Fillable Form R (Part B): Self-declaration for the Revalidation (UK National Health Service)

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Form R (Part B): Self-declaration for the Revalidation (UK National Health Service)

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FRPB_GGV6_Apr2017 Page 1 of 5
Form R (Part B)
Self-declaration for the Revalidation of Doctors in Training
IMPORTANT:
If this form has been pre-populated by your Deanery/HEE local team, please check all details, cross out errors and write on
amendments. By signing this document you are confirming that ALL details (pre-populated or entered by you) are correct.
It remains your own responsibility to keep your Designated Body, and the GMC, informed as soon as possible of any change to your
contact details. Your Deanery/HEE local team remains your Designated Body throughout your time in training. You can update your
Designated Body on your GMC Online account under ‘My Revalidation’.
Failure to appropriately complete a Form R Part B when requested may result in an Outcome 5 at ARCP (Gold Guide V6, 7.74).
Section 1: Doctor’s details
Forename:
GMC-registered surname:
GMC Number:
Primary contact email address:
For reasons of security and due to frequent system failures with internet email accounts, you are strongly advised to provide an
‘NHS.net’ email address.
Current Deanery/HEE local team:
Previous Designated Body for Revalidation (if applicable):
Current Revalidation date:
Programme/
Training Specialty:
Dual specialty (if
applicable):
Section 2: Whole Scope of Practice
Read these instructions carefully!
Please list all placements in your capacity as a registered medical practitioner since last ARCP (or since initial registration
to programme if more recent). This includes: (1) each of your training posts if you are or were in a training programme; (2)
any time out of programme, e.g. OOP, mat leave, career break, etc.; (3) any voluntary or advisory work, work in non-NHS
bodies, or self-employment; (4) any work as a locum. For locum work, please group shifts with one employer within an
unbroken period as one employer-entry. Include the dates and number of shifts worked in each locum employer-entry.
Please add more rows if required, or attach additional sheets for printed copy and entitle ‘Appendix to Scope of Practice’.
Type of Work (e.g. name and
grade of specialty rotation, OOP,
maternity leave, etc.)
Start Date
End date
Was this a
training
post? Y/N
Name and location of Employing/ Hosting
Organisation/GP Practice (Please use full
name of organisation/site and town/city,
rather than acronyms)
TIME OUT OF TRAINING (‘TOOT’)
Self-reported absence whilst part of a training
programme since last ARCP (or, if no ARCP, since
initial registration to programme).
Time out of training should reflect days absent from
the training programme and is considered by the
ARCP panel/Deanery/HEE in recalculation of the
date you should end your current training
programme. Partial days must be rounded up.
Enter 0 for any reasons where you have not had
Time Out Of Training.
If you want to clarify your TOOT further, enter a
comment in the Health Declaration below.
Reason
Days
Short- and long-term sickness absence
Parental leave (incl. maternity/paternity leave)
Career breaks within a programme (OOPC) and non-
training placements for experience (OOPE).
Paid/unpaid leave (e.g. compassionate, jury service)
Unpaid/unauthorised leave including industrial action
Other (see note below first)
TOOT does not include study leave, paid annual leave,
prospectively approved Out of Programme Training/Research
(OOPT/OOPR) or periods of time between training programmes
(e.g. between core and higher training).
TOTAL (NOTE: The above fields must also be completed):
Health Education England - East Midlands
0
FRPB_GGV6_Apr2017 Page 2 of 5
Section 3: Declarations relating to Good Medical Practice
These declarations are compulsory and relate to the Good Medical Practice guidance issued by the GMC.
Honesty & Integrity are at the heart of medical professionalism. This means being honest and trustworthy and acting with
integrity in all areas of your practice, and is covered in Good Medical Practice.
A statement of health is a declaration that you accept the professional obligations placed on you in Good Medical Practice
about your personal health. Doctors must not allow their own health to endanger patients. Health is covered in Good
Medical Practice.
1) I declare that I accept the professional obligations placed on me in Good Medical Practice in relation to
honesty & integrity.
Please tick/cross here to confirm your acceptance
* If you wish to make any declarations in relation to honesty & integrity, please do this in Section 6.
2) I declare that I accept the professional obligations placed on me in Good Medical Practice about my
personal health.
Please tick/cross here to confirm your acceptance
3a) Do you have any GMC conditions, warnings or undertakings placed on you by the GMC, employing Trust
or other organisation?
Yes
No
4) Health statement – Writing something in this section below is not compulsory. If you wish to declare
anything in relation to your health for which you feel it would be beneficial that the ARCP/RITA panel or
Responsible Officer knew about, please do so below.
FRPB_GGV6_Apr2017 Page 3 of 5
Section 4: Update to previous Form R Part B – If you have previously declared any Significant Events, Complaints or
Other Investigations on your last Form R Part B, please provide updates to these declarations below.
Please do not use this space for new declarations. These should be added in Section 5 (New declarations since your
previous Form R Part B).
Please continue on a separate sheet if required. Title the sheet ‘Appendix to previous Form R Part B update’, and attach to
this form.
**REMINDER: DO NOT INCLUDE ANY PATIENT-IDENTIFIABLE INFORMATION ON THIS FORM
1) If you did not declare Significant Events, Complaints or Other Investigations on your previous Form R
