1. health and fitness

Revalidation for Doctors in Training
How to complete the Form R, Part A and B & Wider Scope of Practice form
The Form R has been amended to include information for your revalidation. At every ARCP or RITA all trainees
(including those on RITA) will need to complete both Part A & Part B of the Form R, which will be sent to you
by the School/Specialty teams.
It is important to understand that the review of your training progress is a separate process to
revalidation. It is possible to receive an unsatisfactory outcome but for there to be no concerns over your
fitness to practise. Revalidation information will be reviewed at every ARCP/RITA and not just at the point of
revalidation.
All doctors must expect to receive complaints and be involved in significant events throughout their careers .
The panel is interested in what you have learnt. You should reflect on any resolved or unresolved significant
events, complaints and investigations in your portfolio. Information should be anonymous e.g. you should not
name patients/colleagues.
Appendix A – How to complete Form R. Both Parts A&B must be completed at your annual ARCP/RITA
- For any other ARCP/RITAs carried out during the year, only Part B should be completed.
Appendix B – Wider scope of practice form
What happens at the ARCP / RITA?
There will be two parts to an ARCP / RITA:
1. The panel will consider your training progress and will issue you with an outcome.
2. The panel will consider your fitness to practise by reviewing information from 3 sources:
a. Your completed form R
b. The Educational Supervisor report declaring if they are aware of any concerns / investigations
involving you
c. Report requested by HETV from your employing organisation declaring if you have been
involved in any complaints / investigations / significant events. This is known as a ‘Collective
Exit report’ and will be collated by HETV.
As a doctor in training you should be made aware of any concerns raised against you before the ARCP /
RITA.
The ARCP outcome form has been amended to include the following boxes on revalidation. All panel decisions
are forwarded to the Postgraduate Dean who in his capacity as Responsible Officer will make a revalidation
recommendation to the GMC. The GMC will carry out a number of checks and will ultimately decide to
revalidate a Doctor. The GMC will write and let you know if they have approved the revalidation
recommendation made.
Revalidation:
There are no known causes of concern
There are causes of concern


