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This form should be completed approximately three months prior to your anticipated leave date. If the absence is unplanned please complete this form at the earliest opportunity.

This form is to be completed by the returning Doctor in discussion with their Educational Supervisor or Training Programme Director - as most appropriate for the individual situation.

Further information regarding the Supported Return to Training Programme (SuppoRTT) within the West Midlands can be accessed here.

*Please note* Once completed, you must download a copy of this form.  At the end of the survey a 'Download my responses' box will appear, click 'My responses' then click on 'Download as PDF' at the top right hand side of this page.

The SuppoRTT team will not be able to provide a copy to you.

Please enter a whole number (integer).

Your answer should be no more than 9 characters long.