Form R - Part B

Section 1 - DOCTORS DETAILS (assistance information required) Your form has been partially pre-populated by your Deanery/HEE local team. Please check all details and add or amend where necessary. 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 (Please refer to latest edition of the Gold Guide).

1

Forename

Forename

N

Sebastian

• Pre-populate

• can be overwritten on the Form; no propagation to other parties on submission for MVP

Y

• Cannot be left empty
  

Same as Form R Part A

2

GMC-Registered Surname

Surname

N

Potato

• Pre-populate with Surname

• can be overwritten on the Form; no propagation to other parties on submission for MVP

Y

• Cannot be left empty
  

Same as Form R Part A

3

GMC Number

GMC Number

N

1234567

• Pre-populate

• can be overwritten on the Form; no propagation to other parties on submission for MVP

Y

• No validation with GMC for MVP.
  

There will be trainees with UNKNOWN / N/A pre-populated, but may have a GMC to enter at time of Form R.

Should we wish to update TIS with the date in the future, the TIS Person ID can be linked back to.

4

Primary Contact Email Address

PotatoSeb@nhs.net

• Leave blank, do not pre-populate

• Populate with valid email address. 

• Can be overwritten on the Form; no propagation to other parties on submission for MVP

• Valid email address format

Y

Strongly advised to give 'NHS.net' address

Full text on Form R:
”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.”

5

Deanery / HEE Local Team

Person Owner

Image Added

Y - Local Office

Health Education England North West London

• Pre-populate with Programme Owner

• If no Active/Current Programme membership then leave blank

• Can be overwritten on the Form; no propagation to other parties on submission for MVP

• Overwritten with Local Office Reference table CURRENT values only

  • Note: Exclude 'London LETBs' in the list

Y

Same as Form R Part A

6

Previous Designated Body for Revalidation

Designated body of their previous revalidation episode. (since they were last revalidated)

James Harris Alistair Pringle (Unlicensed)

Y- Local Office

Health Education England South London

• Pre-populate with designated body from previous revalidation episode

• Editable with Local Office reference value

N - if applicable (i.e. only if they have gone through revalidation at the point of ARCP)

7

Current Revalidation Date

Submission date (from Revalidation module)

09/04/2025

• Pre-populate

• Editable

Y - ?

Will be revalidated at five years after gaining full GMC registration with a licence to practise, and again at CCT. 

James Harris Alistair Pringle (Unlicensed) - Should this be mandatory?

8

Date of Previous Revalidation

Submission date (from Revalidation module)

09/04/2020

• Pre-populate

• Editable

N

Can Form R Part B pull previous submission date (if applicable)? Must ignore deferrals.

9

Programme / Training Specialty

Curriculum Specialty from Programme Membership

Cardiology

• Pre-populate with the most recent Curriculum specialty of curriculumSubType = MEDICAL_CURRICULUM and Status = CURRENT and attached to the Most recent Programme membership based on furthermost 'Programme start date' 

Note: Curriculumid in ProgrammeMembership linked to Curriculum table to extract the curriculum sub type info

• Where there are multiple, pick the topmost in alphabetical order

• Can be overwritten on the Form; no propagation to other parties on submission for MVP

• Overwritten with only CURRENT value from

  • Curriculum.name of curriculumSubType = MEDICAL_CURRICULUM and Status = CURRENT from Curriculum table  

Y

Same as Form R Part A

Some curricula may contain a year e.g. “Cardiology - 2007” - potentially confusing to the trainee

James Harris Alistair Pringle (Unlicensed) - Do curriculum names still have year?

Alphabetical order issue:
General (Internal) Medicine
Renal
BSMS HEI

10

Dual Specialty

Curriculum Specialty from Programme Membership

SpecialtyName

General (Internal) Medicine

Same as above, but reverse alphabetical order(?)

• Leave unpopulated

• Overwritten with only CURRENT value from

  • Curriculum.name of curriculumSubType = MEDICAL_CURRICULUM and Status = CURRENT from Curriculum table  

N

Alistair Pringle (Unlicensed)James Harris :

Triple accreditation

Section 2 - WHOLE SCOPE OF PRACTICE (assistance information required) 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.

Multiple of rows of the below can be added.

