Training Year ST3 ST4 ST5 ST6 ST7 ST8

Trainee’s surname / Trainee’s forename(s)
Trainee GMC No / Mandatory / Deanery Training No (NTN) / FICM No.
Educational Supervisor surname / GMC number / Mandatory

GMC Survey / DATE
Training placement
Hospital / Date From / Date To:
Examinations–when relevant
Exam Component / No of attempts / Date passed
FFICM - written
FFICM - SOE
EDIC - MCQ
EDIC - Viva
If other, examination title and awarding body
Logbook/Case Diary
Log book/Case Diary checked
Case numbers / Case Mix / % direct supervision / Total this rotation / Overall total
Intensive care medicine / Sufficient Insufficient / Sufficient Insufficient
Intra-hospital transfers
Inter-hospital transfers
CVCs (including vascath etc)
Tracheostomies
Intubations
Chest drains
Lumbar punctures
Other (specify)
Other (specify)
Comments
Professionalism in medical practice [Annex A]
Domain / Sat/Unsat/Not Observed / Comments
Domain 1 – professional attitudes

Commitment

Compassion

Honesty and integrity

Respect for others

Community

Competence

Domain 2 – clinical practice
Domain 3 – team working
Domain 4 – leadership
Domain 5 – innovation
Domain 6 – management
Domain 7 – education
Domain 8 – safety in clinical practice
Domain 9 – medical ethics and confidentiality
Domain 10 – relationships with patients
Domain 11 – legal framework for practice
Domain 12 – information technology
Workplace based assessments (numbers)
Case Summaries / CBD / DOPS / I-CEX / ACAT / Comments
S / U / S / U / S / U / S / U / S / U
Teaching and training, academic and research [excluding Audit] and management
Achieved Core Outcomes / Satisfactory Progress / Completion date
Teaching and training / Y/N / Y/N
Academic and research / Y/N / Y/N
Management / Y/N / Y/N
Multi-Source Feedback Summary / Number reviewed
Good
Satisfactory
Needs to improve
Unacceptable
Patient survey / Number reviewed:
Comments:
Audit activity
Project / Planned
Y/N / Conducted
Y/N / Presented
Y/N / Date completed
Project activity
Project / Planned
Y/N / Conducted
Y/N / Presented
Y/N / Date completed
Research projects
Project / Planned
Y/N / Conducted
Y/N / Presented
Y/N / Date completed
Publications
Title / Status
Other activities
Teaching/Presentations
1.
2.
3.
4.
5.
Courses/meetings attended
1.
2.
3.
4.
Absence (Number of days)
Annual Leave / Sickness / Other
Other outcomes
Date / Details / Outcome
Adverse events
Complaints
Other
Comments by Educational Supervisor
Comments by trainee
Comments by College Tutor

Enhanced elements to Educational Supervisor Structured Reportfor ARCP Panel

Details of concerns/investigations:
Are you aware if this trainee has been involved in any conduct, capability or Serious Untoward Incidents/ Significant Event Investigation or named in any complaint?
/ Yes/ No
If so are you aware if it has/ these have been resolved satisfactorily with no unresolved concerns about a trainee’s fitness to practice or conduct?
/ Yes/No
Comments, if any:
The section below is only applicable for the Clinical/Educational Supervisor of a GP trainee in a primary care placement:
If there is an unresolved concern or conduct, capability/ SUI investigation or a complaint for this trainee please complete the Exception Exit Report and notify the Deanery

I confirm that this is an accurate descriptive/summary of the trainee’s learning portfolio covering the time period from ____/____/____ to ____/____/____.

Signed by: ______Educational Supervisor

Signed by: ______Trainee

Signed by: ______College Tutor

Trainee Name