Proforma for Requesting Revalidation Specialty Advice

Proforma for requesting Revalidation specialty advice

Please complete this form and email to:

Before contacting the Helpdesk, please refer to the Supporting Information for Appraisal and Revalidation: Guidance for Obstetrics and Gynaecology and/or Sexual and Reproductive Healthcare.
https://www.rcog.org.uk/globalassets/documents/cpd/revalidation/rcogfsrh_og_revalidation_resource_v4.pdf
Please click on the grey fields to complete this form. You can add as much information as you need in the grey text fields as they will expand. Once you have completed the form, please save it on your PC and then email it as an attachment to
Date of enquiry: / Title of enquirer (Mr, Ms, etc)
Surname of enquirer:
Forename of enquirer:
Role / RO: / Appraiser: / Appraisee / Other (specify):
RCOG Fellow or Member: / FSRH member:
Organisation name:
Location:
Telephone:
Email:
Is your request for advice related to Obstetrics and Gynaecology?
Is your request for advice related to Sexual and Reproductive Health Care?
Is this a follow-up to a telephone enquiry?
Specialty advice required
Any request for advice must be in relation to a situation or set of circumstances and not to an individual.
Please describe the situation on which you require advice:
Privacy notice
The RCOG collects and stores personal information for the purposes of providing benefits and services to its membership and associates. If you do not wish your details to be used in this manner, please tick this box:
From time to time, the College may occasionally release details of its members and associates to carefully selected third parties for marketing and survey purposes. If you consent to your details being passed on to such organisations for these purposes, please tick here:
Helpdesk action only:
ENQUIRY ID NUMBER:
Date request received:
Date dealt with by helpdesk:
Action taken:
Date passed to specialty advisor (without name of the enquirer):
Name of specialty advisor:
Date response received from specialty advisor:
Specialty advisor response:
Date email response drafted:
Response reviewed by: / Date:
Final response to enquirer (with disclaimer):
Disclaimer: The RCOG gives this advice on specialty specific matters in response to a specific request. The RCOG prepares or gives such advice in principle, based on the fact presented to them, with reasonable care and in good faith.
Date final response sent to enquirer:

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