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Form R (Part B)
Self-declaration for the Revalidation of Doctors in Training
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
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:
Date of previous Revalidation (if applicable):
Dual specialty (if
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.)
Was this a
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.
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