Application Form 1Privacy Agreement2About you3Employment Information4Equality, Diversity & Inclusion5Your Chair Journey6Your Files7Keeping In Touch8Terms and Conditions9Summary Application-IDThis field is hidden when viewing the formSubmission Date DD dash MM dash YYYY Privacy Agreement Any information you provide in completing this application will be stored and processed in accordance with our Data Privacy Policy which you are required to read and accept before completing your application. By proceeding with this application, you agree that The NHS Leadership Academy may contact you if you have partially completed your application to offer guidance and support with finishing your application. This is a separate agreement to the marketing preferences selected further in this application.Please check the box below to accept the above agreement and our Data Privacy Policy(Required) I confirm I have read and accept the Academy’s Data Privacy Policy and above agreement About youName(Required) First Last Preferred NamePreferred Email(Required) Your primary email addressPreferred contact number(Required)Your main contact number with international dialling code and extension if necessaryPlease enter your 10-digit Academy ID(Required)If you already have an Academy ID, please log on to our new Academy Profile system using your existing log in details to ensure your account is transferred to our new system. If you need help remembering your existing Academy ID, please use the Reset password feature on the Profile system. If you do not have an Academy ID, please register on our Academy Profile system to create one. Home address Street Address City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Region(Required)East of EnglandLondonMidlandsNorth East and YorkshireNorth WestSouth EastSouth WestWalesScotlandNorthern IrelandNon-UK Employment Information Please enter the details of your current main job role.Organisation Region(Required)East of EnglandLondonMidlandsNorth East and YorkshireNorth WestSouth EastSouth WestWalesScotlandNorthern IrelandNon-UKCountry(Required)AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwePlease select your countryOrganisation Name(Required) To be able to access all of our features, you need a browser that supports JavaScript, and it needs to be enabled. The name of your organisation Primary Role APPLIANCE CONTRACTOR APPLICATION SERVICE PROVIDER APPLICATION SERVICE PROVIDER – LEGACY BRANCH SURGERY CANCER NETWORK CANCER REGISTRY CARE TRUST CARE TRUST SITE CLINICAL COMMISSIONING GROUP CLINICAL COMMISSIONING GROUP SITE CLINICAL NETWORK COMMISSIONING SUPPORT UNIT COMMISSIONING SUPPORT UNIT SITE COMMON SERVICE AGENCY (CSA) CONSTABULARY COURT DATA SERVICES FOR COMMISSIONERS REGIONAL OFFICE (DSCRO) DIRECTLY MANAGED UNIT (DMU) DISTRICT HEALTH AUTHORITY (DHA) DMU SITE DSCRO SITE EDUCATION EXECUTIVE AGENCY EXECUTIVE AGENCY PROGRAMME EXECUTIVE AGENCY PROGRAMME – DEPARTMENT EXECUTIVE AGENCY SITE GENERAL DENTAL PRACTICE GOVERNMENT DEPARTMENT GOVERNMENT DEPARTMENT SITE GOVERNMENT OFFICE REGION HEALTH AUTHORITY (HA) HEALTH OBSERVATORY IMMIGRATION REMOVAL CENTRE INDEPENDENT SECTOR H/C PROVIDER SITE INDEPENDENT SECTOR HEALTHCARE PROVIDER ISLE OF MAN GOVERNMENT DEPARTMENT ISLE OF MAN GOVERNMENT DIRECTORATE ISLE OF MAN GOVERNMENT DIRECTORATE SITE LOCAL AUTHORITY LOCAL AUTHORITY – LEGACY LOCAL AUTHORITY DEPARTMENT LOCAL AUTHORITY SITE LOCAL AUTHORITY SITE – LEGACY LOCAL HEALTH BOARD LOCAL HEALTH BOARD SITE LOCAL SERVICE PROVIDER (LSP) LSP SITE MILITARY HOSPITAL NATIONAL APPLICATION SERVICE PROVIDER NHS ENGLAND (REGION, LOCAL OFFICE) NHS ENGLAND (REGION, LOCAL OFFICE) SITE NHS ENGLAND (REGION) NHS SUPPORT AGENCY NHS TRUST NHS TRUST SITE NON STATUTORY NHS ORGANISATION NON-NHS ORGANISATION NORTHERN IRELAND GP PRACTICE NORTHERN IRELAND HEALTH & SOCIAL CARE BOARD NORTHERN IRELAND HEALTH AND SOCIAL CARE TRUST NORTHERN IRELAND LOCAL COMMISSIONING GROUP OPTICAL HEADQUARTERS OPTICAL SITE OTHER STATUTORY AUTHORITY (OSA) OTHER STATUTORY AUTHORITY SITE OTHER UNIT (IN SUPPORT OF NHS BUSINESS) PATHOLOGY LAB PHARMACY PHARMACY HEADQUARTER PHARMACY SITE POLICE CUSTODY SUITE PRESCRIBING COST CENTRE PRIMARY CARE GROUP PRIMARY CARE NETWORK PRIMARY CARE TRUST PRIMARY CARE TRUST SITE PRISON REGIONAL OFFICE (RO) SCHOOL SCOTTISH GP PRACTICE SCOTTISH HEALTH BOARD SECURE CHILDREN’S HOME SECURE TRAINING CENTRE SEXUAL ASSAULT REFERRAL CENTRE SOCIAL CARE PROVIDER SOCIAL CARE SITE SPECIAL HEALTH AUTHORITY (SPHA) SPECIAL HEALTH AUTHORITY SITE STRATEGIC HEALTH AUTHORITY SITE STRATEGIC PARTNERSHIP WELSH ASSEMBLY WELSH LOCAL HEALTH BOARD WELSH LOCAL HEALTH BOARD SITE YOUNG OFFENDER INSTITUTION OTHER The primary role of your organisation Postcode The postcode of your organisation Is this an NHS organisation?(Required) Yes No This field is hidden when viewing the formOrganisation CountryEnglandNorthern IrelandScotlandWalesOutside UK Organisation Type Organisation Name This field is hidden when viewing the formOrganisation TypePlease enter the type of organisationThis field is hidden when viewing the formNew OrganisationHidden section that is only shown when the organisation is unknownThis field is hidden when viewing the formOrganisation NamePlease enter the name of the organisationThis field is hidden when viewing the formOrganisation Post CodePlease enter the post code of the organisationThis field is hidden when viewing the formDoes this organisation provide any NHS-funded care?(Required) Yes No Don’t know This field is hidden when viewing the formRole(Required) Staff GroupAdditional Clinical ServicesAdditional Professional Scientific and TechnicalAdministrative and ClericalAllied Health ProfessionalsEstates and AncillaryHealthcare ScientistsMedical and DentalNursing and Midwifery RegisteredStudent Job Title Please note that you will find the majority of job titles available by selecting the admin and clerical option from the drop down list. If however you do not find your job title listed, please select ‘other’ and type in your FULL job title.Job Title(Required)Please enter your job titleArea of work(Required)Primary careAcute trustMental health trustAmbulance trustAHSNALBICBCommunity careCommissioningOccupational HealthPublic HealthSocial CareCorporateOtherCurrent?(Required) Yes No Are you currently active in this role? Please note: we only require past roles if you are unemployed.If you answered no to the above question, please enter your last active role:What organisation was that role in?(Required)Date of last employment:(Required) DD slash MM slash YYYY Professional Background(Required)DigitalFinanceGovernance/Corporate AffairsMedicalNursingOperationsPerformanceStrategy/TransformationWorkforceOtherPrevious Sector ExperienceALBAmbulanceAviationCivil serviceCommissioningConsultancyDefenceEducation & AcademiaEducation/Local AuthorityInternationalLocal AuthoritySocial CarePolicePrimary CarePublic HealthThis field is hidden when viewing the formSalary/BandBand 1Band 2Band 3Band 4Band 5Band 6Band 7Band 8aBand 8bBand 8cBand 8dBand 9Band VSMOther Salary/BandDo not wish to disclose Equality & Diversity We are committed to promoting equality of opportunity, by developing and retaining a diverse workforce that reflects our diverse communities. To help us achieve our Equality, Diversity and Inclusion (EDI) ambitions, we collect, monitor and analyse diversity data about participants who access leadership development opportunities to identify how well we are doing and remove barriers to awareness and access. We need your help and cooperation to enable us to do this by filling in this form. This data is kept confidential. In line with the Equality Act 2010, positive action is taken when required to help us achieve our EDI ambitions. To find out more about our EDI ambitions/how your data is used please contact us via [email protected]. Which of the following best describes your gender?(Required)FemaleMaleUnknown GenderDo not wish to discloseAre you now or have you ever defined yourself as Trans?(Required)YesNoDo not wish to discloseWhich of the following best describes your sexual orientation?(Required)Heterosexual or StraightLesbianGayBisexualAsexualOther sexual orientation not listedUndecidedDo not wish to discloseWhich of the following best describes your ethnic background?