General
Medical
Council
Regulating doctors
Ensuring good medical practice

Colleague questionnaire

for Dr______

Please write today’s date here: //

Poor / Less than satisfactory / Satisfactory / Good / Very good / Don’t
know
1 / Clinical knowledge / 1 / 2 / 3 / 4 / 5 / 6
2 / Diagnosis / 1 / 2 / 3 / 4 / 5 / 6
3 / Clinical decision making / 1 / 2 / 3 / 4 / 5 / 6
4 / Treatment (including practical procedures / 1 / 2 / 3 / 4 / 5 / 6
5 / Prescribing / 1 / 2 / 3 / 4 / 5 / 6
6 / Medical record keeping / 1 / 2 / 3 / 4 / 5 / 6
7 / Recognising and working
within limitations / 1 / 2 / 3 / 4 / 5 / 6
8 / Keeping knowledge and
skills up to date / 1 / 2 / 3 / 4 / 5 / 6
9 / Reviewing and reflecting on
own performance / 1 / 2 / 3 / 4 / 5 / 6
10 / Teaching (students, trainees, others) / 1 / 2 / 3 / 4 / 5 / 6
11 / Supervising colleagues / 1 / 2 / 3 / 4 / 5 / 6
12 / Commitment to care and
wellbeing of patients / 1 / 2 / 3 / 4 / 5 / 6
13 / Communication with
patients and relatives / 1 / 2 / 3 / 4 / 5 / 6
14 / Working effectively
with colleagues / 1 / 2 / 3 / 4 / 5 / 6
15 / Effective time management / 1 / 2 / 3 / 4 / 5 / 6

Please decide how far you agree with the following statements by ticking one box in each line.

Strongly disagree / Disagree / Neutral / Agree / Strongly agree / Don’t
know
16 / This doctor respects patient
confidentiality / 1 / 2 / 3 / 4 / 5 / 6
17 / This doctor is honest and
trustworthy / 1 / 2 / 3 / 4 / 5 / 6
18 / This doctor’s performance is not
impaired by ill health / 1 / 2 / 3 / 4 / 5 / 6
19 / This doctor is fit to practise medicine / Yes1 / No2 / Don’t know3
20 / Please add any other comments you want to make about this doctor. Please note: No one will be identified when this information is given back to the doctor.
The next questions will give us some basic information about who took part in the survey.
21 / Are you / Female1 / Male2
22 / Age / 16-191 / 20-292 / 30-393 / 40-494 / 50-595 / 60 or over6
23 / Your professional role (please tick only one box):
Doctor 1 / 23a If you are a doctor, are you in a training grade? / Yes1 / No2
Registered Nurse 2 / Health Visitor/Midwife3 / Pharmacist4
Admin/Receptionist/Secretary 5 / Allied Healthcare Professional6 / Health Care Assistant7
Non-clinical Manager 8 / Other (please specify): ______9
24 / How recently have you been familiar with this doctor’s clinical practice?
Current colleague1 / Within the last two years2 / Between two and five years ago3
Between six and ten years ago4 / More than ten years ago5
25 / During this period of your familiarity with this doctor’s clinical practice, how often did you have contact
with the doctor?
Most days1 / Weekly2 / Monthly3 / Less often4
26 / What is your ethnic group? Please choose one section from A to E, and then tick the appropriate box to indicate your cultural background.
A White / B Mixed / C Asian or Asian British / D Black or Black British / E Chinese or other ethnic group
British1 / White and Black Caribbean / 1 / Indian1 / Caribbean1 / Chinese1
Irish2 / White and Black African / 2 / Pakistani2 / African2 / Any other2
Any other white background / 3 / White and Asian / 3 / Bangladeshi3 / Any other black background / 3
Any other mixed background / 4 / Any other Asian background / 3
Please write in: / Please write in: / Please write in: / Please write in: / Please write in: