YEAR 5

CLINICAL ASSESSMENT FORMS

2014-2015

CLINICAL ASSESSMENT During your medicine and surgery blocks you are required to complete a minimum of the following:

• Educational needs assessment form (at start of block) • 2x mini-CEX forms • 1x end of block assessment • 2x DOPS assessments as part of your clinical assistantship • 1x prescribing DOPS assessment • 3x TABS – see separate booklet

During your GP/Psychiatry block, you are required to complete the following:

• Educational needs assessment form (at start of block) • 2x mini-CEX forms • 1x mid block formative assessment (GP only) • 1x end of block formative assessment • Log diary • 2x DOPS assessments as part of your clinical assistantship (where possible) • 3x TABS – see separate booklet

You may be asked to complete additional mini-CEX assessments in the professional practice block: information will be available nearer the time. You do not need to complete any of these assessment forms for your elective block. The Educational Needs Assessment Form The form is an opportunity for you to discuss with your supervisor at the start of each block any areas where you feel you may need extra experience or if you have any concerns. You may find it useful to reflect on this during your end of block assessment with your supervisor to see if you have achieved your goals. Although this does not form part of the assessment we would recommend you hand the form into the MBChB office at the end of the block along with your other assessments. The mini-CEX (Clinical Evaluation Exercise) What is the mini-CEX? The mini-CEX is designed to provide feedback on skills essential to the provision of good clinical care by observing an actual clinical encounter. Strengths, areas for development and agreed action points should be identified following each mini-CEX encounter. This form samples a range of areas within the curriculum. Multiple mini-CEX assessments are known to be as valid as other forms of assessment when repeated over time, and the six you submit will go towards your final summative mark at the end of final year. You have been issued with this booklet which contains 8 mini-CEX assessment forms, allowing you to have more than the proscribed six throughout the course of the year. If you wish to undertake more assessments mini-CEX assessment forms can be downloaded from MyMBChB or collected from the MBChB office. When will I have my mini-CEX? Your educational supervisor/GP tutor is aware that you will have this assessment during your clinical blocks. You are expected to contact your supervisor early in the block, to arrange a suitable time for at least two mini-CEXs. One of these MUST be completed by the end of week 4 and one by week 8. Your mini-CEX can be supervised by your supervisor/tutor or with another senior member of staff on the same ward/surgery/clinic (e.g. another consultant, ST3 or above or GP but NOT an FY). The assessor will usually take you to a patient and ask you to take a focused history and perform a relevant examination. You may then be asked about areas of diagnosis and management. The exact format will vary with the ward/outpatient setting. You need to take the marking form along with you: while you can keep the second copy to help with your reflective practice on your performance. It is your responsibility to ensure that you have at least two mini-CEX examinations for each block and to return the marked form as instructed. Failure to do so will result in a 0 mark for that component of your final summative mark and refusal of your class certificate. Any incomplete forms or assessments carried out by an FY or CMT will be rejected and you may be required to re-do the assessment.

If you complete more than two mini-CEXs per block, the two highest marks will be used for your summative mark. What should you be assessed doing? The mini-CEX is suitable for use in a community-based, out-patient, in-patient or acute care setting. It is designed to provide feedback that should be of help to you. Therefore you should be assessed undertaking the actual clinical encounters normally expected of you, such as clerking in a new patient. How should it work? The observed process should take about 15-20 minutes. Do what you would normally do in the situation. Your assessor will then provide some immediate feedback which should take no longer than 5 minutes. End of block assessment These reflect your attendance, knowledge and attitude during the block and are used to identify any potential problems that you might be having. In GP and Psychiatry you will also complete a reflective log diary. Although these assessments are formative they will be taken into consideration at the end of final year. You need to arrange to meet with your supervisor to complete these and ensure that they are submitted by the relevant deadline. DOPS (Direct Observation of Practical Skills) What are DOPS? Direct observation of procedural skills (DOPS) is a form of assessment used to assess technical and professional skills in a range of basic diagnostic and interventional procedures, or parts of procedures. This structured observation helps facilitate feedback and highlight good practice in the development of your practical skills as preparation for foundation programme. The assessment involves the observation of a practical procedure within your clinical block relevant to that particular specialty. You have been issued with this booklet which contains 8 mark sheets, allowing you to have more than the proscribed six throughout the course of the year. If you wish to undertake more assessments, DOPS mark sheets can be downloaded from MyMBChB or collected from the MBChB office. When should I use DOPS? Your educational supervisor/GP tutor is aware that you will have this assessment during your clinical assistantship. These need to be performed by the end of your clinical block and you need to bring them to your end of block review with your clinical supervisor. DOPS can be supervised by any member of staff competent to perform the procedure themselves. This can include FY trainees. What should you be assessed doing? DOPS are suitable for any practical skill performed in a community-based, out-patient, in-patient or acute care setting. It is designed to provide feedback that should be of help to you. Therefore you should be assessed undertaking any procedure relevant to your block. Examples are: venesection, safe disposal of ‘sharps’, catheterisation, measuring blood glucose, ECG, urinanalysis, skin suturing, moving and handling patients, hand washing. A complete list of practical procedures is detailed in your study guide. DOPS provide evidence that you have achieved a certain level of competency with that skill or procedure. How should it work? You need to bring your assessment book and provide your assessor with the DOPS form. They observe you perform the procedure. Your assessor will then provide some immediate feedback which should take no longer than 5 minutes.

