17.Have you received Vocational Training in General Practice? □ Yes □ No 18.If yes, please provide scheme name: 19.Please provide date of graduation from scheme: 20.Number of years in full-time General Practice: (Or equivalent years in part-time) (Please specify) 21.Number of years in current practice: HOSPITAL EXPERIENCE 22.Please provide a summary of hospital experience, including dates: RESEARCH & TEACHING EXPERIENCE 23.Have you undertaken any Research or Audit in General Practice? □Yes □No 24.If yes, please provide details: 25.Please provide details of any research undertaken and /or papers published, including dates: 26.Please list any teaching experience you may have:(Additional qualifications can be added on page 9) OTHER AREAS OF RESPONSIBILITY 27.Other professional responsibilities (e.g., insurance, factory work etc):
44.If yes, what Training Programme and in what role?: 45.If yes, what day is Day Release held?: 46.If yeswho is the designated Trainer for that Programme? 47.What effect will an additional training post have on the practice with regard to? 47.1 Room Availability: 47.2One to One Tutorials: 47.3Supervision of the Registrar: 47.4Day Release for Scheme: 47.5Contractual Leave for the Registrar: MEMBERS OF PRACTICE TEAM 48.Partners: 49.Assistants 50.Practice Nurses: 51.Administration: (Including Practice Mgr) 52. Please indicate what other team members would be involvedwith training the Registrar in your practice or in your locality? 52.1 Other Partners /Assistants (please tick): □ Yes □ No 52.2 Practice Nurse (please tick): □ Yes □ No 52.3 Public Health Nurse (please tick): □ Yes □ No 52.4 Receptionist (please tick): □ Yes □ No 52.5 Community Welfare Officer (please tick): □ Yes □ No 52.6 Pharmacist (please tick): □ Yes □ No 52.7 Community Psychiatric (pleasetick): □ Yes □ No 52.8 Social Work (please tick): □ Yes □ No 52.9 Practice Manager (please tick): □ Yes □ No 52.10 Psychologist (please circle): □ Yes □ No 54.Please describe your partner's attitude towards training (if applicable):
55.Outline any expertise of your partners which might contribute towards training of the registrar: 56.Please give details of any staff / practice training in the last two years: 57.Please list any regular practice meetings, describing their function, participants, and their timing: 58.Outline any planned developments in the practice in the coming 5 years: THE PREMISES 59.With regard to the current arrangement in your practice please answer the following: Main Surgery (Location 1): Is the main surgery located in (please tick one box or fill out "other"): 59.1 Residence of one partner: □ Yes □ No 59.2 Adapted or residential property elsewhere: □ Yes □ No 59.3 Adapted office or shop: □ Yes □ No 59.4 Purpose built privately owned centre: □ Yes □ No 59.5 Health Centre: □ Yes □ No 59.6Other (please specify): 60.In the premises, please specify the number of rooms for (Specifynumber ): 60.1 Consulting - Examination: 60.2 Nurse treatment: 60.3Practice admin (excl. reception): 60.4Conference/Tutorial/Staff/Library: 60.5Other (please specify): 61.Would the Registrar have his /her own room?: □ Yes □ No 62.Ifno, please outline planned accommodation arrangements for the Registrar: 63.Branch Surgery (Location 2): 63.1 Type of Premises (refer to list above at 59): 63.2Distance from main surgery:
63.3Number of consulting rooms: 63.4 How do records differ from main surgery: 63.5 What are the security arrangements in this surgery: 64.Current literature- Are the following available to the Registrar in your practice (Please tick yes /no): 64.1Reference books: □ Yes □No64.2Journals: □ Yes □ No 64.3Internet: □ Yes □No64.4Medline: □ Yes □ No 64.5List of journal subscribed by your practice: 65. A Trainer is required to actively participate in Trainer Workshops, including National Trainer Workshops. Will you be in a position to meet this commitment? □ Yes □ No Comments: PRACTICE EQUIPMENT 66.Clinical Equipment: Will the Registrars room be equipped for purpose?□ Yes □No 67.Does the practice have the following office equipment? 67.1 PCs in each consulting room: □ Yes □ No 67.2 Dictation equipment: □Yes □No 67.3 Fax machine: □Yes□No 67.4 Photocopier: □Yes□No 67.5 Answering service: □Yes □No PRACTICE WORKLOAD AND PATIENT POPULATION active list size (approx): 69.GMS: 70.Private: 71.Number of patients seen per day within the practice: 71.1By GPs: 71.2By Nurses: 72. How many of these are: 72.1GMS: 72.2Private: 73.Number of patients seen per day by you? (proposed trainer): 74.Estimate the number of patients who would be seen by a Registrar: 75.Average number of domiciliary visits per week: 76. What are your Out of arrangements? (please specify
77.Will this arrangement allow the Registrar fulfilthe ICGP Criteria of 120 hours? □ No 78.Do you operate a full appointment system: □ Yes □No 79. Describe how you deal with walk in patients: 80.How are details about newly registered patients acquired?: 81. Does your practice currently offer chronic disease clinics for any particular group of patients? (e.g. Diabetes, Asthma, Child Health Surveillance): □ Yes □ No 82.If yes, please provide details of guidelines used: 83.Please list special interests or specialist clinics within the practice /building: 84.Please list any special features of the practice population, (e.g. age, sex profile, social class, cultural mix, employment level): 85.Do you provide care in any other setting? (e.g.Nursing Homes, Community Nursing Units, Industry): 86.Is the practice computerised? □Yes □No 87.Name of computer programme used: 88. Can the practice records be accessed remotely? □Yes □No 89.If your records are not currentlycomputerised, please outline how they are maintained: 90.Bearing in mind that practice records will need to be used for teaching and research, what percentage of your current records would be: 90.1 Legible: % 90.2In date order: %