(Required)White – BritishWhite – IrishWhite – Any other White backgroundMixed – White and Black CaribbeanMixed – White and Black AfricanMixed – White and AsianMixed – Any other Mixed backgroundAsian or Asian British – IndianAsian or Asian British – PakistaniAsian or Asian British – BangladeshiAsian or Asian British – Any other Asian backgroundBlack or Black British – CaribbeanBlack or Black British – AfricanBlack or Black British – Any other Black backgroundOther ethnic groups – ChineseOther ethnic groups – Any other ethnic groupDo not wish to discloseWhich of the following best describes your religion or belief system?(Required)AtheismBuddhismChristianityHinduismIslamJainismJudaismSikhismNot religiousOtherDo not wish to discloseWhich of the following best describes your nationality?(Required)AfghanAlbanianAlgerianAmericanAmerican SamoanAndorranAngolanAnguillanAntiguanArgentineanArmenianArubanAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBarbudanBasothoBatswanaBelarusianBelgianBelizeanBenineseBermudianBhutaneseBolivianBosnianBrazilianBritishBritish Virgin IslanderBruneianBulgarianBurkinabeBurmeseBurundianCambodianCameroonianCanadianCape VerdeanCentral AfricanChadianChannel IslanderChileanChineseChristmas IslanderChuukeseCocos IslanderColombianComoranCongoleseCook IslanderCosta RicanCroatianCubanCypriotCzechDanishDjiboutianDominicanDutchDutch AntilleanEast TimoreseEcuadoreanEgyptianEnglishEmiratiEquatorial GuineanEritreanEstonianEthiopianFalkland IslanderFaroeseFijianFilipinoFinnishFrenchFrench GuianeseFrench PolynesianGaboneseGambianGeorgianGermanGhanaianGibraltarGreekGreenlandicGrenadianGuadeloupianGuamanianGuatemalanGuineanGuyaneseHaitianHonduranHong Kong (British/Chinese)HungarianI-KiribatiIcelandicIndianIndonesianIranianIraqiIrishIsraeliItalianIvorianJamaicanJapaneseJordanianKazakhstaniKenyanKittian and NevisianKuwaitiKyrgyzLaotianLatvianLebaneseLiberianLibyanLiechtensteinLithuanianLuxembourgerMacedonianMahoranMalagasyMalawianMalaysianMaldivanMalianMalteseManxMarshalleseMartiniquaisMauritanianMauritianMexicanMicronesianMoldovanMonegasqueMongolianMontenegrinMontserratianMoroccanMosothoMotswanaMozambicanNamibianNauruanNAURNepaleseNew ZealanderNicaraguanNigerianNigerienNiueanNi-VanuatuNorfolk IslanderNorth KoreanNorthern IrishNorwegianOmaniPakistaniPalauanPalestinianPanamanianPapua New GuineanParaguayanPeruvianPitcairn IslanderPohnpeianPolishPortuguesePuerto RicanQatariReunioneseRomanianRussianRwandanSahrawianSaint HelenianSaint LucianSaint VincentianSalvadoranSammarineseSamoanSan MarineseSao TomeanSaudi ArabianScottishSenegaleseSerbianSeychelloisSierra LeoneanSingaporeanSlovakianSlovenianSolomon IslanderSomaliSouth AfricanSouth KoreanSpanishSri LankanSudaneseSurinameseSwaziSwedishSwissSyrianTaiwaneseTajikTanzanianThaiTimoreseTobagonianTogoleseTokelauanTonganTrinidadianTrukeseTunisianTurkishTuvaluanUgandanUkrainianUruguayanUzbekistaniVenezuelanVietnameseVirgin IslanderWallis and Futuna IslanderWelshYapeseYemeniteZambianZimbabweanDo not wish to discloseDo you consider yourself to have a disability?(Required)YesNoDo not wish to discloseMany people do not consider themselves to be disabled. However under the Disability Discrimination Act 1995 and the Equality Act 2010, you are protected from discrimination if you have a physical or mental impairment or long term health condition, the effects are expected to last – or have lasted – for a year or longer and have a substantial impact on your ability to carry out day to day activities; or your day to day activities would be limited without medication, treatment or adjustments (for example the use of inhalers, physiotherapy, a hearing or visual aid or insulin). Taking this into account, do you consider yourself to have a disability?About your disabilityVisual impairmentHearing impairmentDisability affecting mobilityOther physical disabilityOther medical condition (for example epilepsy, asthma, diabetes)Emotional/behavioural difficultiesMental health difficultyTemporary disability after illness (for example post-viral) or accidentProfound complex disabilitiesAspergers syndromeOtherNot known/not providedWhat was the occupation of your main household earner when you were about aged 14?