given here will be treated in strict confidence and will not form part of the registration assessment process. This information will not be made available to the registration assessors.
- Date of Birth:
- Gender:
- Ethnic Group:
- Do you consider yourself as having a disability?
