GP EDUCATIONAL PATHWAYFOUNDATION SUPERVSIOR ONLY APPLICATION FORM

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SECTION A: Person Specification
Are you a Salaried or Partner GP in your practice for a minimum of 4 sessions per week? / YES / NO
Are you a Retainer, refresher or Locum? / YES / NO
Do you have MRCGP? / YES / NO
Will you have you been a qualified GP for at least 3 years, at the time of hosting and FY2? / YES / NO
If no, when did you qualify as a GP? / _____/____/_____
Will you have been in the same practice for at least 1year at the end of Part 1 course in Autumn? (Please note that you need to notify us if your situation changes) / YES / NO
When did you join your current practice? / _____/____/_____
Do you have the full support from your fellow GPs and the practice? / YES / NO
Do you have any other job roles, inside or outside of the Practice? / YES / NO
If yes, state no. of sessions and describe the role/s:
SECTION B: PLEASE INDICATE YOUR INTENTIONSFOR TRAINING:

I would like to train to become a Medical Educator and Foundation Supervisor ONLY

/ YES
Do you have any intention to apply to become a GP Trainer in the next 2 years? / YES / NO
Do you have any intention to apply to become a GP Trainer in the future? / YES / NO
SECTION C: CONTACT DETAILS

First Name

Surname
Practice Name and Address
Practice Telephone
Mobile Telephone
Email
Practice Manager
Practice Manager Telephone
Practice Manager Email
Date of Birth
GMC no.
Defence Organisation
SECTION D: PRACTICE DETAILS
Is your Practice a GMC approved GP Training Practice in the HEKSS area? / YES / NO
If yes, how many approved GP Trainers and Foundation Supervisors are in the Practice at this time?
Does the practice take Medical Students? / YES / NO
Total practice QoF points for the last complete year (April – April). / / 900
Has your practice had a CQC visit in the last year?
Were there any recommendations made about the practice?
If yes please describe on a separate page. / YES / NO
YES / NO
What % of Patient notes have been summarised to date? / %
Total number of FY2s / ST Traineesor Paramedics your practice can accommodate at the same time?
Is your practice willing to have a Nurse Mentor and host Trainee Nurses as part of the Community Education Provider Network (CEPN)? / YES / NO
Your Local CCG / LocalHospital Trust
Practice Type / Urban / Rural / Mixed
Practice status / GMS / PMS / Other
Number of patients / (please indicate in thousands)
Is your Practice team willing to support FY2 doctors and non GP trainees? / YES / NO
SECTION E: FUNDING & SIGNATURE
Please note:
Terms of application from 01 January 2013:
I would like to apply for the educational pathway to become an Foundation Supervisor.
I am aware that funding is not available from HEKSS to reimburse any locum costs for attending any of the educational pathway courses.
I agree to make myself available for hosting FY2 Doctors on completion of the course and I have no intentions to move from KSS in the next 5 years.
I understand the above and agree to abide by the terms and conditions listed. / Course Required
Educator Pathway Introduction Day
Foundation Supervisor Educators Course (Part 1)
Print Name (FS):
Signature:
Foundation Supervisor Applicant
Date:

Please return the signed and completed application together with form Form FS2to

Lizzie Hall, Educational Pathway

Health Education KSS, 7 Bermondsey Street, London, SE1 2DD. Tel 020 7415 3435

FOR OFFICE USE ONLY

Form FS1 Recv’d / Form FS1a Sent LMC / LAT / Form FS5 EOD Sent
Form FS2 Recv’d / Form FS1a Rec’d LMC / LAT / Form FS5 EOD Recv’d
Form FS1a Sent / FSAQ FS4 Rec’d / Scanned & filed

Foundation SupervisorApplication Form V1Page 1 of 2 August 2014 –Form FS1