Brief summary of concern:
HE Thames Valley Guide to complete Form R Jan14
Page 1 of 9
Appendix A
Form R (Part A)
Trainee registration for Postgraduate Specialty Training
This has been pre-populated as an example on how to complete the form.
Forename
GMC Number
Joe
GMC-registered surname
123456
Deanery / LETB
Date of Birth:
01.01.1991
Bloggs
Health Education Thames Valley
Gender:
Male
Primary Qualification and date awarded:
add details of your medical degree and date awarded ???
Medical School awarding primary qualification (name and country):
????
{If newly registering,
attach passport-sized
photo of face here}
Current Home Address:
Current Work Address:
It is important you complete these fields so we can be
sure our records are up to date
Add details of current employer (e.g. trust or GP practice)
Home Phone / Mobile:
Work Phone / Mobile:
Preferred email address for all communications: This is important so we can be sure our records are up to date
Immigration Status:
Post Type or Appointment:
(e.g. resident, settled, work permit required)
Choose from above examples or add information about
other categories
(e.g. LAT, Run Through, core trainee, FTSTA etc.)
Choose from above examples or information about other
post types
Programme Specialty:
National Training Number:
e.g. Paediatrics
GMC Programme Approval Number:
(to be completed by Postgraduate Dean on first registration)
OXF/... (your NTN number will start with OXF and can be
found in your portfolio)
(to be completed by Postgraduate Dean)
Please tick only one of these three options :
I confirm I have been appointed to a programme
leading to award of CCT
Deanery Reference Number:
(to be completed by Postgraduate Dean)
(this will start with a number)
I confirm that I will be seeking specialist registration
by application for a CESR
Specialty 1 for Award of CCT (if applicable):
e.g. Paediatrics
Specialty 2 for Award of CCT (if applicable):
I confirm that I will be seeking specialist registration
by application for a CEGPR
(complete for dual CCT)
Provisional CCT Date (or CESR/CEGPR where
applicable), if known: If you are not sure check with
Royal College/Faculty assessing training for the award
of CCT (if undertaking full prospectively approved
programme): e.g. Royal College of Paediatrics and Child
your TPD and College
Health
Initial Appointment to Programme (Full time or % of
Full time Training): (at initial appointment) e.g. Full time
Date of Entry to Grade/Programme (Substantive date
started in Programme of appointment):
e.g. 6 August
2009
I confirm that the information above is correct.
Trainee Signature :
Signature of Postgraduate Dean or representative of PGD:
(*for Deanery/LETB use only upon return)
HE Thames Valley Guide to complete Form R Jan14
Sign here
Date:
Date:
Page 2 of 9
Form R (Part B)
Self-declaration for the Revalidation of Doctors in Training
Forename
GMC
Number
Date of Birth:
Section 1: Doctor’s details.
Highlighted questions in Section 1 are mandatory
GMC-registered surname
Deanery /
LETB
Gender:
Date of previous Revalidation (if applicable):
Name of previous Designated Body for Revalidation (if applicable): e.g. Health Education Wessex
Specialty (e.g. Foundation, Core Medical Training, Anaesthetics, General Practice, Rheumatology, etc.):
If dual specialty, second specialty:
Current Home Address:
Home Phone / Mobile:
Preferred email address for all communications:
Section 2: Whole Scope of Practice
Read these instructions carefully!
Please list all placements in your capacity as a registered medical practitioner since your last ARCP/RITA or appraisal.
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 number of shifts worked during each employer-period.
Please add more rows if required, or attach additional sheets for printed copy and entitle ‘Appendix to Scope of Practice’.
Type of Work (e.g. name
Name and location of Employing/ Hosting
Was this a
and grade of specialty
Organisation/GP Practice (Please use full name
training
Start Date
End date
rotation, OOP, maternity
of organisation/site and town/city, rather than
post? Y/N
leave, etc.)
acronyms)
ST3 Paediatrics
01.08.13
31.01.14
Y
Add name of first trust
Voluntary Medic,
Kilimanjaro Expedition
07.12.13
22.12.14
N
VSO
ST3 Paediatrics
03.02.14
31.07.13
Y
Add name of second trust if different
Locum work (name
specialty) 5 shifts
05.04.14
27.04.14
N
Add name of trust / locum agency
Time out of training: Trainee self-reported absence since last ARCP/RITA as mandated by the
GMC:
‘Time out of training’ includes all forms of absence such as sickness, maternity, compassionate
paid/unpaid leave, jury service, etc. You do not need to include study or annual leave or
prospectively approved Out of Programme Training/ Research.
HE Thames Valley Guide to complete Form R Jan14
10 days
(Sickness)
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Section 3: Declarations relating to Good Medical Practice
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.
1) I declare that I accept the professional obligations placed on me in Good Medical Practice in relation to
honesty & integrity.
Please tick/cross here to confirm your acceptance
* If you wish to make any declarations in relation to honesty & integrity, please do this in Section 6.
2) I declare that I accept the professional obligations placed on me in Good Medical Practice about my
personal health.
Please tick/cross here to confirm your acceptance
3a) Do you have any GMC conditions or undertakings placed on you by the GMC, employing Trust or other
organisation?
Yes
No
- Go to Q3b
- Go to Q4
Tick as appropriate
3b) If YES, are you complying with these conditions/undertakings?
Yes
Tick as appropriate
No
4) Health statement – Writing something in this section below is not compulsory. If you wish to declare
anything in relation to your health for which you feel it would be beneficial that the ARCP/RITA panel or
Responsible Officer knew about, please do so below.
HE Thames Valley Guide to complete Form R Jan14
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Section 4: Significant Events - 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.
Please continue on a separate sheet if required and attach and entitle ‘Appendix to Significant Events’.
**REMINDER: DO NOT INCLUDE ANY PATIENT-IDENTIFIABLE INFORMATION ON THIS FORM
1) Please tick/cross ONE of the following only:

I am NOT aware of any significant event investigations since my last ARCP/RITA/Appraisal

I am aware of significant event investigations since my last ARCP/RITA/Appraisal
2) If you know of any RESOLVED significant event 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. (Add additional lines if required).
Date of entry in Portfolio ___12.12.2013_________ Title/Topic of Reflection/Event _Drug error _________
Location of entry in Portfolio ________Development Log _______________________________
**
Date of entry in Portfolio ____________ Title/Topic of Reflection/Event _________________________________
Location of entry in Portfolio __________________________________________________________________
**
Date of entry in Portfolio ____________ Title/Topic of Reflection/Event _________________________________
Location of entry in Portfolio __________________________________________________________________
3) If you know of any UNRESOLVED significant event 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 this investigation.
N/A
HE Thames Valley Guide to complete Form R Jan14
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Section 5: 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.
**REMINDER: DO NOT INCLUDE ANY PATIENT-IDENTIFIABLE INFORMATION ON THIS FORM
1) Please tick/cross ONE of the following only:

I am NOT aware of any complaints since my last ARCP/RITA/Appraisal

I am aware of complaints since my last ARCP/RITA/Appraisal
2) If you know of any RESOLVED complaints 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. (Add additional lines if required).
Date of entry in Portfolio ____________ Title/Topic of Complaint _____________________________________
Location of entry in Portfolio __________________________________________________________________
**
Date of entry in Portfolio ____________ Title/Topic of Complaint _____________________________________
Location of entry in Portfolio __________________________________________________________________
**
Date of entry in Portfolio ____________ Title/Topic of Complaint _____________________________________
Location of entry in Portfolio __________________________________________________________________
3) If you know of any UNRESOLVED complaints since your last ARCP/RITA/Appraisal, please provide below a
brief summary, including where you were working, the date of the complaint/incident, and your reflection
where appropriate. If known, please identify what investigations are pending relating to the complaint and
which organisation is undertaking this investigation.
I have been named in a complaint by a family member of a patient. I am currently awaiting further details on
the nature of the complaint. My educational supervisor is aware, and I will discuss this further with her and
reflect on the incident once I have more information.
HE Thames Valley Guide to complete Form R Jan14
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Section 6: Other investigations - In this section you should declare any on-going investigations, such as honesty,
integrity, conduct, or any other matters that you feel the ARCP/RITA/Appraisal panel or Responsible Officer should be
made aware of. Use non-identifiable patient data only.
1) In relation to being subject to any other investigation of any kind since my last ARCP/RITA /Appraisal,
please tick/cross ONE of the following only:

I have nothing to declare

I have something to declare
2) If you know of any other RESOLVED 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. (Add additional lines if required).
Date of entry in Portfolio ____________ Title/Topic of Issue ________________________________________
Location of entry in Portfolio __________________________________________________________________
**
Date of entry in Portfolio ____________ Title/Topic of Issue ________________________________________
Location of entry in Portfolio __________________________________________________________________
**
Date of entry in Portfolio ____________ Title/Topic of Issue ________________________________________
Location of entry in Portfolio __________________________________________________________________
3) If you know of any other UNRESOLVED investigations since your last ARCP/RITA/Appraisal, please provide
below a brief summary, including where you were working, the date of the incident/investigation, and your
reflection where appropriate. If known, please identify what investigations are pending relating to the
matter and which organisation is undertaking this investigation.
Unauthorised absence at previous rotation which is being discussed with the employing Trust and School.
Full reflection can be found in entry dated 5 January 2014, named ‘Absence’ in the development log.
HE Thames Valley Guide to complete Form R Jan14
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Section 7: Compliments - 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. Please use a separate sheet if required. This section is not compulsory.
Use non-identifiable patient data only
I confirm this is a true and accurate declaration at this point in time and will immediately notify the
Deanery/LETB and my employer if I am aware of any changes to the information provided.
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.
Trainee Signature :
Sign here
HE Thames Valley Guide to complete Form R Jan14
Date:
Page 8 of 9
Appendix B
Wider scope of practice form
You do not need to complete this form if you carry out locum work in your own specialty through your
own employing organisation, but you will need to declare this work on your Form R.
All doctors in training who carry out clinical work outside of a training programme (voluntary or paid) should
declare this information on the Form R and complete the below information to share with the Educational
Supervisor.
Any work carried out as a health professional should be declared below. Examples are locum work
carried out at another organisation/specialty; editor of a medical journal; section 12 if you are a doctor in
training in Psychiatry; private practice; Territorial Army etc (add more rows below if necessary)
Type of Work (locum;
expedition; editor of medical
journal)
Start
Date
End
date
Details of Employing / Hosting Organisation / GP
Practice (name and address)
Voluntary Medic, Kilimanjaro
Expedition
07.12.13
22.12.14
VSO
Locum work Paediatrics 5
shifts
05.04.14
27.04.14
At another organisation (not employing
organisation)
To be completed by the doctor in training:
Reflection on practice noted above: (e.g. are you up to date with CPD; what have you learnt / experienced which
will change your every day practice)
Add your reflection on the above work here
Are you involved in any incidents/complaints/investigations in these roles that
are not already declared in the Form R?
Yes* / No
(delete as appropriate)
If Yes, please add further information:
To be completed by the Educational Supervisor:
Comments / developments for the doctor in training (e.g does this doctor have sufficient training / experience for
this role, CME requirements etc).
Educational Supervisor to add comments here
Name of Doctor in training:
Signature:
Date:
Name of Educational
Supervisor:
Signature:
Date:
This completed, signed form should be returned with your ARCP/RITA paperwork to Oxford PGMDE at least 2
weeks prior to the ARCP/RITA.
HE Thames Valley Guide to complete Form R Jan14
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