(Required)Social Mobility Commission (SMC) research shows that people from lower socio-economic backgrounds may face a ‘progression gap’. The SMC regard this question as the best measure we have to assess someone’s socio-economic background and is applicable to those of all ages and from all countries, see Cross-industry toolkit – Social Mobility Commission. This will enable us to make opportunities for applications to our programmes equitable for people from lower socio-economic backgrounds and work towards better representation (at Board level) of the communities we serve. Your data will be stored and handled in line with GDPR best practice, be used in aggregate to help make evidence-based decisions and will not be used for appointment and promotion decisions. Age(Required)Please Select…18-2021-2930-3940-4950-5960 or older Do you aspire to a first time Chair role within 12-18 months of commencing this programme?(Required)Please Select…YesNoWhilst the Aspirant Chair Programme will not guarantee a role, this information will help us understand the mobility of successful participants. What type of organisation are you looking to for your first time Chair role?(Required)Would you be willing to take a Chair role to another region?(Required)Please Select…YesNoN/APlease Select a region:(Required)LondonSouth WestSouth EastMidlandsEast of EnglandNorth East and YorkshireNorth WestAny Region/flexible Your Files:Please upload the relevant files into the correct locations.How to apply The closing date for applications is 14 May at 10 am. All applications will be acknowledged. Candidates who are successful at the application stage will be asked to attend a half day assessment on any of 25/26 June or 2/3 July. As part of the application process, you will be required to fill in/upload the following documents: A full CV which details your education and professional qualifications and full employment history. Please ensure this includes daytime and evening contact details, which will be used with discretion. (Of no more than 3 sides of A4). A cover letter (of no more than 2 sides of A4) outlining why you wish to become an NHS chief executive, the experience, knowledge, skills, personal qualities and behaviours that will enable you to become a successful chief executive, and what you hope to get out of this programme. Please refer to the eligibility criteria for guidance. Please ensure you have had a career conversation with your sponsoring Chief Executive/Chair before you apply and upload the signed sponsorship declaration form. Cover Letter:(Required)Max. file size: 98 MB.CV:(Required)Max. file size: 98 MB.Your signed declaration form based on your career/talent conversation with your Chair:(Required)Max. file size: 98 MB. Keeping in touch We’d like to keep in touch with you on updates about our products, services, promotions, news and events. Please select your preferences to help us keep you up-to-dateWhere did you hear about the programme?NHS Leadership Academy websiteAnother NHS websiteA Journal's website (EG. Nursing Times or Nursing Standard)My organisation's intranetSearch enginePrinted advert in a journal (E.g. Nursing times, Nursing Standard)Email advertWord of mouth (friend or colleague)NHS Leadership Academy Programme GuideLine ManagerStaff BriefingWould you like to receive updates from the Leadership Academy about other programmes on offer?YesNoWould you like to receive updates from the Leadership Academy about other learning opportunities such as bite size learning, mentoring, news and events?YesNoWould you be happy to be contacted by the Academy for research purposes?YesNo(Your views are important to us and help us grow).At the moment updates are delivered via email but we are exploring options to communicate via mobile, would you be happy to receive notifications from us via mobile in the future?YesNoDo you agree to us sharing your details with regional talent teams so that we can contact you as and when other development and career opportunities arise?(Required)Please Select…YesNo Terms and ConditionsBy applying for this programme I have both the agreement of my Chair, organisation and secured the time away for my chosen cohort(s) Please check the box below to accept our Terms and Conditions(Required) I agree to the Terms and Conditions SummaryPlease check your details and, if correct, submit this form. {all_fields:value,nohidden,noadmin}Please ensure you have uploaded the following documents: 1. Cover letter 2. CV 3. Signed declaration form, based on your career/talent conversation with your CEO/Chair.