Team Assessment of Behaviour (TAB) The TAB is an assessment for your Student Assistantship component of your placement. This addresses various components that are important as you begin to take on more responsibilities and progress your professional practice. We would like you to identify a minimum of 3 persons (i.e.1 senior doctor, 1 junior doctor and 1 nurse) you have worked with during your assistantship and ask them to complete the forms. They should then be returned to your educational supervisor for discussion at your end of block assessment. There is a second form called the Student Team Assessment of Behaviour (sTAB) which is for you to reflect on and bring to your meeting. It is your responsibility to hand out these forms and for the rater to return to your supervisor in time for the end of block assessment.

IF YOU HAVE ANY PROBLEMS WITH ORGANISING THESE, LET FIONA PETRIE (f.petrie@abdn.ac.uk) KNOW AS SOON AS POSSIBLE, AND CERTAINLY BEFORE

THE FINAL WEEK OF THE BLOCK. What next? The top copy of all the assessment sheets should be returned to Fiona Petrie in the MBChB office . The bottom copy should be retained in the booklet for future reference. You must ensure your name is clearly indicated on the form prior to submission. Clinical Procedural Skills Logbook You have all also been supplied with a Clinical Procedural Skills Logbook. This is being piloted across 4th and 5th year to enable students to document their progress in achieving competencies in set procedural skills. This should be used alongside your assessment booklet and we may ask you to submit these logbooks during the year so we can determine your progress. Deadlines You must complete all of the assessments during the specified block. This reflects practice in the FY training programme and means you must consider staff vacations or absences and take these into account when planning the assessment. It is not acceptable to complete the assessments in a subsequent block. All forms must be submitted to Fiona Petrie in the MBChB office, Room 318, Suttie Centre, Foresterhill, Aberdeen, AB25 2ZD First mini-CEX assessment (completed week 1-4) must be submitted by the end of week 5 of current block. All other assessments must be submitted within 1 week of completion of block. Late forms may not be considered and late or no submission could result in refusal of your class certificate.

You must ensure your name is on all forms!!

It is your responsibility to arrange these and to submit the completed forms.

Mini-CEX (Clinical Evaluation Exercise): Year 5 ASSESSOR INFORMATION

Thank you for completing this assessment for this student. For Medicine and Surgery you should also complete the formative eight week assessment mark, as these are used to reflect attendance, knowledge and attitude during the block and are used to identify any potential problems that the student might be having. What is the mini-CEX? The mini-CEX is designed to provide feedback on skills essential to the provision of good clinical care by observing an actual clinical encounter. It is a “snapshot” of a doctor or student/patient interaction. The mini-CEX is suitable for use in a community-based, out-patient, in-patient or acute care setting. Not all elements need be assessed on each occasion. The form samples a range of areas within the curriculum. You have been asked to assess this student as you are their GP/ Psychiatry tutor or Educational Supervisor in Medicine or Surgery. You need not have prior knowledge of the student. If you are unable to undertake two assessments during the block, it is acceptable for a senior member of staff to deputise (e.g. ST3 or above, SASG or GP colleague). This assessment counts towards the final year mark and should not be delegated to a junior member of staff. How should it work? Having selected a willing and appropriate patient, you should then direct the student to perform a relevant history and examination, which may also cover investigation and diagnosis. The observed process should take no longer than 15-20 minutes. Immediate feedback should take no longer than 5 minutes. Specific points: The overall mark for each assessment will be calculated from the total of the scores for each domain tested. It is therefore important that all relevant domains are assessed. This will be converted to the University of Aberdeen Common Grading Scale (CGS) for assessment by the MBChB office. Further information on this is available in the student handbook. Focus of clinical encounter: Diagnosis should include an assessment of the students examination skills and their abilities to reach a provisional diagnosis. Complexity of case: Please score the difficulty of the clinical case for the level of a Year 5 student at this stage of the course. Feedback: In order to maximise the educational impact of using mini-CEX, you and the student need to identify agreed strengths, areas for development and an action plan. It is the student’s responsibility to return the top copy to the MBChB office. Thank you very much for completing this form and feeding back to the student.

Year 5 Clinical Block Educational Needs Assessment Student Name: _____________________________ Date: _________________________ Block: ____________________________________

This form is to be completed and discussed with your clinical supervisor at the start of your clinical attachment to help you and your supervisor to make plans in line with the requirements of the Year 5 course and your educational needs. Please refer to the requirements of your attachment in the Year 5 Handbook. 1. Please list the previous clinical attachments you have had in Year 5 prior to this attachment. 2. Are there any particular areas you want to gain experience in during your attachment?