Part B, check this box and go to Section 5
2) If any previously declared Significant Events, Complaints or Other Investigations have been resolved
since your last ARCP/RITA/Appraisal, you are required to have written a reflection on these in your
Portfolio. Please identify where in your Portfolio the reflection(s) can be found.
(Add additional lines if required).
Significant event: Complaint: Other investigation:
Date of entry in Portfolio ____________ Title/Topic of Reflection/Event _________________________________
Location of entry in Portfolio __________________________________________________________________
**
Significant event: Complaint: Other investigation:
Date of entry in Portfolio ____________ Title/Topic of Reflection/Event _________________________________
Location of entry in Portfolio __________________________________________________________________
**
Significant event: Complaint: Other investigation:
Date of entry in Portfolio ____________ Title/Topic of Reflection/Event _________________________________
Location of entry in Portfolio __________________________________________________________________
3) If any previously declared Significant Events, Complaints or Other Investigations remain unresolved,
please provide a brief summary below, including where you were working, the date of the event, and
your reflection where appropriate. If known, please identify what investigations are pending relating to
the event and which organisation is undertaking this investigation.
FRPB_GGV6_Apr2017 Page 4 of 5
Section 5: New declarations since your previous Form R Part B
Significant Event: The GMC state that a significant event (also known as an untoward or critical incident) is any
unintended or unexpected event, which could or did lead to harm of one or more patients. This includes incidents which
did not cause harm but could have done, or where the event should have been prevented. All doctors as part of
revalidation are required to record and reflect on Significant events in their work with the focus on what you have learnt
as a result of the event/s. Use non-identifiable patient data only.
Complaints: A complaint is a formal expression of dissatisfaction or grievance. It can be about an individual doctor, the
team or about the care of patients where a doctor could be expected to have had influence or responsibility. As a matter
of honesty & integrity you are obliged to include all complaints, even when you are the only person aware of them. All
doctors should reflect on how complaints influence their practice. Use non-identifiable patient data only.
Other investigations: Any on-going investigations, such as honesty, integrity, conduct, or any other matters that you feel
the ARCP panel or Responsible Officer should be made aware of. Use non-identifiable patient data only.
Please continue on a separate sheet if required. Title the sheet ‘Appendix to new declarations’, and attach to this form.
**REMINDER: DO NOT INCLUDE ANY PATIENT-IDENTIFIABLE INFORMATION ON THIS FORM
1) Please tick/cross ONE of the following only:
I do NOT have anything new to declare since my last ARCP/RITA/Appraisal
I HAVE been involved in significant events/complaints/other investigations since my last
ARCP/RITA/Appraisal
2) If you know of any RESOLVED significant events/complaints/other investigations since your last
ARCP/RITA/Appraisal, you are required to have written a reflection on these in your Portfolio. Please
identify where in your Portfolio the reflection(s) can be found. (Add additional lines if required).
Significant event: Complaint: Other investigation:
Date of entry in Portfolio ____________ Title/Topic of Reflection/Event _________________________________
Location of entry in Portfolio __________________________________________________________________
**
Significant event: Complaint: Other investigation:
Date of entry in Portfolio ____________ Title/Topic of Reflection/Event _________________________________
Location of entry in Portfolio __________________________________________________________________
**
Significant event: Complaint: Other investigation:
Date of entry in Portfolio ____________ Title/Topic of Reflection/Event _________________________________
Location of entry in Portfolio __________________________________________________________________
3) If you know of any UNRESOLVED significant events/complaints/other investigations since your last
ARCP/RITA/Appraisal, please provide below a brief summary, including where you were working, the
date of the event, and your reflection where appropriate. If known, please identify what investigations
are pending relating to the event and which organisation is undertaking this investigation.
FRPB_GGV6_Apr2017 Page 5 of 5
Section 6: Compliments - Compliments are another important piece of feedback. You may wish to detail here
any compliments that you have received which are not already recorded in your portfolio, to help give a better
picture of your practice as a whole. Please use a separate sheet if required. This section is not compulsory.
Section 7: Declaration
I confirm this form is a true and accurate declaration at this point in time and will immediately notify the
Deanery/HEE local team and my employer if I am aware of any changes to the information provided in this
form.
I give permission for my past and present ARCP/RITA portfolios and / or appraisal documentation to be viewed
by my Responsible Officer and any appropriate person nominated by the Responsible Officer. Additionally if my
Responsible Officer or Designated Body changes during my training period, I give permission for my current
Responsible Officer to share this information with my new Responsible Officer for the purposes of Revalidation.
Trainee Signature :
Date:
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Form R (Part B): Self-declaration for the Revalidation (UK National Health Service)

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