General Practice Assistant Enrolment Pack | Webform Portal

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General Practice Assistant Application Form - Northeast & Yorkshire

All fields Highlighted in Yellow in this form are Mandatory for you to complete.

Please complete 1 application per General Practice Assistant that you wish to enrol.

Please note that by completing this application it does not guarantee a place on the programme. Places are limited and will need to be distributed across the region by the Training Hub.

Upon successful completion of the application form by ALL the relevant parties including the practice, the applicant, the GP mentor you will be contacted by your training hub.

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TO BE COMPLETED BY THE PRACTICE

Practice Information

Name of Practice: *

Address of Practice: *

Practice Postcode: *

ICB Area: *

PCN: *

Practice Manager Name: *

Practice Manager NHS Email: *

Practice Manager Contact Number: *

GP Assistant Applicant Information

GP Assistant Applicant Name: *

GP Assistant NHS Email: *

GP Assistant Contact Number: *

Is the applicant now employed in a trainee GPA role? *

Yes No

Is the applicant in position due to Additional Roles Reimbursement Scheme (ARRS)? *

Yes No

Has the applicant started gathering evidence towards the programme? *

Yes No

Mentor Information

GP Mentor Name: *

GP Mentor NHS Email: *

GP Mentor Contact Number: *

Please attach CV / Professional profile for the GP Mentor:

It is a requirement from the Awarding Body that we must have a CV/Professional profile for the GP mentor and we will require this before the GP Assistant can start their programme.

Secondary Mentor Information (if applicable)

Secondary Mentor Name (inc title):

Secondary Mentor Email:

GP Mentor Contact Number:

Confirmation & Signature

I confirm that this candidate is appropriate for the General Practice Assistant programme.

Practice Signature: *

Tap or click on the signature above to sign

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TO BE COMPLETED BY THE GP MENTOR

Please attach CV / Professional profile for the GP Mentor:

It is a requirement from the Awarding Body that we must have a CV/Professional profile for the GP mentor and we will require this before the GP Assistant can start their programme.

GP Assistant:

I can confirm that I am going to be the GP mentor for the above named GP assistant.

I understand that I will mentor the candidate and that I am responsible for approving their competencies in the relevant areas.

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TO BE COMPLETED BY THE HUB

Has the GP Assistant become a successful applicant on the course:

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General Practice Assistant Application Form - Northeast & Yorkshire

GP Practice

GP Assistant

GP Mentor

The HUB

The Provider

TO BE COMPLETED BY THE PRACTICE

Practice Information

GP Assistant Applicant Information

Mentor Information

Secondary Mentor Information (if applicable)

Confirmation & Signature

TO BE COMPLETED BY THE GP ASSISTANT

Personal Details

Health/Disabilities

Current Job Information

DBS Information

Baseline Pre Programme Survey

Confirmation & Signature

TO BE COMPLETED BY THE GP MENTOR

TO BE COMPLETED BY THE HUB