Form R: Registering for Postgraduate Specialty Training2

Form R: Registering for Postgraduate Specialty Training2

SHA:
Deanery: / Forename (s):
Surname:
Medical School awarding primary qualification: (name and country) / Date of Birth: / Attach Passport Size Photo
GMC/GDC Reg No.:
Primary Qualification and date awarded: / Gender:
Work Address:
Work Phone:
Email: / Home/Other Address:
Home Phone:
Mobile Phone:
Email:
Immigration Status:
(eg resident, settled, work permit required) / Post Type or Appointment:
(e. LAT, Run Through, FTSTA etc.)
GMC Programme Approval Number:
(to be completed by Postgraduate Dean)
Deanery Reference Number:
Specialty: / National Training Number:
(to be completed by Postgraduate Dean on first registration)
I confirm that I have been appointed to a programme leading to award of a CCT subject to satisfactory progress 
Specialty 1 for Award of CCT:
Specialty 2 for Award of CCT: / I confirm that I will be seeking specialist registration by application for a CESR 
I confirm that I will be seeking specialist registration by application for a CESR CP 
I confirm that I will be seeking GP registration by application for a CESPR 
I confirm that I will be seeking GP registration by application for a CEGPR CP 
Provisional Date for CCT/CESR/CEGPR Award: / Royal College/Faculty assessing training for the award of CCT (if undertaking full prospectively approved programme):
Initial Appointment to Programme:
(Full time or % of Full time Training) / Date of Entry to Grade/Programme:
(Substantive date started in Programme of appointment)

I confirm that information recorded above is correct

Specialty Trainee:______Date:______

Postgraduate Dean/Head of School/
STC Chair/TPD:______Date:______

2 (to be confirmed on appointment to/ on entering specialty training and before a National Training Number (NTN) or Deanery Reference Number (DRN) is issued. Must be updated and submitted annually with the Postgraduate Dean in order to renew registration for specialty training

Dear Postgraduate Dean

Conditions of taking up a Training Post

(Note: this is NOT an offer of employment)

By accepting an offer of a place on training programme in the West Midlands Deanery, I agree to meet the following conditions throughout the duration of the programme:

• To always have at the forefront of my clinical and professional practice the principles of Good Medical Practice for the benefit of safe patient care.

• To be aware that Good Medical Practice (2006) requires doctors to keep their knowledge and skill up to date throughout their working life, and to regularly take part in educational activities that maintain and further develop their competence and performance.

• To ensure that the care I give to patients is responsive to their needs, that it is equitable, respects human rights, challenges discrimination, promotes equality and maintains the dignity of patients and carers.

• To acknowledge that as an employee within a healthcare organisation I accept the responsibility to abide by and work effectively as an employee for that organisation, including participating in workplace based appraisal as well as educational appraisal and acknowledging and agreeing to the need to share information about my performance as a doctor in training with other employers involved in my training and with the Postgraduate Dean on a regular basis.

• To maintain regular contact with my Training Programme Director (TPD) and the Deanery by responding promptly to communications from them, usually through email correspondence.

• To participate proactively in the appraisal, assessment and programme planning process, including providing documentation which will be required to the prescribed timescales

• To ensure that I develop and keep up to date my learning portfolio which underpins the training process and documents my progress through the programme

• To use training resources available optimally to develop my competences to the standards set by the specialty curriculum

• To support the development and evaluation of this training programme by participating actively in the national annual GMC/COPMeD trainee survey and any other activities that contribute to the quality improvement of training.

• To accept the need to work within the policies and procedures of each NHS employer and meet the standards of employment required by them.

I acknowledge that my national training number (NTN) could be removed by the Postgraduate Dean and that I could be required to leave the training programme if I fail to meet these conditions. I understand that this document does not constitute an offer of employment.

Yours faithfully

Signed: ______Date: ______

Print Name: ______

[Please sign and also print your name above]

Chairman: Sarah Boulton

Chief Executive: Sir Neil McKay CB

West Midlands Strategic Health Authority – Workforce Deanery

Equality and Diversity Monitoring Form

The West Midlands Deanery strives to operate a policy of equality and diversity and not discriminate against any person. The information you provide will be treated in the strictest confidence and is for monitoring purposes only.

Please note: to make your selection, double click on the box field and select “checked” under default value.

Title: ______ / Surname: ______ / Forenames: ______
Date of Birth: ___/___/_____ / GMC/GDC No: ______
Ethnic Origin (please indicate by a tick in the appropriate box)
White / Mixed / Black or Black British
British / White and Black Caribbean / Caribbean
Irish / White and Black African / African
Any other White background / White and Asian / Any other Black background
Any other mixed background
Asian or Asian British / Other Ethnic groups / Not Stated
Indian / Chinese
Pakistani / Any other ethnic group / I do not wish to disclose my
ethnic group
Bangladeshi
Any other Asian background
Gender: / Male / Female / Hours of Post: / Full Time / Part Time
Age Group
16-19 / 20-24 / 25-29 / 30-34 / 35-39 / 40-44
45-49 / 50-54 / 55-59 / 60-64 / 65 or over
Sexual orientation / Religion or Belief
Please select that which best describes your sexuality: / Please indicate your religion or belief:
I do not wish to disclose my sexual orientation / Atheism / Buddhism
Lesbian / Christianity / Hinduism
Gay / Islam / Jainism
Bisexual / Judaism / Sikhism
Heterosexual / Other / I do not wish to disclose my religion/belief
Transgender
Do you now present full or part-time in a gender role that differs from the gender assigned to you at birth?
Yes / No
Marital Status
Single / Married/Civil Partnership / Divorced
Widowed / Common Law Partnership / Other

West Midlands Strategic Health Authority – Workforce Deanery

Disability
A person has a disability under the Disability Discrimination Act if he/she has a physical or mental impairment which has a substantial and long term adverse effect on his/her ability to carry out normal day to day activities. Long term means has lasted, or is expected to last, for 12 months. Do you consider yourself to be a disabled person?
Yes / No / I do not wish to disclose whether or not I have a disability
If answering yes, please give details of your disability below:
Are you blind or do you have a visual impairment?
Do you have learning difficulties?
Are you a person with experience of mental health distress?
Do you use a hearing aid or communicate using BSL or any other Sign Language?
Do you use a walking stick or a wheelchair?
Do you have any other medical conditions (e.g. diabetes, epilepsy, Multiple Sclerosis, back problem etc. – please state)?

Thank you for completing this form