This table specifically specifies the fields relevant to Form R, Part B only
As Is Form
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
| Order | Field name | DR field | Reference Table | Example value | Other fields available in DR | Type (free text, drop down, check box) & Interaction (autopopulate etc) | Mandatory (Y/N) | Validation / Error Messaging | Filter (Y/N) | Search (Y/N) | Sort (Y/N) | Summary (S) / Detail (D) | Notes | Delete field | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Form R - Part B | |||||||||||||||
| DOCTORS DETAILS | |||||||||||||||
| 1 | Forename | Forenames | DR | vwPerson | Pre-populate Editable | ||||||||||
| 2 | GMC-Registered Surname | LegalSurname | DR | vwPerson | Pre-populate | ||||||||||
| 3 | GMC Number | GMCNumber | DR | vwPerson | Pre-populate | ||||||||||
| Primary Contact Email Address | Strongly advised to give 'NHS.net' address | ||||||||||||||
| 4 | Deanery / HEE Local Team | LocalOfficeName | DR | vwPerson | Pre-populate | ||||||||||
| Previous Designated Body for Revalidation | Y - if applicable | ||||||||||||||
| 5 | Current Revalidation Date | Y | |||||||||||||
| 6 | Date of Previous Revalidation | Y - if applicable | |||||||||||||
| 7 | Programme / Training Specialty | ||||||||||||||
| 8 | Dual Specialty | ||||||||||||||
| WHOLE SCOPE OF PRACTICE (assistance information required) | |||||||||||||||
| 10 | Type of Work | Free Text Add multiple | |||||||||||||
| 11 | Start Date | Calendar Picker Add multiple | |||||||||||||
| 12 | End Date | Calendar Picker Add multiple | |||||||||||||
| 13 | Training Post? | Options: Y or N Add multiple | |||||||||||||
| 14 | Site Name | Smart-search / drop down | |||||||||||||
| 15A | Site 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
| Y - If (2) is yes | |||||||||||||
| 2b) Date of entry into Portfolio | Calendar picker | Y - If (2) is yes | |||||||||||||
| 2c) Title / Topic of Reflection/Event | Free text | Y - If (2) is yes | |||||||||||||
| 2d) Location of entry in Portfolio | Free text | Y - If (2) is yes | |||||||||||||
| 3) Unresolved detail | Free text | N | Guidance text required | ||||||||||||
| Section 5: NEW DECLARATION SINCE YOUR PREVIOUS FORM R PART B | |||||||||||||||
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