Part Six: Supporting statement from designated supervising medical practitioner. Name of supervising medical Practitioner (Print details) Qualifications GMC Registration No. Contact Address Contact Telephone Email Number Address Please supply the following information. This will assist in ensuring the Department of Health criteria for the supervision in practice of independent pharmacist prescribers are being met. Please delete YES / NO as appropriate. Are you a registered medical practitioner who has had at least 3 years medical, A treatment and prescribing responsibility for a group of patient / service users in YES / NO the relevant field of practice, as described in part three of the application form Are you: (please answer either statement B or C below): working within a GP practice and either vocationally trained or in possession of a B certificate of equivalent experience from the Joint or Post-Graduate Training in YES / NO General Practice? a specialist registrar, clinical assistant or a consultant within an NHS Trust or C YES / NO other NHS employer? In addition to statement B or C above have you: The support of the employing organisation or GP practice to act as the D designated medical practitioner who will provide supervision, support and YES / NO opportunities to develop competence in prescribing practice? E Experience or training in teaching and / or supervision in practice? YES / NO Please outline below your experience of teaching, supervision and assessment of students in the box below I have discussed the requirements of the course with [insert applicant name] and agree to provide supervision, support and shadowing opportunities to facilitate the achievement of the learning outcomes. I agree to supervise [insert applicant name] in their prescribing role for a period of learning in practice of at least twelve days. I am familiar with the General Pharmaceutical Council’s requirements and learning outcomes for the programme. Signature: Date:
Part Six: Supporting statement from designated supervising medical practitioner. Name of supervising medical Practitioner (Print details) Qualifications GMC Registration No. Contact Address Contact Telephone Number Email Address Please supply the following information. This will assist in ensuring the Department of Health criteria for the supervision in practice of independent pharmacist prescribers are being met. Please delete YES / NO as appropriate. A Are you a registered medical practitioner who has had at least 3 years medical, treatment and prescribing responsibility for a group of patient / service users in the relevant field of practice, as described in part three of the application form YES / NO Are you: (please answer either statement B or C below): B working within a GP practice and either vocationally trained or in possession of a certificate of equivalent experience from the Joint or Post-Graduate Training in General Practice? YES / NO C a specialist registrar, clinical assistant or a consultant within an NHS Trust or other NHS employer? YES / NO In addition to statement B or C above have you: D The support of the employing organisation or GP practice to act as the designated medical practitioner who will provide supervision, support and opportunities to develop competence in prescribing practice? YES / NO E Experience or training in teaching and / or supervision in practice? YES / NO Please outline below your experience of teaching, supervision and assessment of students in the box below I have discussed the requirements of the course with [insert applicant name] and agree to provide supervision, support and shadowing opportunities to facilitate the achievement of the learning outcomes. I agree to supervise [insert applicant name] in their prescribing role for a period of learning in practice of at least twelve days. I am familiar with the General Pharmaceutical Council’s requirements and learning outcomes for the programme. Signature: Date:
ip-appication-form-2018-19.docx