Why Are You Asking Me to Fill in This Questionnaire?

GCC Test of Competence Evidence of Practice Questionnaire

Your details Name: Click here to enter text. Contact Number: Click here to enter text. UK Contact Number: Click here to enter text. (If different from above) Email Address: Click here to enter text.

Introduction All chiropractors who wish to practise in the United Kingdom must first of all register with the General Chiropractic Council (GCC). However, before we can register you, you will need to show us that you meet the standards set out in The Code, Standards of Conduct, Performance and Ethics for Chiropractors (http://www.gcc- uk.org/UserFiles/Docs/G20.006%20CofP_stage%203%20hyperlinks%202708.pdf)

Why are you asking me to fill in this questionnaire? We will check the information you provide on this Evidence of Practice Questionnaire, along with the contents of your qualification to inform the test interview. This is so that you can show us how you meet the same standards as those chiropractors who have a qualification that we recognise.

As the applicant it is your responsibility to send us the information that we ask you for, we will not be seeking it on your behalf.

This questionnaire forms a key part of your application and will be considered by the TOC assessment panel along with the content of your chiropractic education before the test. You will also be asked questions about it during the TOC interview.

Before filling in the questionnaire, you should make yourself very familiar with The Code, Standards of Conduct, Performance and Ethics for Chiropractors. (June 2016) This is because we will need to make sure you meet the standards in the Code before the Registrar grants you registration. Also, these are the standards you must maintain all the time you are on the Register.

How do I fill in this questionnaire? The questionnaire is split into 8 sections, in sections 1 – 7 you are asked to give details on your practise as a chiropractor. There are text boxes for each response which you can click on and then type in.

In sections with check boxes, you can simply click on the check box to select it.

of 30 In this questionnaire we ask you to demonstrate your understanding of our Code by linking aspects of your practice to the principles and standards in it. You are also likely to be asked about the Code during the Test of Competence interview.

The questionnaire focuses on your practice. You are asked to provide specific examples of what you have done – this should be where you have taken clinical responsibility for a case. You must complete the questionnaire yourself and without help.

What evidence must I send to back up the answers I give on the questionnaire?

Anonymised Patient Records This questionnaire requires you to attach anonymised patient records to support your answers to Sections 2, 3 and 4. You must also clearly label which of your records relate to which section of the questionnaire. You do not need to provide patient records for all the patients mentioned in Section 1. Where real clinical cases or examples are asked for, we expect you to normally use cases or examples within the last 24 months.

You must protect patient confidentiality by anonymising any patient information. If you do not do this, we will have concerns that you are not able to meet the duty of confidentiality set out in our Code. Please note that anonymised patient records will be used for the sole purpose of the Test of Competence. The GCC will not use them for any other purpose nor share the records with any third parties.

Please note that the patient records are compulsory supporting evidence in your application to take the TOC. You must provide complete patient records including case histories.

What if I’m not unable to obtain and anonymise real patient records for some reason? If you are an educationist who does not treat patients you may use the clinical cases of chiropractic students that you have supervised rather than ones you have assessed or cared for directly. But make sure your role and the actions you took in relation to the patient are made clear. If you are a recent graduate you may use patient notes taken as part of your supervised practical sessions within your course.

We recommend that you obtain real anonymised patient records where possible. We will accept patient records taken while observing or shadowing chiropractic care. In instances where you have exhausted all other options of obtaining real records, you may create patient records based on real patients you have treated or cases you have observed. In this case, you must ensure that you make explicit on your application that you have not provided real patient records and provide us with an explanation for why you have been unable to obtain these. Please be aware that if you are unable to submit real records, you will be subject to a longer, more intensive, interview process to ensure that you meet the standards. If you have queries in regards to patient records,

of 30 please contact the GCC for guidance either on 020 7713 5115, or email us at [email protected]

The maximum word counts given in each section of the questionnaire are mandatory. We are interested in the quality of your response not its quantity. We will not consider any words beyond the maximum word count.

What happens when you receive my application and questionnaire? When we receive your completed questionnaire, a member of the GCC staff will check that you have completed all of the section and provided all required information and kept within the word count. If you have, then your application will be passed to the assessment panel.

