Request for Specialist Support for Reviews Forum of Postgraduate Training Bodies Section 1: Request Details Date of Request : Requesting agency: Specify name of the requesting Hospital Group/ CHO Request to: Name of training body or bodies from who support is being requested. Request for: Consultant specialty Outline the steps taken to secure the required input from within or Confirmation that specialist input requested cannot be provided across hospital groups/ CHOs from within or across Hospital Groups Commissioner of Investigation Name of Commissioner Chairperson of investigation Name of chairperson. Section 2: Type of Investigation Systems Analysis Investigation of a single incident Yes/No Look-back Review Yes/No Also indicate how many cases will be under review Has any investigation/ look back review commenced prior to this Yes/No request? Has the investigation/review been completed? Yes/No Section 3: Type of Assistance Required Support Type 1: To answer a specific clinical or technical question Specify that has arisen for that investigation team. Support Type 2: To validate that the draft report prepared by the Specify investigation team is clinically/technically accurate and addresses the clinical/technical issues highlighted appropriately
Request for Specialist Support for Reviews Forum of Postgraduate Training Bodies Section 1: Request Details Date of Request : Requesting agency: Specify name of the requesting Hospital Group/ CHO Request to: Name of training body or bodies from who support is being requested. Request for: Consultant specialty Confirmation that specialist input requested cannot be provided from within or across Hospital Groups Outline the steps taken to secure the required input from within or across hospital groups/ CHOs Commissioner of Investigation Name of Commissioner Chairperson of investigation Name of chairperson. Section 2: Type of Investigation Systems Analysis Investigation of a single incident Yes/No Look-back Review Also indicate how many cases will be under review Yes/No Has any investigation/ look back review commenced prior to this request? Yes/No Has the investigation/review been completed? Yes/No Section 3: Type of Assistance Required Support Type 1: To answer a specific clinical or technical question that has arisen for that investigation team. Specify Support Type 2: To validate that the draft report prepared by the investigation team is clinically/technically accurate and addresses the clinical/technical issues highlighted appropriately Specify
request-for-specialist-support-for-reviews-fpgtb-application-form.docx