First Trainee:- Surname: Date: GMC Number: School/Specialty: Grade: Educational Supervisor: Clinical Supervisor: Training Programme Director: Location (at time of referral): Is the trainee working Less Than Full Time (LTFT)? Yes No Is the trainee currently considered safe to practice? Yes No If you answered no the previous question, have you informed Clinical /Medical Yes No Director and HR? Is the trainee registered with a local GP? Yes No Please tick any of the below where it is felt the trainee is not meeting the required standards and would benefit from further support (based on GMC Good Medical Practice 2013): Knowledge skills and performance Developing and maintaining professional performance Applying knowledge and experience to practice Recording work clearly, accurately and legibly Safety and quality Contributing and complying with systems to protect patients Responding to risks to safety Protecting patients and colleagues from any risk by the trainees health Complying with employer processes and policies Communication, partnership and teamwork Communicating effectively Working collaboratively with colleagues to maintain or improve patients care Teaching, training, supporting and assessing Continuity and coordination of care Establishing and maintaining partnership with patients Maintaining trust Showing respect for patients Treating patients and colleagues fairly and without discrimination Acting with honesty and integrity Progression in training Passing required exam Satisfactory ARCP outcome E-portfolio engagement Please tick any of the below areas which it is felt are impacting on the trainee (if any): Personality Language
First Trainee:- Surname: GMC Number: Date: School/Specialty: Grade: Educational Supervisor: Clinical Supervisor: Training Programme Director: Location (at time of referral): Is the trainee working Less Than Full Time (LTFT)? Yes No Is the trainee currently considered safe to practice? Yes No If you answered no the previous question, have you informed Clinical /Medical Director and HR? Yes No Is the trainee registered with a local GP? Yes No Please tick any of the below where it is felt the trainee is not meeting the required standards and would benefit from further support (based on GMC Good Medical Practice 2013): Knowledge skills and performance Developing and maintaining professional performance Applying knowledge and experience to practice Recording work clearly, accurately and legibly Safety and quality Contributing and complying with systems to protect patients Responding to risks to safety Protecting patients and colleagues from any risk by the trainees health Complying with employer processes and policies Communication, partnership and teamwork Communicating effectively Working collaboratively with colleagues to maintain or improve patients care Teaching, training, supporting and assessing Continuity and coordination of care Establishing and maintaining partnership with patients Maintaining trust Showing respect for patients Treating patients and colleagues fairly and without discrimination Acting with honesty and integrity Progression in training Passing required exam Satisfactory ARCP outcome E-portfolio engagement Please tick any of the below areas which it is felt are impacting on the trainee (if any): Personality Language
Referral-Form-Feb-2017.docx