Page 1: Basic Details

This form should be completed by the Educational Supervisor or SuppoRTT Champion on behalf of a trainee who has been away on unplanned leave for a period of 3 months or more. 

It allows Health Education England SouthWest to keep a contemporaneous log of all trainees currently on absences from clinical practice and ensures that a trainee is offered the appropriate support upon their return.

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If you are completing this survey as a "trial run", please just enter the trainee details as:

Trainee First Name: x

Trainee Last Name: x

GMC / GDC / Public Health Number: 123

This will enable us to delete any completed forms that make it into our database, but are not the official entries.

Please note that it is not possible to save drafts of these data entry forms and return to complete them at a later date.

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Your answer should be no more than 7 characters long.