It is in your own interest to check the questionnaire before you send it to us, this is because your application will be delayed if we need to contact you for further information or ask you to resubmit the questionnaire.

The TOC assessment panel will then consider your responses in this questionnaire before you take the assessment interview. They will look at the questionnaire to see how you have demonstrated to us your understanding of the Code and practising in the UK.

What about the interview itself? The TOC assessment interview will focus on:  your responses to this questionnaire  requirements set out in the Code, specifically where we have identified differences in content between our standards and those of other chiropractic regulatory authorities across the world.

Also remember…  the questionnaire must be completed in English and typed. Hand written questionnaires will be returned.  to clearly label any diagrams or charts you include in your response .

Standards of behaviour we expect from applicants Our Student Fitness to Practise guidance (http://www.gcc- uk.org/UserFiles/Docs/FtPGuidanceforStudents.pd f) sets out the standards of behaviour that we require of chiropractic students and prospective registrants. It outlines the seriousness of behaviours such as plagiarism. If we find an applicant has submitted evidence that it is not their own work, this will raise serious questions about their fitness to register with us.

When you have filled in this questionnaire, please send it, together with your evidence, to: [email protected]

of 30 Section 1: profile of your caseload This section is designed to give us an insight into:  the scope and breadth of your clinical practice  a profile of the patients you have provided chiropractic assessment and care to; and  how you collect and analyse data about your professional practice. Please identify 10 patients in your caseload and then fill in the information in the table below about each of those patients. When identifying the patients’ health needs, remember we are interested in the individual’s main health needs which helped you to maintain your knowledge, skills and competence. You are not required to submit patient records for all 10 of these cases. Health needs (Might include health problems/ conditions/ injuries you were Patient Age presented with, what the patient reported to you, information on the symptoms presented, and any medication they were on. Information may also include any past treatments or tests.) 1. Click here to enter text. Click here to enter text.

2. Click here to enter text. Click here to enter text.

of 30 Health needs (Might include health problems/ conditions/ injuries you were Patient Age presented with, what the patient reported to you, information on the symptoms presented, and any medication they were on. Information may also include any past treatments or tests.) 6. Click here to enter text. Click here to enter text.

Describe here how the above group of 10 patients you have selected and their health needs have helped you to maintain your clinical and professional knowledge, skills and competence. Link this to our Code. (Maximum total number of words - 600) Click here to enter text.

of 30 Word count (max 600) = Click here to enter text. Explain here how you identify your patients’ health needs (Maximum total number of words - 200) Click here to enter text.

Word count (max 200) = Click here to enter text.

of 30 Section 2: a neuromusculoskeletal case presentation Describe a case in which a patient presented with neurological symptoms and where you suspected or found neurological involvement as a result of musculoskeletal dysfunction. This can be one of the patients you included in section 1 or another patient. You must respond to all aspects of this section from a – l, using a maximum number of 2,000 words for this whole section. You must send us an anonymised copy of the complete patient record. a) the case history including the patient profile, presenting complaint, and relevant medical, family and social history Click here to enter text. b) the methods you used to physically examine the patient and why you chose these methods Click here to enter text. c) how did you check for, identify and address any extremity conditions if relevant? Click here to enter text. d) if you obtained further information or carried out further investigations (eg clinical imaging, laboratory tests) on the patient and why you did this Click here to enter text. e) your evaluation of the patient’s health and health needs, including any relevant physiological, psychological, and social factors Click here to enter text. f) your differential diagnosis / rationale for care Click here to enter text. g) whether the case was: i. suitable for chiropractic treatment, and if so your treatment and management plan based upon your working diagnosis / rationale for care, the patient, and the likely effects and/or risks of treatment ii. not suitable for chiropractic treatment and the steps you took to ensure ongoing care for the patient Click here to enter text. h) what you told the patient about the risks of the treatment and the management plan

of 30 Click here to enter text. i) how you involved the patient in making informed decisions about their care Click here to enter text. j) your ongoing management of the patient, including the frequency and duration of care, the frequency of patient review / re-evaluation, the evidence for the care used, any outcome measures you used, whether you changed your treatment approach through the course of the treatment and the reasons for this Click here to enter text. k) how you applied chiropractic principles and concepts in the assessment and care of the patient Click here to enter text. l) Which specific, relevant sections of the Code does this refer to? Click here to enter text. Total word count (max 2,000) = Click here to enter text.

