POSTGRADUATE GENERAL PRACTICE EDUCATION GENERAL PRACTICE SPECIALTY TRAINING REGISTRAR PAYMENT FORM (FPGR1) EPSOM TRAINEES ONLY A SEPARATE FORM MUST BE COMPLETED FOR EACH GP PLACEMENT 1. GP SPECIALTY TRAINING REGISTRAR (GPSTR)
Surname First Names
Maiden Name Date of Birth Gender M F (if applicable) dd/mm/yy Home Address Correspondence Address during training (if different)
Postcode Postcode Mobile National Insurance
Number Number
Email Nationality
2. GP TRAINER – (THE GPSTRS GP TRAINER IN THE PRACTICE WHERE THE TRAINEE IS TO BE EMPLOYED – TRAINER ALSO TO COMPLETE PAGE 6)
Scheme Name (e.g. Dartford)
Surname First Name Name and Address of Training Practice Name of Practice
Manager Telephone number of
Practice Manager Email address of
Practice Manager 3. TYPE OF TRAINING POST Please tick the appropriate box below to indicate the type of training post to which you have been appointed and complete further sections of the form as indicated.
Tick Type of training post GP Specialty Trainee – year 1(GPStR ST1)* GP Specialty Trainee – year 2 (GPStR ST2)* * If this post is an Integrated Training Post (ITP = combined general practice and hospital post, where you are based in a general practice training practice) please state the Specialty and Site below: ITP Specialty: GP & Site Trust GP Specialty Trainee – year 3 (GPStR ST3) GPStR ST3 accepted for an extension to the normal training period GP Induction and Refresher scheme
4 PERIOD OF TRAINING d d m m y y y y
Actual date this appointment will commence Actual date this appointment will terminate If at any time either of the dates above should change you must inform the Deanery as soon as possible. Is this a full-time appointment? YES NO If NO please state the % of full time hours %
0d9a5ff24eb653a906cc5c257305299d.doc 1 worked (minimum 50% of ftime) Has a contract of employment been signed between the GP trainer and GPStR? YES NO
5 GMC REGISTRATION
Type of Please tick the Registration Number Date of Full Date current period of Registration appropriate box Registration membership with GMC below expires FULL
OTHER please complete box below
IF YOU ARE APPLYING FOR FULL GMC REGISTRATION PLEASE STATE THE DATE ON dd/mm/yy WHICH YOU EXPECT THIS TO COMMENCE Please give details of the circumstances you anticipate will result in your being granted registration on or around the date stated above (e.g. satisfactory completion of- year)
6 PREVIOUS/PRESENT EMPLOYMENT a Present or most recent NHS Hospital appointment
(please state specialty e.g. paediatrics) Grade of Post Was this a locum post? YES NO (e.g. FY1, FY2, ST1, ST2 CONSULTANT) Name of Hospital where the post was undertaken
Address of Hospital where post was undertaken (including postcode)
d m y D M y Date Commenced Date Terminated *Annual Salary Increment Date Salary £ Scale *If possible, please attach a copy of your most recent payslip*
b QUALIFICATIONS:
Date of Qualification: (Including place)
Qualifications including Postgraduate qualifications: (with dates)
0d9a5ff24eb653a906cc5c257305299d.doc 2 b Previous Hospital Experience in the UK (please include any previous GPR posts)
Duration Speciality Hospital Consultant(s) Grade of Post Date started Post Approval by Experience recognised (months)
1 Pre-reg
2
1 Post-reg
2
3
4
5
6
Previous Hospital Experience outside the UK
Hospital Consultant(s) Grade of Post Date started Duration (months)
1 Pre-reg
2
3
1 Post-re
2
3
0d9a5ff24eb653a906cc5c257305299d.doc 3 c If you currently (or have previously) work(ed) or Foundation Programme train(ed) in general practice, please indicate the type GP Registrar Training Post of position held in the box opposite and complete the information below. Other (please state) Please state the name of the health authority responsible for the area where you currently/most recently work(ed)/train(ed) in general practice
Please give the full name and address of the surgery
d m y d m y Annual Date Commenced Date Terminated Salary £
d Was your last full-time appointment in one of the following categories?
A medical branch of the Armed Forces YES NO The medical services of another country YES NO The Community Health Services YES NO A teaching post in a medical school YES NO
If you have answered Yes to any of the above, your salary in this appointment will be determined by the Secretary of State. Please give details of the duties that were involved: continue on a separate page if necessary.
7 MEDICAL DEFENCE ORGANISATION SUBSCRIPTIONS It is confirmed that: (tick box if applicable)
ST3 The GPStR has paid the subscription and the cost thereof may not be reclaimed elsewhere. The GP trainer will reimburse the appropriate proportion to the GP Registrar. ST1/ Then ST1 / ST2 have paid the subscription. The Practice will reimburse the cost of the Medical Indemnity Fees for a ST2 doctor working more than 30 days in general practice during that year, but not the subscription fee - (this will be detailed on the Medical Defence organisations form).
ST3 only - The primary care support agency will reimburse medical defence body subscriptions to the GP trainer after production of the GPStR’s receipt from the defence body.
0d9a5ff24eb653a906cc5c257305299d.doc 4 8 DOCUMENTATION You are required to provide certified copies of the documents as listed; the copies must be signed and stamped by your GP Trainer or a hospital Consultant Please tick appropriate box
Enclosed Documentation
Current Certificate of Annual Registration of the General Medical Council Evidence of Membership of a Recognised Professional Medical Defence Organisation National Passport (or Birth Certificate if National Passport is not available) Original evidence of your eligibility to take up employment in the UK and evidence of current immigration status is required for all non UK/EEA applicants. UK/EEA applicants should provide a passport, birth certificate or any naturalisation papers. Most recent payslip
9 GP REGISTRAR DECLARATION I confirm that (tick the boxes that apply):
I will not make a claim to the primary care support agency in respect of any expenses that have been/will be recovered elsewhere (e.g. removal expenses recovered by a partner) I am and will continue to be a member of a recognised medical defence organisation during this period of training. I currently have and will maintain full registration with the GMC during this period of training.
I understand that a copy of this form and accompanying documentation will be supplied to the Primary Care Support Agency responsible for the area in which my GP Training Practice is located. Information supplied on this form will be recorded on a computer in accordance with the Data Protection Act 1998. I have received a contract of employment from my employer.
I have received a copy of the educational contract signed by the GP Trainer I confirm that I have read the Deanery guidance notes for GPStR’s regarding car mileage allowance reimbursement and have signed the authorised vehicle user application, and will submit any claims via my GP Trainer in accordance with these guidelines.
Signature: GP Registrar Date of Signature
0d9a5ff24eb653a906cc5c257305299d.doc 5 GP TRAINER TO COMPLETE
10 CONTRACTS
I confirm that the following have been signed or will be signed before the GPStR commences in the Practice : Contract of employment (BMA recommended model) Educational contract GP Specialist Training Service Level Agreement
The primary care support agency will reimburse telephone expenses to the GP trainer on production of the appropriate receipts.
11 GPStR Car Mileage Allowance Reimbursement
I confirm that the GPStR has received the Deanery car mileage allowance reimbursement guidance, signed the Authorised Vehicle User Application form and I will authorise and record claims accordingly.
12 Is your practice a PMS? YES NO
13 Name of your PCT
14 GP TRAINER DECLARATION I confirm that (tick the boxes that apply): I understand that a copy of this form and accompanying documentation will be supplied to the primary care support agency responsible for the area in which my training practice is located. Information supplied on this form will be recorded on a computer in accordance with the Data Protection Act 1998.
Signature: GP Trainer Date of Signature
Name (PRINTED)
This Form and the GP Registrar’s documents should now be sent to: Sultana Parvez, Health Education Kent, Surrey and Sussex, Stewart House, 3rd Floor, 32 Russell Square, London, WC1B 5DN
FOR DEANERY OFFICE USE ONLY
15 POSTGRADUATE GENERAL PRACTICE EDUCATION
I confirm that the health authority may commence payments in respect of this period of training in accordance with the agreement for the provision of postgraduate general practice education issued by the Kent, Surrey and Sussex Deanery. I confirm that there is an approved educational contract between the Kent, Surrey and Sussex Deanery and the GP Trainer.
Signature - Postgraduate General Practice Education Date : Name Position Department Stamp:
0d9a5ff24eb653a906cc5c257305299d.doc 6