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Trainee Name:
Trainee MIN:
Date Submitted:
3)
Any questions regarding the completion of the follow-up activities logbook can be
directed to the Education Officer to the SAC in Neonatal/Perinatal Medicine, on (02)
8247 6284 or via email at NeonatalPerinatal@racp.edu.au.
Date of
meeting
Date of clinic
Date of clinic
4.
5.
6.
Age
of
chil
d
Date
Reason for
assessment and
diagnosis
Testing done
Your role
Name &
Signature of
Supervisor
Age
of
chil
d
Date
Reason for
assessment and
diagnosis
Testing done
Your role
Name &
Signature of
Supervisor
COMPETENCY SIGN-OFF
PLEASE ENSURE THIS SECTION IS COMPLETED PRIOR TO
SUBMISSION
TRAINEE TO COMPLETE:
Do you feel that you are competent to conduct follow-up activities
at a consultant level?
Yes
No
Comments:
Trainees Signature:
Date: //
SUPERVISOR TO COMPLETE:
Do you feel that the trainee is competent to conduct follow-up
activities at a consultant level?
Yes
No
Comments:
Supervisors Name:
Supervisors Signature:
Date: //