of 30 Section 3: a case presentation in which the patient was considered unsuitable for chiropractic treatment and/ or was referred to another healthcare practitioner

Describe a recent case in which, after clinical evaluation, you concluded that the patient was either unsuitable for chiropractic care or you referred them to another healthcare professional for co-management. This can be one of the patients you included in section 1 or another patient. It should be a different case to the ones you used in sections 2 and 4 of this questionnaire. You must respond to all aspects of this section from a – m, using a maximum number of 2,000 words for this whole section. You must send us an anonymised copy of the complete patient record. a) the case history including the patient profile, presenting complaint, and relevant medical, family and social history Click here to enter text. b) the methods you used to physically examine the patient and why you chose these methods Click here to enter text. c) how did you check for, identify and address any extremity conditions if relevant? Click here to enter text. d) if you obtained further information or carried out further investigations (eg clinical imaging, laboratory tests) on the patient and why you did this Click here to enter text. e) your evaluation of the patient’s health and health needs, including any relevant physiological, psychological, and social factors Click here to enter text. f) your differential diagnosis / rationale for care Click here to enter text. g) why you concluded that the case: a. was not suitable for chiropractic treatment b. required referral to another healthcare professional and how this would benefit the patient Click here to enter text.

of 30 h) the actions that you took and your role in the patient’s ongoing care Click here to enter text. i) how you involved the patient in making this decision and gained their consent

Click here to enter text. j) the mechanism you used for referring the patient – supply a copy with your questionnaire Click here to enter text. k) the outcome of the referral and any ensuing modification of your treatment and management plan Click here to enter text. l) the evidence that informed your practice Click here to enter text. m)Which specific, relevant sections of the Code does this refer to?. Click here to enter text.

Total word count (max 2,000) = Click here to enter text.

of 30 Section 4: a case presentation in which you concluded that certain techniques were unsuitable (contra-indicated) Describe a recent case in which, after clinical evaluation, you concluded that some chiropractic techniques should not be used with the patient because they were unsuitable (contra-indicated). This can be one of the patients you included in section 1 or another patient. It should be a different case from the ones you use in sections 2 and 3 of this questionnaire. You must respond to all aspects of this section from a – l, using a maximum number of 2,000 words for this whole section. You must send us an anonymised copy of the complete patient record. a) the case history including the patient profile, presenting complaint, and relevant medical, family and social history Click here to enter text. b) the methods you used to physically examine the patient and why you chose these methods Click here to enter text. c) how did you check for, identify and address any extremity conditions if relevant? Click here to enter text. d) if you obtained further information or carried out further investigations (e.g. clinical imaging, laboratory tests) on the patient and why you did this Click here to enter text. e) your evaluation of the patient’s health and health needs, including any relevant physiological, psychological, and social factors Click here to enter text. f) your differential diagnosis / rationale for care Click here to enter text. g) whether the case was suitable for chiropractic treatment and if so your management plan based upon your working diagnosis / rationale for care, the patient, and the likely effects and/or risks of treatment

of 30 Click here to enter text. h) why you concluded that the case: i. some chiropractic techniques were contraindicated for this patient ii. how you selected the techniques that you decided to use and how you explained this to the patient Click here to enter text. i) how you involved the patient in making this decision and gained their consent to the treatment used Click here to enter text. j) your ongoing management of the patient, including the frequency and duration of care, the frequency of patient review / re-evaluation, the evidence for the care used, any outcome measures you used, whether you changed your treatment approach through the course of the treatment and the reasons for this Click here to enter text. k) how you applied chiropractic principles and concepts in the assessment and care of the patient Click here to enter text. l) Which specific, relevant sections of the Code does this refer to? Click here to enter text.

of 30 Section 5: Definition of Acronyms and Abbreviations In the table below please list all acronyms and abbreviations you have used in both your case presentations and in your supporting patient records. (This section will not be used to assess competence but will be used to inform the review of your evidence.) Abbreviation/ Definition Where in your application has this been Acronym used? (Please state the document and the particular page(s) it is used on.)

