Your name:
Date/Year of appraisal:
Appraisers name:
- Personal details
GMC number:
Contact address
Contact telephone number
Contact email address
Name of designated body(used to be PCT performers list)
Responsible officer
Medical qualifications. – do attach CV if appropriate
Date of last appraisal:
Name of last appraiser:
Name of last RO if different to this year:
Name of last designated body if different to this year:
2. Appraisal history
Until 2013 – I have attached copy of my last appraisal summary and PDP – if no please state reasons
April 2013 onwards
I have attached copies of my last 4 appraisal summaries and PDPs
– If no please state reasons:
Dates of appraisals in the last 5 years
------
3. Scope of work
If you have worked less than 1 day a week over last 2 years please contact the appraisal team for advice
Clinical
Details / Duration in role / OrganisationEducational / Academic / Research/Management
Details / Duration in role / OrganisationOther
Details / Duration in role / OrganisationCommentary: Any changes since last appraisal:
Actions - any likely changes in coming year – actions needed
Last year’s PDP attached: yes no if no please state reasons.
How did you address these learning needs?
12
3
etc.
------
4. CPD
Please attach diary or log of CPD activity and reflections (or list below) and any supporting info
Please state for each how many credits you are claiming _ please note: to claim extra credits you need to have demonstrated impact
Date / Nature/ reflection / Hours / impact / Credit claimedHow did your CPD activities support the areas described in your scope of work.
Commentary------
5. Quality improvement activity – that you have participated, reflected and acted on over last year:guidance re areas to cover can be found at GMC / RCGP websites
Commentary:------
6. Significant Events:
Delete as necessary - guidance re areas to cover can be found at GMC / RCGP websites
I have not been named in, or carried clinical or managerial responsibility for, any significant events in the last year.
I have been named in, or carried clinical or managerial responsibility for, one or more significant events in thelast year.
Date / Title / Key learningIf none and you have shared learning from others significant event – please add reflection as part of quality improvement activity section
------
7. Feedback from colleagues and patients – needs to meet GMC criteria
Date of last colleague feedback:
Date of last patient feedback:
If in last year – please attach supporting info and comments
Date / Method / Key learning------
8. Complaints / compliments:
Complaints:Delete as appropriate
I have not been named in, or carried clinical or managerial responsibility for, any complaints in the last year
I have been named in, or carried clinical or managerial responsibility for, one or more complaints in the last year.
Date / Summary / Key learningCompliments
Attach supporting info
Date / Summary / Key learning------
9. Achievements / challenges in the last year impacting on your professional role
------
Aspirations for coming year
10. Anything else you might wish to discuss at appraisal?
------
11. Statements required
- Probity
"I declare that I accept the professional obligations placed on me in Good Medical Practice in relation to probity."
If you feel that you are unable to make this statement for whatever reason, please explain why
In relation to suspensions, restrictions on practice or being subject to an investigation of any kind since my last appraisal:
“I have nothing to declare" Or
“I have something to declare” - please explain
Have you been requested, or suggested,that youbring any specific information, to your appraisal by your organisation or responsible officer or other party?
Yes- pleaseprovide further info
No
- Health
Do you have a GP independent of your practice and family?
Yes
No - pleaseprovide further info
"I declare that I accept the professional obligations placed on me in Good Medical Practice about my personal health."
If you feel that you are unable to make this statement for whatever reason, please explain why - or if you have any health issues you may wish to discuss at appraisal please indicate below
------
Additional information –use this section for anything that might help with revalidation CQC etc e.g.
When did you last undertake?BLS, Safeguarding children training, Safeguarding vulnerable adults training , Equality and Diversity training, Mental capacity act training.,Infection control training, Fire training
Information governance training
Any exceptional circumstances to be considered
------
Proposed PDP
Need / Method / Outcomes planned. / Date planned to achieve------
List all supporting info here:
Title / Section to relate to------
12. How are you meeting requirements of Good Medical Practice?
a. Knowledge skills and performance:Maintain your professional performance. Apply knowledge and experience to practice. Ensure that all documentation (including clinical records) formally recording your work is clear, accurate and legible
ReflectionsAims for the coming year
b. Safety and quality:Contribute to and comply with systems to protect patients. Respond to risks to safety. Protect patients and colleagues from any risk posed by your health
ReflectionsAims for the coming year
c. Communication, partnership and teamworkCommunicate effectively. Work constructively with colleagues and delegate effectively. Establish and maintain partnerships with patients
ReflectionsAims for the coming year
d. Maintaining trust.Show respect for patients. Treat patients and colleagues fairly and without discrimination. Act with honesty and integrity
ReflectionsAims for the coming year
------
I confirm that I have completed this form and compiled the supporting information listed tosupport this appraisal. I am responsible for the contents and confirm that it is appropriate for thisinformation to be shared with my appraiser and responsible officer.”
Check list to ensure you have covered info to support revalidation and other organizational needs
2012/13 / 2013/14 / 2014/15 / 2015/16 / 2016/17 / 2017/18Scope of work
Annual appraisals
PDP and reviews
Probity
Health
CPD
Significant events
Feedback from colleagues
Feedback from patients
Review of complaints and compliments
Quality improvement activity
Exceptional circumstances
CPR / resus
Safeguarding children
Equality and diversity
Fire training
Anything a third party has told you to bring to appraisal
Mental capacity act / Deprivation of liberty
Safeguarding of vulnerable adults
Infection control
Information governance
Information security
Secure transfers of personal data
Records management
Other roles
Note:
By emailing this document to your appraiser you are confirming all the statements declared above
1