APPLICATION FOR SPECIALTY TRAINING IN SCOTLAND EDUCATIONAL / CLINICAL SUPERVISOR REPORT Please note that references should be from

two recent clinical or educational supervisors, both of whom should have supervised you in the past two years and one in the past year. The completed, signed reports must be brought to the Selection Centre by shortlisted candidates. It will not be scored as part of the process. APPLICANT NAME: CANDIDATE IDENTIFICATION NUMBER: APPLICANT GMC NUMBER: SPECIALTY AND LEVEL APPLIED FOR:

EDUCATIONAL/CLINICAL SUPERVISOR NAME: DESIGNATION : INSTITUTION ADDRESS: GMC NUMBER: DATES YOU WERE EDUCATIONAL/CLINICAL SUPERVISOR FOR THIS APPLICANT: FromTo

Please rate the applicants performance against each of the criteria listed in the following table by ticking the appropriate box. You should base your ratings on workplace assessments and reports completed while the trainee was under your educational/clinical supervision. You may subsequently be asked for evidence to support your ratings. Performance ratings: 1 = Less than satisfactory for level at which applying 2 = Satisfactory but below average performance 3 = Satisfactory and average performance 4 = More than satisfactory, above average performance
PLEASE SIGN AND DATE EACH PAGE OF THIS REPORT
EDUCATIONAL/CLINICAL SUPERVISOR NAME . SIGNATURE.. DATE :

APPLICANT NAME : CANDIDATE IDENTIFICATION NUMBER:.

CRITERIA Capacity to apply sound clinical knowledge & judgement & prioritise clinical need. Technical ability and potential for developing strong and complex clinical/diagnostic skills Capacity to operate effectively under pressure & remain objective in highly emotive/pressurised situations. Awareness of own limitations & when to ask for help Capacity to communicate effectively & sensitively with others, able to discuss treatment options with patients in a way they can understand Capacity to think beyond the obvious, with analytical and flexible mind. Capacity to bring a range of approaches to problem solving Capacity to monitor and anticipate situations that may change rapidly Demonstrates effective judgement and decision-making skills Capacity to work effectively in a multi-disciplinary team & demonstrate leadership when appropriate. Capacity to establish good working relations with others Capacity to manage time and prioritise workload, balance urgent & important demands, & follow instructions. Understanding of importance & impact of information systems Commitment to professional integrity in all actions and behaviour Willingness to take responsibility for own actions Awareness of ethical principles, safety, confidentiality & consent. Awareness of importance of clinical governance & responsibilities of an NHS employee Motivation and commitment to self-directed learning Fitness to practise safely Understanding of the basic principles of audit Completion of audit projects Understanding of the basic principles of research and evidence-based practice, with potential to contribute to research Evidence of ability to communicate knowledge and understanding to others Overall professionalism 1 2 3 4

EDUCATIONAL/CLINICAL SUPERVISOR NAME . SIGNATURE.. DATE :