Click here to Click here to enter text. Click here to enter text. enter text.

of 30 Abbreviation/ Definition Where in your application has this been Acronym used? (Please state the document and the particular page(s) it is used on.)

Click here to Click here to enter text. Click here to enter text. enter text.

of 30 Section 6: application of patient management We wish to gain an understanding of the methods of chiropractic patient management that you use and how these relate to those specified in our education standards that set out what chiropractic degrees have to cover to be recognised by the GCC. We will not be making an assessment of this information directly but will use it to inform the interview process. Check one box for column a – c for each row of the table below and give brief details of the contraindications and cross referencing in columns c) and d) to show the following: a) your familiarity with the techniques/ elements of patient management. b) how frequently you use them in practice c) contra-indications to the use of the techniques (if applicable) d) cross – referencing with your cases (i.e. When was this element of patient management used within the cases you have presented in sections 2 - 4) the outcomes measures you use (see final row of the table.)

Patient (a) Familiarity (b) Frequency of use (c) Contra-indications (d) Cross-referencing management

Give Partly Very familiar Unfamiliar Frequently Occasionally Never brief Give brief details familiar details Assessment Case history ☐ ☐ ☐ ☐ ☐ ☐ Click Click here to enter here text. to enter text.

of 30 Patient (a) Familiarity (b) Frequency of use (c) Contra-indications (d) Cross-referencing management Physical ☐ ☐ ☐ ☐ ☐ ☐ Click Click here to enter examination here text. methods to enter text. Laboratory ☐ ☐ ☐ ☐ ☐ ☐ Click Click here to enter tests here text. to enter text. Plain film ☐ ☐ ☐ ☐ ☐ ☐ Click Click here to enter radiographs here text. to enter text. Other forms ☐ ☐ ☐ ☐ ☐ ☐ Click Click here to enter of imaging (eg here text. CT scans, to MRI scans) enter text. Assessment of ☐ ☐ ☐ ☐ ☐ ☐ Click Click here to enter extremities here text. to enter text.

of 30 Patient (a) Familiarity (b) Frequency of use (c) Contra-indications (d) Cross-referencing management Chiropractic care - manipulation Soft tissue ☐ ☐ ☐ ☐ ☐ ☐ Click Click here to enter techniques here text. to enter text. Articulatory ☐ ☐ ☐ ☐ ☐ ☐ Click Click here to enter techniques here text. to enter text. Thrust ☐ ☐ ☐ ☐ ☐ ☐ Click Click here to enter techniques here text. to enter text. Other chiropractic interventions Advice, ☐ ☐ ☐ ☐ ☐ ☐ Click Click here to enter explanation here text. and to reassurance enter text. Exercise and ☐ ☐ ☐ ☐ ☐ ☐ Click Click here to enter rehabilitation here text. to

of 30 Patient (a) Familiarity (b) Frequency of use (c) Contra-indications (d) Cross-referencing management enter text. Multi- ☐ ☐ ☐ ☐ ☐ ☐ Click Click here to enter disciplinary here text. approaches to enter text. Preventive ☐ ☐ ☐ ☐ ☐ ☐ Click Click here to enter measures here text. to enter text. Supporting ☐ ☐ ☐ ☐ ☐ ☐ Click Click here to enter the patient’s here text. health and to wellbeing enter with others text. Promoting ☐ ☐ ☐ ☐ ☐ ☐ Click Click here to enter health and here text. wellbeing to enter text. Advising on ☐ ☐ ☐ ☐ ☐ ☐ Click Click here to enter medications here text. to

of 30 Patient (a) Familiarity (b) Frequency of use (c) Contra-indications (d) Cross-referencing management enter text. e) Do you use outcome measures for your chiropractic care? And if so, which outcome measures do you use? Click here to enter text.

If you refer out for some methods of assessment (e.g. laboratory tests), please indicate this in your response in the table below. For each of the three cases you discussed in sections 2 – 4, explain your rationale for choosing the forms of patient management that you used (for assessment and care) and demonstrate their relationship to the Code Maximum 400 words for each part of this section Case study referred to in section 2: A neuromusculoskeletal case presentation Click here to enter text.

