FAMUS Supervisors and Mentors

FAMUS New Supervisor Application Form

Personal Details

Relevant ultrasound qualification(s)

FAMUS / FUSIC accreditation (with dates)

Other relevant qualifications

Current Ultrasound Usage

Frequency of ultrasound scanning: DailyWeeklyMonthly

Supervisor area(s) applied for: ThoracicAbdominal / renalDVT/peripheral vascularNeph-accessNeph-transplant

Would you be prepared to attend a 'Train the Trainers' event, if recommended (no cost) YesNo

Confirmation of correct data

I confirm that the above is an accurate reflection of my ultrasound experience/qualification(s) and that having reviewed the curriculum pack I am competent in overseeing the FAMUS module(s) applied for.

yes

Data Protection

Your registration details will be stored on a database by Eventage Ltd on behalf of the Society for Acute Medicine (SAM) in compliance with the General Data Protection Regulation (GDPR), accessed only by administrative staff working on behalf of SAM for the purposes of administering your registration. SAM may, from time to time, send you communications relating to your registration. As a supervisor, your name, position, trust/hospital, date of registration and email address will be made available in the FAMUS directory of supervisors on the SAM website, if you consent. I consent to having my email address displayed in the FAMUS Supervisor directory on the SAM website

yes

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