11

Type of Work

N/A

(Placement Type in reference will not suffice)

ST5 Cardiology

In Post

OOPC/E/P/R/T

Parental Leave

Locum

Volunteering

• Can add multiple rows

• Pre-populate with all placements since last ARCP if possible

• <Placement Type> <Placement Grade> <Placement Specialty> format taken from their placements on TIS

Image Added

• Can be overwritten with freetext
  

Y

Alistair Pringle (Unlicensed) James Harris

This should consist of 

• placement data

• leave data

• Could be anything outside of TIS e.g Locum, Volunteering

• Must include current placement and any previous placement(s) subsequent to previous ARCP

12

Start Date

Starts

N/A

02/10/2019

• Pre-populate with Placement start date

• Can be overwritten with date format

Y

• Must include current placement and any previous placement(s) subsequent to previous ARCP
  

13

End Date

Ends

N/A

06/10/2020

• Pre-populate with Placement start date

• Can be overwritten with date format

Y

14

Training Post?

Placement Type? Or No

N/A

Placement Type in reference?

Y

• Pre-populate Y for where Type of Work isa Placement and Placement Type is one of: In Post, OOPT, Acting Up, possibly Phased Return (tbc)

• Pre-populate N for OOPC/E, and anything not “In Post”

• OOPR/P may count towards training

• Can be overwritten with Y/N

• If Type of Work is not Placement from TIS, allow to input freetext

Y

Alistair Pringle (Unlicensed) James Harris

15

Site Name

Hammersmith Hospital

• Pre-populate with siteknownas from Placement site if Type of work = Placement

• Else freetext that can be overwritten (trainee may not be necessarily at an ODS list site)

Y

Alistair Pringle (Unlicensed) James Harris

• Pre-population unlikely to capture overseas sites and sites where the trainee volunteered at
  

16

Site Location

• Pre-populate with the address field of the Site from #15 if Type of work = Placement

• Else freetext that can be overwritten (trainee may not be necessarily at an ODS list site)

Y

Guidance text needed (see Form)

Time Out of Training - guidance text see document

17

Short and Long-term sickness absence

N/A

3

• Pre-populate with 0/None?

• Editable - Can only populate with integer numbers. Referring to the guidance half days to be rounded up.

Y

Alistair Pringle (Unlicensed) James Harris

• Can pull from ESR Absence data?

• Must be from date after the previous ARCP

• Should we limit to a max of 365 days to match ARCP?

18

Parental leave (incl Maternity / Paternity leave)

N/A

0

• Pre-populate with 0/None?

• Editable - Can only populate with integer numbers. Referring to the guidance half days to be rounded up.

Y

• Can pull duration from placements subsequent to previous ARCP marked as “Parental Leave”?

• Must calculate TOOT from day after ARCP and not the actual parental leave start date
  

19

Career breaks within a Programme (OOPC) and non-training placements for experience (OOPE)

N/A

0

• Pre-populate with 0/None?

• Editable - Can only populate with integer numbers. Referring to the guidance half days to be rounded up.

Y

• Can pull duration from placements subsequent to previous ARCP with Type marked as “OOPC” or “OOPE”?

• OOPP?

20

Paid / unpaid leave (e.g. compassionate, jury service)

N/A

0

• Pre-populate with 0/None?

• Editable - Can only populate with integer numbers. Referring to the guidance half days to be rounded up.

Y

Alistair Pringle (Unlicensed) James Harris - can this come from absence data?

Unpaid leave appears in both #20 and #21.

21

Unpaid/unauthorised leave including industrial action

N/A

0

• Pre-populate with 0/None?

• Editable - Can only populate with integer numbers. Referring to the guidance half days to be rounded up.

Y

• Can pull from ESR data?

• Unpaid leave appears in both #20 and #21.
  

22

Other (see guidance)

N/A

0

• Pre-populate with 0/None?

• Editable - Can only populate with integer numbers. Referring to the guidance half days to be rounded up.

Y

23

Total

N/A

3

Autopopulated

= Total of above fields 16-22

Y

Section 3 - DECLARATIONS RELATING TO GOOD MEDICAL PRACTICE (assistance information required)

These declarations are compulsory and relate to the Good Medical Practice guidance issued by the GMC. Honesty & Integrity are at the heart of medical professionalism. This means being honest and trustworthy and acting with integrity in all areas of your practice, and is covered in Good Medical Practice. A statement of health is a declaration that you accept the professional obligations placed on you in Good Medical Practice about your personal health. Doctors must not allow their own health to endanger patients. Health is covered in Good Medical Practice.