Word count (max 400) = Click here to enter text. Case study referred to in section 3: A case presentation in which the patient was considered unsuitable for chiropractic treatment / was referred to another healthcare practitioner Click here to enter text.

of 30 Word count (max 400) = Click here to enter text. Case study referred to in section 4: A case presentation in which you concluded that certain techniques were unsuitable (contra-indicated) Click here to enter text.

Word count (max 400) = Click here to enter text.

of 30 Section 7: learning undertaken in the last three years We are interested in understanding how you function as a self-directed learner. We are interested in any assessment and learning activities that you have undertaken in relation to chiropractic, including: peer review, patient feedback, self-reflection, professional networking, audit, lectures, seminars, conferences, case studies, online learning etc. Include any specific learning activities that you have undertaken in readiness for your potential move to the UK. If you are a student / new graduate, then please relate the headings below to your development as a student. If you are an experienced practitioner, then relate your answers to your Continuing Professional Development (CPD). You must respond to all aspects of this section from a – g, using a maximum number of 1,500 words for this section. a) how you have assessed your learning needs and interests Click here to enter text. b) how you have planned your learning Click here to enter text. c) the learning and development you have undertaken to: a.i. keep your professional knowledge and skills up-to-date a.ii. monitor and enhance the quality of chiropractic assessment and care you provide Click here to enter text. d) your evaluation of the learning and development you have undertaken Click here to enter text. e) how you have used your learning and development in your practice, and if not, why not Click here to enter text.

of 30 f) what are your current learning needs? Click here to enter text. g) Which specific, relevant sections of the Code does this refer to? Click here to enter text.

of 30 Section 8: Test of Competence (TOC) – Application Checklist

Use this checklist to make sure you have included all of the documents we need to confirm if you are eligible for the TOC interview.

1. Confirmation of your chiropractic qualification ☐ A letter from the education institution which awarded your chiropractic qualification, giving details of how it meets the registration requirements. Details can be found on our website. (http://www.gcc- uk.org/UserFiles/Docs/Registrations/Qualification%20requirements%20for %20overseas%20applicants%200216.pdf)

2. List of modules taken as part of your chiropractic qualification and learning outcomes of these modules ☐A list of the modules you undertook as part of your primary chiropractic qualification, along with the criteria you were assessed against (learning outcomes.) The form is available to download from the website

3. Completed Evidence of Practice Questionnaire ☐A completed copy of this questionnaire

4. Copies of anonymised patient records ☐Anonymised patient records that support the information you have provided in the evidence of practice questionnaire. (Please refer to page 2)

4a. Have you submitted real anonymised records either taken when assessing and treating patients or through observing/shadowing chiropractic care?

Yes ☐ No☐

4b. If you answered ‘No’ to the above, please explain why you have chosen to submit records that you have fabricated and indicate whether these are based on real or hypothetical cases. (Please be aware that you will be subject to a longer, more intensive, interview process to ensure that you meet the standards.)

Click here to enter text.

of 30 5. Your current curriculum vitae (CV) / résumé ☐ An up-to-date CV/ résumé including details of all chiropractic work undertaken outside the UK since you gained your primary chiropractic qualification

6. Copy of passport ☐A copy of the relevant pages of your passport containing your photo and personal details. The copy must be signed by someone of professional standing

*Please note all documents must be completed and submitted in English. All documents listed must be submitted to the GCC at the same time. This checklist must be completed as part of your application. Further information on the above documents can be found on our website at: http://www.gcc-uk.org/registration/test-of-competence/before-the-toc.aspx

If you have any queries about your application or the TOC process please email us at [email protected]

of 30 Section 8: declaration Sign and date the declaration below to confirm you have read and understood it.  Caution: Should any entry on the Register be fraudulently procured or incorrectly made, action will be taken under the provisions of Section 10 of the Chiropractors Act 1994

 I declare that all information supplied by me in support of my application for registration with the General Chiropractic Council is, to the best of my knowledge and belief, true and accurate

 I understand that the Registrar may take steps to verify any such information supplied by me, and that in the event of any such steps being taken, I agree to cooperate fully

 I declare that I have read the current General Chiropractic Council’s Code: Standards of conduct, performance and ethics for chiropractors and understand that my actions may be judged against the standards and principles it contains.

