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This table specifically specifies the fields relevant to Form R, Part A only


As Is Form

...

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Assumptions
  • All fields are mandatory
  • Specified fields should also be editable, should the Trainee need to make changes to what is held in the system - these are currently captured on the 
  • Appropriate field assistance should be displayed
  • Photograph from the original form is not needed


OrderField nameDR field

Reference Table

Example valueOther fields available in DRType (free text, drop down, check box) & Interaction (autopopulate etc)Mandatory (Y/N)Validation / Error MessagingFilter (Y/N)Search (Y/N)Sort (Y/N)Summary (S) / Detail (D)NotesDelete field
Form R - Part
A
B
DOCTORS DETAILS
1ForenameForenamesDRvwPerson

Pre-populate

Editable









2GMC-Registered SurnameLegalSurnameDRvwPerson
Pre-populate







3GMC NumberGMCNumberDRvwPerson
Pre-populate








Primary Contact Email Address










Strongly advised to give 'NHS.net' address
4Deanery / HEE Local TeamLocalOfficeNameDRvwPerson
Pre-populate
5DOBDateOfBirthDRvwPerson

Pre-populate

Editable

6GenderGenderDRvwPerson

Pre-populate

Editable

7Immigration StatusTBCTBCTBCPre-populate8Primary QualificationQualificationDRvwPerson

Pre-populate

Editable

9Date AwardedTBCTBCTBC

Pre-populate

Editable

10Medical School Awarding Primary Qualification (name and country)TBCTBCTBC

Pre-populate

Editable

11Home address

AddressLine1

AddressLine2

AddressLine3

AddressLine4

AddressPostCode

vwPerson

Pre-populate

Editable

12Contact TelephoneTelephoneNumbervwPerson

Pre-populate

Editable

13Contact MobileMobileNumbervwPerson

Pre-populate

Editable

14Email AddressEmailAddressvwPerson

Pre-populate

Editable

15AI confirm I have been appointed to a programme leading to award of CCTN/AN/A

Selection

Choose one between 155A - 15F

15BI confirm that I will be seeking specialist registration by application for a CESRN/AN/A

Selection 

Choose one between 155A - 15F

15CI confirm that I will be seeking specialist registration by application for a CESR CPN/AN/A

Selection

Choose one between 155A - 15F

15DI confirm that I will be seeking specialist registration by application for a CEGPRN/AN/A

Selection

Choose one between 155A - 15F

15EI confirm that I will be seeking specialist registration by application for a CEGPR CPN/AN/A

Selection

Choose one between 155A - 15F

15FI confirm that I am a core trainee, not yet eligible for CCTN/AN/A

Selection

Choose one between 155A - 15F

16Programme SpecialtyTBCTBCPre-populate 17Specialty 1 for Award of CCTTBCTBCPre-populate if 15A is selected18Specialty 2 for Award of CCTTBCTBCPre-populate if 15A is selected19Royal College / Faculty Assessing Training for the Award of CCTvwCollegeCollegePre-populate20Anticipated Completion Date of Current Programme (if known)vwAssessment

ProgrammeEndDateWithPOG

Pre-populate

Calculation

21Training gradevwPlacementGradeNamePre-populateOnly applicable if completed post training start date22Date StartedvwPlacementStartDatePre-populateOnly applicable if completed post training start date23Post Type / AppointmentTBCTBC

Pre-populate

Smart Search; FTSTA / LAT / MILITARY / SUBSTANTIVE (default) / VISITOR

24Full Time / % of Full Time TrainingvwPlacementWholeTimeEquivalentPre-populate25Trainee SignatureTBCTBCTBC26DateTBCTBC

Pre-populate

Today's Date (of submission)

27National Training Number / Deanery Reference NumberTBCTBC

Autopopulate 

No view/editing for Trainee unless submitted

Free Text for Admin

28GMC Programme Approval NumberN/AN/A

No editing for Trainee

No view/editing for Trainee unless submitted

Free text for Admin









Previous Designated Body for Revalidation




Y - if applicable






5Current Revalidation Date




Y






6Date of Previous Revalidation




Y - if applicable






7Programme / Training Specialty












8Dual Specialty












WHOLE SCOPE OF PRACTICE (assistance information required)


10Type of Work



Drop Down: Name+Grade of Specialty Rotation, OOP, Maternity

Add multiple









11Start Date



Calendar Picker

Add multiple









12End Date



Calendar Picker

Add multiple









13Training Post?



Options:

Y or N

Add multiple









14Site Name



Smart-search / drop down







15ASite Location



Smart-search / Drop down

Constrain list based on  site name chosen









Section 2 - Time Out of Training (assistance information required)



Short- and Long-term sickness absence



Number counter / entry








Parental leave (incl Maternity / Paternity leave)



Number counter / entry








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



Number counter / entry








Paid / unpaid leave



Number counter / entry








Other 



Number counter / entry





Assistance information required here - see actual form Page 1

Total



Autopopulated

count of above fileds xx- yy









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



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



Selection box

Y / N







Guidance information required here - related to field XX

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



Selection box

Y / N










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



Selection box

Yes - go to Q3b

No - go to Q4










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



Yes - go to Q4

No - TBC










4) Health Statement 



Free text

500 words

N




Guidance text needed here
SECTION 4 - UPDATE TO PREVIOUS FPRM R PART B (guidance/warning info needed)



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



Check box

Go to Section 5










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



Selection: Y/N

Add multiple










2a) Declaration Type



Smart-search / drop down

  • significant event
  • Complaint
  • Other investigation


Y - If (2) is yes







2b) Date of entry into Portfolio



Calendar pickerY - If (2) is yes







2c) Title / Topic of Reflection/Event



Free textY - If (2) is yes







2d) Location of entry in Portfolio



Free textY - If (2) is yes







3) Unresolved detail



Free textN




Guidance text required
Section 5: NEW DECLARATION SINCE YOUR PREVIOUS FORM R PART B