School of Medicine
Faculty of Medicine and Health Sciences
University of Nottingham
Intervention Request for a Medical Student
Student Name:
(block capitals)
Gender:
Male
Year of Study:
Female
State nature of concern (Please see guidance notes at end of this document)
Knowledge, skills
and performance
Safety and quality
Communication,
partnership and
teamwork
Maintaining trust
Tick Area(s) of Concern in the boxes above – see guidance for details
Please write an account of why additional support is request, describing circumstances and any witnessed
events – continue on next page if needed
Position in relation to student (eg clinical
teacher, personal tutor, administrator, student):
Self-referral (please tick if request is for yourself)
Your signature (If sent electronically a paper copy with signature should follow)
Date:
Your Details (block capitals)
Reported by:
Address:
Telephone number:
Email:
If you believe that a concern may need a student to be suspended from contact with patients, because it may
raise an immediate issue of patient safety, please contact the Dean for Medical Education directly
( Gillian.Doody@Nottingham.ac.uk Tel: 0115 82 30028) as soon as the concern is noted.
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Document Control
Intervention Request for a medical student
Lead Author: Student Support and Professionalism Coordinator
Version: 6
Date: November 2014
Review date; November 2015
(Continuation – account of concern)
Please return to: The Student Support and Development Administrator, Medical Education Centre,
B Floor, Medical School, QMC or email studentconcerns@nottingham.ac.uk For GEM students on the pre
clinical course, please send these to the School Administrative Officer, Division of GEM & Health, The
Medical School, Royal Derby Hospital, Derby.
Student ID
FOR OFFICE USE ONLY
Record ID
Year of Entry
Series of
Form
Personal
Tutor
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Document Control
Intervention Request for a medical student
Lead Author: Student Support and Professionalism Coordinator
Version: 6
Date: November 2014
Review date; November 2015
Guidance on use of the “Intervention Request Form”
Introduction
1. The “Intervention Request for a Medical Student” procedure helps identify medical students
experiencing professional, academic, personal or health problems enabling the school to secure the
appropriate level of support.
2. Filling in an intervention request form is important as it is part of the systems in place to assess the
developing professionalism of medical students. In most cases when a concern is received a student
receives advice and support to address the area of concern. Unless a concern is known, remedial
support and advice cannot be given.
3. The development and assessment of professional behaviour is part of the UG medical curriculum as
specified in GMC Tomorrow’s Doctors (2009) including that related to students being aware of the
importance of their own health. It is important that attitudes and behaviour are assessed so that
students can be supported in developing professionalism and in rare serious cases that action is taken
so that the safety and care of patients is not jeopardised. The GMC publication Medical Students
Professional Values and Fitness to Practice gives further details.
4. The intervention request form is designed to provide an effective means of communicating concerns
about medical students to the Medical School so that appropriate action may be taken to address such
concerns and help a student in the domain of developing professionalism. All medical students sign a
code of conduct on entry to the medical course which describes fully the attitudes and behaviour which
are expected of them. Logbooks and study guides further specify areas around conduct and behaviour.
Medical students are expected to follow local guidance in NHS premises related to conduct, dress,
infection control, health and safety.
5. The GMC has revised its advice on Good Medical Practice and concerns about a student map onto this
professional guidance as follows in the table on the next page
6. The form may be used by clinical staff responsible for supervising medical students, by other academic
staff, by administrative staff, health professionals with whom the student might come in contact or by
patients and members of the public.
7. The form may also be used by medical students who have concerns about a fellow medical student.
Medical students have a responsibility to report any issues that may have a bearing upon the
professionalism of others who may come into contact with patients. It may also be used for selfreferral.
8. This procedure accompanies the ‘Whistleblowing’ code of practice which gives guidance on how
medical students should raise concerns about behaviour or practice in the University or the NHS which
does not involve a medical student. The ‘Whistleblowing’ code of practice and the ‘Intervention
Request Form” are designed to complement each other.
9. A concern usually results in the student having a meeting to address the issue through education and
pastoral care. It is only very serious concerns that rarely might result in a disciplinary outcome.
10. This form will be kept on file permanently, unless negated and could be used as evidence in a Fitness to
Practice investigation.
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Document Control
Intervention Request for a medical student
Lead Author: Student Support and Professionalism Coordinator
Version: 6
Date: November 2014
Review date; November 2015
Domain
Knowledge, skills and performance
Sub domain
Develop and maintain your
professional performance
Apply knowledge and
experience to practice
Examples of concern *
Not making good progress in developing clinical
skills
Failure to attend scheduled teaching sessions or
tutor sessions
Not attending appointments or meetings
Lack of commitment
Record your work clearly,
accurately and legibly
Not maintaining appropriate professional
boundaries
Inappropriate dress
Failure to respond to the training environment
despite support
Working beyond specified limitations. Failure to
follow guidelines or instructions.