Signed:

Date: Click here to enter a date.

Please provide your credit/ debit card details on page 25 for payment of the £2,000 test of competence fee.

What the fee covers The fee covers costs for administering the test as well as the costs associated with the interview process.

Your Evidence of Practice Questionnaire, along with your application, should be completed and returned to [email protected]

Tel: (0)20 7713 5155 Email: [email protected] Website: www.gcc-uk.org

of 30 Payment of the Registration fee by credit/ debit card You can pay your fee by filling in this form, we do not take card payments over the phone.

Candidates name: Click here to enter text.

I wish to pay £2,000 in respect of the fee for the test of competence by: American Express ☐ Delta ☐ Mastercard ☐ Visa Credit ☐ Visa Debit ☐

Card number:

Expiry date: / Issue date: /

Security code (last 3 digits on the back of the card):

Card holder’s name: Click here to enter text.

Card holder’s signature:

Date (dd/mm/yy): Click here to enter text.

Refund policy Payment will be collected from the above account when your TOC interview has been confirmed. If you decide to withdraw your application for the TOC after your place has been confirmed we will refund 50% of your fee (£1000) if you withdraw up to 1 day before the closing date.

If you decide to withdraw your application on or after the closing date, your fee will be non-refundable unless there is an Exceptional Mitigating Circumstance.

of 30 Evidence of Practice Questionnaire Diversity Monitoring Form

The General Chiropractic Council is committed to promoting and developing equality and diversity in all our work. We want to be as sure as we can that our policies and ways of working are fair and do not discriminate against individuals or groups. To help us monitor the effectiveness of our policies and practices we ask you to complete this diversity questionnaire. This information will be treated in the strictest confidence under the Data Protection Act 1998. Through this we can check a variety of processes to ensure equality and address issues as they arise. This form will be detached and securely held away from the rest of your application.

What is your gender?

Male ☐

Female ☐

Which of the following age brackets do you fall into?

Under 24 ☐

25-34 ☐

35-44 ☐

45-54 ☐

55-64 ☐

65+ ☐

Prefer not to say ☐

of 30 What is your ethnicity?

White – English/Welsh/Scottish/Northern Irish/British ☐

White – Irish ☐

White – Gypsy or Irish Traveller ☐

☐ Click here to enter White – other (please specify) text. Mixed/Multiple ethnic groups – White and Black ☐ Caribbean

Mixed/Multiple ethnic groups- White and Black African ☐

Mixed/Multiple ethnic groups – White and Asian ☐

☐ Click here to enter Mixed/Multiple ethnic groups – other (please specify) text.

Asian / Asian British – Indian ☐

Asian / Asian British – Pakistani ☐

Asian / Asian British - Bangladeshi ☐

Asian / Asian British - Chinese ☐

☐ Click here to enter Asian / Asian British – other (please specify) text.

Black/African/Caribbean/Black British - African ☐

Black/African/Caribbean/Black British - Caribbean ☐

Black/African/Caribbean/Black British – other (please ☐ Click here to enter specify) text.

Other – Arab ☐

☐ Click here to enter Any other ethnic group (Please specify text.

What is your religion or belief?

of 30 Buddhist ☐

Christian ☐

Hindu ☐

Jewish ☐

Muslim ☐

Sikh ☐

No religion ☐

Other (Please specify) ☐ Click here to enter text.

The Equality Act 2010 defines a person as disabled if they have a physical or mental impairment, which has a substantial and long-term (i.e. has lasted or is expected to last at least 12 months) and adverse effect on the person’s ability to carry out normal day-to-day activities. Do you consider yourself to have a disability according to the definition in the Equality Act?

Yes ☐

No ☐

Which of the following best describes your sexual orientation?

Bisexual ☐

Gay man ☐

Gay woman or lesbian ☐

Heterosexual or straight ☐

of 30 Other ☐