APPROVAL AND REAPPROVAL REPORT FOR WESSEX GP CLINICAL SUPERVISORS This form will be sent to you for completion by your Patch Office. The information provided within this form will be treated as private and confidential. The GP applying for approval or re-approval must complete the sections of the form and return it, with supporting evidence, to the Patch Office at least two weeks before the agreed date of the GP Clinical Supervisor Visit. You can email or post the completed form to the Patch Office. The sections highlighted in blue are to be completed by the Lead Visitor following your visit. GMC training standards are referenced throughout the form within Domain’ in the hand column. ‘GMC Appendix A: Patch Contact Details Appendix B: GMC Training Standards (see GMC Domain in right hand column) Appendix C: Approval/Re-approval Process for GP Foundation Supervisors Appendix D: Clinical Supervisor Courses Appendix E: Roles & Responsibilities of a Clinical Supervisor Section One: Applicant’s Details GMC Applicant’s Details Item Domain 1.1 Applicant’s Name GI (full name and as ) 1.2 GI GMC Number 1.3 Practice Name and GI Address Practice NACS Code 1.4 Programme GI (e.g. J12345) SECTION 1 VISITOR COMMENTS: Date of GI Visitors/Interviewers and roles: Other Practice members seen at visit GI (if any): a) Previous Areas for Development / a/b/c/d/ Agreed Actions (from last report) e/f/g b) Highlights GI c) Current Areas for Development / a/b/c/d/ Agreed Action e/f/g
APPROVAL AND REAPPROVAL REPORT FOR WESSEX GP CLINICAL SUPERVISORS This form will be sent to you for completion by your Patch Office. The information provided within this form will be treated as private and confidential. The GP applying for approval or re-approval must complete the sections of the form and return it, with supporting evidence, to the Patch Office at least two weeks before the agreed date of the GP Clinical Supervisor Visit. You can email or post the completed form to the Patch Office. The sections highlighted in blue are to be completed by the Lead Visitor following your visit. GMC training standards are referenced throughout the form within ‘GMC Domain’ in the hand column. Appendix A: Patch Contact Details Appendix B: GMC Training Standards (see GMC Domain in right hand column) Appendix C: Approval/Re-approval Process for GP Foundation Supervisors Appendix D: Clinical Supervisor Courses Appendix E: Roles & Responsibilities of a Clinical Supervisor Section One: Applicant’s Details Item Applicant’s Details GMC Domain 1.1 Applicant’s Name (full name and as ) GI 1.2 GMC Number GI 1.3 Practice Name and Address GI 1.4 Practice NACS Code (e.g. J12345) Programme GI SECTION 1 VISITOR COMMENTS: Date of Visitors/Interviewers and roles: GI Other Practice members seen at visit (if any): GI a) Previous Areas for Development / Agreed Actions (from last report) a/b/c/d/ e/f/g b) Highlights GI c) Current Areas for Development / Agreed Action a/b/c/d/ e/f/g