Form R - Part B

Section 1 - DOCTORS DETAILS (assistance information required)

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

vwPerson

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

Programme Owner

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

Programme Owner

vwRevalidationEpisode

Local Office?

Health Education England South London

Pre-populate

Read-Only

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

7

Current Revalidation Date

vwRevalidationEpisode

09/04/2025

Pre-populate

Read-Only

Y - if applicable

8

Date of Previous Revalidation

vwRevalidationEpisode

09/04/2020

Pre-populate

Read-Only

Y - if applicable

9

Programme / Training Specialty

Curriculum Specialty from Programme Membership

ProgrammeNumber

Cardiology

Pre-populate

Read-only

Y

10

Dual Specialty

SpecialtyName

General (Internal) Medicine

Pre-populate

Read-only

Y - if applicable

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

11

Type of Work

N/A

ST5 Cardiology

Pre-populate

Editable

Multiple lines

Y

This should consist of 

• placement data

• leave data*

Alistair Pringle (Unlicensed) - we need to finalise which leave types apply here

12

Start Date

N/A

02/10/2019

Pre-populate

Read-only & Editable

Multiple lines

Y

13

End Date

N/A

06/10/2020

Pre-populate

Read-only & Editable

Multiple lines

Y

14

Training Post?

N/A

Y

Pre-populate

Read-only & Editable

Multiple lines

Y

15

Site Name

N/A

Hammersmith Hospital

Pre-populate

Read-only & Editable

Multiple lines

Y

16

Site Location

Pre-populate

Read-only & Editable

Multiple lines

Y

Guidance text needed

Time Out of Training - guidance text see document

17

Short- and Long-term sickness absence

N/A

3

Pre-populate

Number counter 

read only

Y

18

Parental leave (incl Maternity / Paternity leave)

N/A

0

Pre-populate

Number counter

read-only

Y

19

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

N/A

0

Pre-populate

Number counter

read only

Y

20

Paid / unpaid leave

N/A

0

Pre-populate

Number counter

Read only

Y

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

21

Unpaid / unauthorised leave

N/A

0

Editable

Number counter / entry

Y

22

Other (see guidance)

N/A

0

Editable

Number counter / entry

Y

23

Total

N/A

3

Autopopulated

=Count of above fields 16-22

Y

Confirm this should not include line 21

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

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 FPRM R PART B - 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

Y

30

2a) Declaration Type

N/A

N/A

Smart-search / drop down

• significant event

• Complaint

• Other investigation

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  - see guidance text doc

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

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 35B

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

Calendar picker

add multiple

Y - if 35B is selected

36D

Title / Topic of Entry

N/A

N/A

Free text

Add multiple

Y - if 35B is selected

36E

Location of Entry in Portfolio

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

Trainee Signature

N/A

N/A

Name autopopulated based on user logged in

• validation of email address required to confirm

Y

41

Date

N/A

N/A

Autopopulated on submission date

Y