Form R (Part A)
Trainee registration for Postgraduate Specialty Training
IMPORTANT: If this form has been pre-populated by your Deanery/LETB, please check all details, cross out errors and write on
amendments. By signing this document you are confirming that ALL details (pre-populated or entered by you) are correct.
Forename
GMC-registered surname
GMC Number
Deanery / LETB
Date of Birth:
Gender:
Primary Qualification and date awarded:
Medical School awarding primary qualification (name and country):
Current Home Address:
Current Work Address:
Home Phone / Mobile:
Work Phone / Mobile:
{If newly registering,
attach passport-sized
photo of face here}
Preferred email address for all communications:
Immigration Status:
Post Type or Appointment:
(e.g. resident, settled, work permit required)
(e.g. LAT, Run Through, core trainee, FTSTA etc.)
Programme Specialty:
National Training Number:
(to be completed by Postgraduate Dean on first registration)
GMC Programme Approval Number:
(to be completed by Postgraduate Dean)
Deanery Reference Number:
(to be completed by Postgraduate Dean)
Specialty 1 for Award of CCT (if applicable):
Specialty 2 for Award of CCT (if applicable):
Please tick only one of these three options :
I confirm I have been appointed to a programme
leading to 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 CEGPR
Provisional CCT Date (or CESR/CEGPR where
applicable), if known:
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 the information above is correct.
I confirm I have read and accept the terms and conditions of joining a Specialty Training Programme
Trainee Signature :
Date:
Signature of Postgraduate Dean or
representative of PGD:
Date:
(*for Deanery/LETB use only upon return)
Conditions of joining a Specialty Training Programme
(Note: this is NOT an offer of employment)
Dear Postgraduate Dean
On accepting an offer to join a training programme (Specialty, Core or FTSTA/LAT) in the Health Education North
East, I agree to meet the following conditions throughout the duration of the programme:
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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. Trainees should 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; this includes 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 Health Education North East
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 trainee survey and any other activities that contribute to the quality improvement of
training
I will collect, demonstrate and reflect my practice through appraisal and complete the Enhanced Form R on
an annual basis for Revalidation purposes.
Collection & use of personal information:
The data collected about you will be stored on Health Education North East Intrepid database. The information
held will be used to communicate with you and may be shared with NHS and other related organisations in relation
to your employment, training and assessment within Health Education North East. These organisations include the
Department of Health, GMC (PMETB), GDC, Royal Colleges/Faculties and Trusts. Health Education North East will
process all personal data in accordance with the eight principles of good practice as set out in the Data Protection
Act (1998). Should you have any questions regarding the use of your data please contact the Data Protection/FOI
Lead on comms@ne.hee.nhs.uk or write to us at Waterfront 4, Goldcrest Way, Newcastle upon Tyne, NE15 8NY.
I acknowledge the importance of these responsibilities. If I fail to meet them I understand that the Postgraduate
Dean may require me to meet with him/her to discuss why I have failed to comply with these conditions. I
understand that this document does not constitute an offer of employment.