23

1) I declare that I accept the professional obligations paced on me in Good Medical Practice in relation to honesty and integrity.

N/A

N/A

Selection box

Y / N

Y

Guidance information required here 

24

2) I declare that I accept the professional obligations placed on me in Good Medical Practice about my personal health

N/A

N/A

Selection box

Y / N

Y

25

3a) Do you have any GMC conditions, warnings or undertakings placed on you by the GMC, employing Trust or other organisation?

N/A

N/A

Selection box

Yes - present Q3b

No - present Q4

Y

26

3b) If yes, are you complying with these conditions / undertakings?

N/A

N/A

Yes - present Q4

No - TBC

Y - if 3a = yes

what happens if no? Alistair Pringle (Unlicensed)

27

4) Health Statement 

N/A

N/A

Free text

500 words max

N

Guidance text needed here

SECTION 4 - UPDATE TO PREVIOUS FORM R PART B - see guidance text doc

If you have previously declared any Significant Events, Complaints or Other Investigations on your last Form R Part B, please provide updates to these declarations below. Please do not use this space for new declarations. These should be added in Section 5 (New declarations since your previous Form R Part B).

Can add multiple rows of the below

28

1) If you did not declare significant events, complaints, or other investigations on your previous Form R Part B, check this box

N/A

N/A

Check box

Go to Section 5

Y - IF 3A = no

29

2) If any previously declared significant events, complaints, or other investigations have been resolved since your last ARCP/RITA/Appraisal, you are required to have written a reflection on these in your Portfolio

N/A

N/A

Selection: Y/N

Add multiple

Y

30

2a) Declaration Type

N/A

N/A

Smart-search / drop down

• Significant event

• Complaint

• Other investigation

Y - If (2) is yes

Guidance text/definitions

31

2b) Date of entry into Portfolio

N/A

N/A

Calendar picker

Y - If (2) is yes

32

2c) Title / Topic of Reflection/Event

N/A

N/A

Free text

Y - If (2) is yes

33

2d) Location of entry in Portfolio

N/A

N/A

Free text

Y - If (2) is yes

34

3) If any previously declared Significant Events, Complaints or Other Investigations remain unresolved,
please provide a brief summary below, including where you were working, the date of the event, and
your reflection where appropriate. If known, please identify what investigations are pending relating to
the event and which organisation is undertaking this investigation.

N/A

N/A

Free text

500 words max

N

Guidance text needed here

required:

Y

30

2a) Declaration Type

N/A

N/A

Y - If (2) is yes

31

2b) Date of entry into Portfolio

N/A

N/A

Calendar picker

Y - If (2) is yes

32

2c) Title / Topic of Reflection/Event

N/A

N/A

Free text

Y - If (2) is yes

33

2d) Location of entry in Portfolio

N/A

N/A

Free text

Y - If (2) is yes

34

3) Unresolved detail

N/A

N/A

Free text

N

Guidance text required

Section 5: NEW DECLARATION SINCE YOUR PREVIOUS FORM R PART B B  - see  see guidance text doc

28

1) If you did not declare significant events, complaints, or other investigations on your previous Form R Part B, check this box

N/A

N/A

Check box

Go to Section 5

Y - IF 3A = no

29

2) If any previously declared significant events, complaints, or other investigations have been resolved since your last ARCP/RITA/Appraisal, you are required to have written a reflection on these in your Portfolio

N/A

N/A

Selection: Y/N

Add multiple

Section 5: NEW DECLARATION SINCE YOUR PREVIOUS FORM R PART B  - see guidance text docSignificant Event: The GMC state that a significant event (also known as an untoward or critical incident) is any unintended or unexpected event, which could or did lead to harm of one or more patients. This includes incidents which did not cause harm but could have done, or where the event should have been prevented. All doctors as part of revalidation are required to record and reflect on Significant events in their work with the focus on what you have learnt as a result of the event/s. Use non-identifiable patient data only.