Poor record keeping in logbook or similar
Illegible handwriting
Failure to maintain confidentiality
Safety and quality
Contribute to and comply with
systems to protect patients
Respond to risks to safety
Protect patients and colleagues
from any risks posed by your
health
Communication, partnership and
teamwork
Maintaining trust
Communicate effectively
Work collaboratively with
colleagues to maintain or
improve patient care
Teaching, training, supporting
and assessing
Continuity and coordination of
care
Establish and maintain
partnerships with patients
Show respect for patients
Failure to comply with instructions around infection
control
Any action that might lead to patient safety being
compromised
Failure to report witnessed inappropriate attitude or
conduct by another person
A health issue (withdrawn, depressed, anxious)
A health issue that may need a review by
Occupational Health
Alcohol or substance misuse
Not responding to communications (emails,
telephone calls, letters)
Poor communication skills
Poor interaction with colleagues or staff
Being rude to staff or colleagues
Inappropriate use of language
Inappropriate conduct in teaching session
Unable or unwilling to work as part of a team
Poor interactions with patients
Rudeness to patients or their relatives
Treat patients and colleagues
fairly and without discrimination
Act with honesty and integrity
Examination of patients without permission or
consent
Inappropriate discrimination. Bullying or harassment
Dishonesty. Breach of codes or regulations.
Criminal caution or conviction
Falsifying attendance record
Falsifying a logbook signoff
Plagiarism or cheating
*Some of these areas might be more appropriately dealt with through the “Support Request for a Medical
Student” form
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Document Control
Intervention Request for a medical student
Lead Author: Student Support and Professionalism Coordinator
Version: 6
Date: November 2014
Review date; November 2015
Notes
1. Intervention forms raised anonymously will not normally be considered.
2. All concerns will be treated in confidence but we cannot guarantee that the identity of the person raising
the concern will not be revealed. In the rare event of a concern about a student proceeding to the
fitness to practise committee, only in exceptional circumstances will their identity not be disclosed.
3. Raising concerns maliciously, recklessly or irresponsibly will be considered to contravene the
Nottingham University Code of Conduct for Medical Students and may result in a FTP referral in itself.
What happens next?
1. Following receipt of an Intervention Request Form, the Student Support and Professionalism
Coordinator, Medical Education Centre, will, as soon as possible, either refer the case to an appropriate
Senior Tutor or Clinical Sub-Dean or in some cases directly to the Associate Dean for Medical
Education for review. The student, about whom the concern has been expressed, may be required to
attend a meeting to discuss the concern.
2. The Senior Tutor or Clinical Sub-Dean will decide on one the following:
a) Recommend negation of the intervention request, if confirmed, all records destroyed (see point 4
below).
b) Commence an educational approach, record to be held on student’s file. Progress monitored by
Clinical Sub Dean or Senior Tutor.
c) Refer for counselling/support:
 Academic Progress Committee
 Divert to “Support Request for a Medical Student” procedure
Record held on student’s file.
d) Verbal or written warning, record to be held on student’s file.
e) Refer the case on to the Associate Dean for Medical Education for review (see below).
The student will be informed of the outcome of the review of the concern within 10 working days of the
referral except in exceptional circumstances
3. For more serious concerns, the Associate Dean for Medical Education will decide whether cases
should be referred directly to an appropriate committee, procedure or agency for consideration.
Depending on the nature of the concern and whether there have been previous expressions of concern,
the student may be referred, for example to one or more of the following:





The Academic Offences Committee
The Senate Disciplinary Committee
The Fitness to Practise procedure.
Any other appropriate University procedure, for example to comply with the Dignity
(harassment) Policy.
An external body such as an NHS Trust or, if criminal activity is suspected, the police.
4. The Associate Dean for Medical Education will also consider all recommendations for an intervention
request to be negated and will discuss each recommendation with either a Senior Tutor or Clinical SubDean different to the one making the initial review, or the Student Welfare Manager. Upon confirming
such a recommendation this will be communicated to the Student Support and Professionalism
Coordinator who will ensure that the intervention request form is removed from the student file. This
will be in exceptional circumstances.
The student will normally be informed of the outcome within 5 working days.
5. Unless the intervention request has been negated, upon closure of the review:
 The student’s Personal Tutor will be advised of their tutee’s involvement in an Intervention
Request form, (with specific details being released only with the student’s agreement).
 The person who submitted the form will also receive notification that the matter has been dealt
with and the manner of disposal.
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Document Control
Intervention Request for a medical student
Lead Author: Student Support and Professionalism Coordinator
Version: 6
Date: November 2014
Review date; November 2015
 The request form will be kept on file permanently and could be used as evidence in a Fitness to
Practice investigation.
6. Should a student be referred to the Fitness to Practice procedure, the student’s Personal Tutor will be
informed of any stage by stage process (if appropriate) until the matter is closed. This guidance will be
provided by the Faculty FTP Committee as well as the School of Medicine UG Curriculum Group to
ensure consistency, fairness and proportionality.
Support and Follow-Up
Where appropriate, the Senior Tutor/Clinical Sub Dean or their nominee will agree a support plan to help the
student which may involve the University Student Services Centre, a Senior Tutor or Clinical Sub-Dean and/or
medical or other support. A student may be required to attend remediation.
The staff member should ensure that follow-up continues until both the student and staff member agree that
support is no longer needed. This decision will be documented and a record held in the student file.
Page 6 of 6
Document Control
Intervention Request for a medical student
Lead Author: Student Support and Professionalism Coordinator
Version: 6
Date: November 2014
Review date; November 2015