Complaints: A complaint is a formal expression of dissatisfaction or grievance. It can be about an individual doctor, the team or about the care of patients where a doctor could be expected to have had influence or responsibility. As a matter of honesty & integrity you are obliged to include all complaints, even when you are the only person aware of them. All doctors should reflect on how complaints influence their practice. Use non-identifiable patient data only.

Other investigations: Any on-going investigations, such as honesty, integrity, conduct, or any other matters that you feel the ARCP panel or Responsible Officer should be made aware of. Use non-identifiable patient data only.

**REMINDER: DO NOT INCLUDE ANY PATIENT-IDENTIFIABLE INFORMATION ON THIS FORM

Can add multiple rows of the below.

35A

I do not have anything new to declare since my last ARCP/RITA/Appraisal

N/A

N/A

selection box

Y - must select either 35A or 35B

Alistair Pringle (Unlicensed) James Harris

Should we exclude RITA?

35B

I have been involved in significant events/complaints/other investigations since my last ARCP/RITA/Appraisal

N/A

N/A

selection box

Y - must select either 35A or 35B35A or 35B

Alistair Pringle (Unlicensed) James Harris

Should we exclude RITA?

36A

If you know of any resolved significant events/complaints/other investigations since your last ARCP/RITA/Appraisal, you are required to have written a reflection on these in your Portfolio. Please identify where in your Portfolio the reflection(s) can be found

N/A

N/A

Read only text field 

36B

Issue Type

N/A

N/A

Drop down:

• Significant event

• complaint

• other investigation

Add multiple

Y - if 35B is selected

36C

Date of Entry in Portfolio

N/A

N/A

Read only text field 

36B

Issue TypeA

Calendar picker

add multiple

Y - if 35B is selected

36D

Title / Topic of Entry

N/A

N/A

Drop down:

• significant event

• complaint

• other investigation

Free text

Add multiple

Y - if 35B if 35B is selected

36C36E

Date Location of Entry in Portfolio

N/A

N/A

Calendar pickerFree text

add Add multiple

Y - if 35B is selected

36D

Title / Topic of Entry- if 35B is selected

37

If you know of any unresolved significant events/complaints/other investigations since your last ARCP/RITA/Appraisal, please provide below a brief summary, including where you were working, the date of the event and your reflection where appropriate. If known, please identify what investigations are pending relating to the event and which organisation is undertaking the investigation.

N/A

N/A

Free text

Add multipleFREE TEXT

500 characters limit?

Y - if 35B is if 35B selected

36E

SECTION 6: COMPLIMENTS - see guidance text doc

Compliments are another important piece of feedback. You may wish to detail here any compliments that you have received which are not already recorded in your portfolio, to help give a better picture of your practice as a whole. This section is not compulsory.

38

Free text

N/A

N/A

Free text

Add multiple

Y - if 35B is selected

37

If you know of any unresolved significant events/complaints/other investigations since your last ARCP/RITA/Appraisal, please provide below a brief summary, including where you were working, the date of the event and your reflection where appropriate. If known, please identify what investigations are pending relating to the event and which organisation is undertaking the investigation.

N/A

N/A

FREE TEXT

500 characters

Y - if 35B selected

SECTION 6: COMPLIMENTS - see guidance text doc

38

Free text

N/A

N/A

Free text

1000 characters

N

SECTION 7: DECLARATION - see guidance text doc

39

Declaration statement (see form)

N/A

N/A

Read only

Read only text field

40

1000 characters limit?

N

SECTION 7: DECLARATION - see guidance text doc

I confirm this form is a true and accurate declaration at this point in time and will immediately notify the Deanery/HEE local team and my employer if I am aware of any changes to the information provided in this form. I give permission for my past and present ARCP/RITA portfolios and / or appraisal documentation to be viewed by my Responsible Officer and any appropriate person nominated by the Responsible Officer. Additionally if my Responsible Officer or Designated Body changes during my training period, I give permission for my current Responsible Officer to share this information with my new Responsible Officer for the purposes of Revalidation.

39

Trainee Signature

N/A

N/A

• Populate with Forename<space>Surname entered earlier on the form

• Read-only: If needs amending then correct on the form above.

• on submission

Y

As with Form R Part A

4140

Date

N/A

N/A

Pre-populate

• Read-only

• Today's Date

• On submission

• On re-submission, overwritten new date

Y

As with Form R Part A