3. Do you have any concerns that you want to share with your supervisor?

4. Have you any additional requirements to attain during this block?

E.g. Authorised absence for health or personal reasons, monitoring of attendance. 5. After discussing the above with your supervisor, what actions are you going to take to address your

educational needs?

Blue top copy to be returned to Fiona Petrie, MBChB office Bottom yellow copy to be retained by student

Year 5 Assessment: Mini- Clinical Evaluation Exercise (CEX) Please complete questions or circle appropriate response.

Student ID No………………………… Student name ……………………………………….

Assessor ………………………………………. Assessor Grade: Consultant SAS >ST3 GP

(This must not be completed by a foundation or core training doctor)

Year 5 block Medical Surgical GP Psychiatry

Clinical setting In patient (Hosp...........Ward ……) Outpatient

Main clinical problem(s)……………………………………

Complexity of case Focus of clinical examination

Low Average High History Diagnosis Management Explanation

Please grade the following areas using the scale below:

Unsatisfactory Pass Good Very Good Excellent

1. History taking

1

2

3

4

5

n/a

2. Physical examination skills

1

2

3

4

5

n/a

3. Mental state examination

1

2

3

4

5

n/a

4. Communication skills

1

2

3

4

5

n/a

5. Clinical judgement

1

2

3

4

5

n/a

6. Professionalism

1

2

3

4

5

n/a

7. Organisation/Efficiency

1

2

3

4

5

n/a

8. Overall clinical care

1

2

3

4

5

n/a

*U/C: Please mark this if you have not observed the behaviour and therefore feel unable to comment. Anything especially good?

Suggestions for development

Agreed action: Assessor’s signature

Date

Time taken for observation (mins) Time taken for feedback (mins)

White top copy to be returned to Fiona Petrie, MBChB office Bottom yellow copy to be retained by student

Direct Observation of Procedural Skills (DOPS) For medical undergraduate assessment of core procedural skills

Assessor Name ____________________ Student Name: ________________________ Procedure being observed (CAPITALS) _______________________________________ Indication for procedure/diagnosis (CAPITALS)________________________________ Please mark one of the boxes for each component of the exercise on a scale of 1 (extremely poor) to 5 (extremely good). A score of 1 is considered unsatisfactory, 2 borderline, 3 or 4 indicates successful performance and 5 indicates outstanding performance. Please note that your scoring should reflect the performance of the students against that which you would reasonably expect at their stage of training and level of experience. You must justify each score of 1-2 with at least one explanation/example in the comments box. Please feel free to add any other constructive and relevant comments about the student’s strengths and weaknesses. Unsatisfactory Pass Good Very good Excellent Demonstrates understanding of indications

Obtains informed content Demonstrates appropriate knowledge of procedure and anatomy

Technical ability Demonstrates appropriate & safe handling of equipment

Demonstrates asepsis before, during & after procedure if appropriate

Completes required communications (written & verbal) appropriately (content, clarity, professional to required personnel including patient and carers)

Deals with any unexpected events appropriately (e.g. failure to cannulate vein)

Overall professionalism & patient consideration

Assessor’s comments on student performance

Pink top copy to be returned to Fiona Petrie, MBChB office Bottom yellow copy to be retained by student

Direct Observation of procedural skills (DOPS) – PRESCRIBING For medical undergraduate assessment of core procedural skills

Assessor Name Student Name Procedure being observed – PRESCRIPTION WRITING Please mark one of the boxes for each component of the exercise. A score of 1 is considered unsatisfactory, 2 borderline, 3 or 4 indicates successful performance and 5 indicates outstanding performance. Please note that your scoring should reflect the performance of the student against that which you would reasonably expect at their stage of training and level of experience. You must justify each score of 1-2 with at least one explanation/example in the comments box. Please feel free to add any other constructive and relevant comments about the student’s strengths and weaknesses.

Unsatisfactory Pass Good Very good Excellent

Obtains appropriate medication history Demonstrates appropriate knowledge of drugs to be prescribed or gathers information about

Describes treatment objective, suitability of drug for this patient and indications for review

Technical ability (correct completion of kardex, legible, signed, allergy documentation complete)

Prescribes each medication appropriately (drug, dose, route, frequency correct/appropriate)

Completes required communications (written & verbal) appropriately (content, clarity, professional, to required personnel including patient and carers)

Overall professionalism & patient consideration

Assessor’s comments on student performance

Assessor’s signature: Date:

Pink top copy to be returned to Fiona Petrie, MBChB office

Bottom yellow copy to be retained by student

YEAR 5 (SURGERY & MEDICINE) CLINICAL BLOCK END OF BLOCK ASSESSMENT FORM

Student Name: _____________________________________ Block: Medicine Surgery Tutor Name: _______________________________________ Tutor Grade: Consultant SAS >ST3 GP (This must not be completed by a foundation or core training doctor) Please comment on the above student: Unsatisfactory Satisfactory Attendance

Student Assistantship (minimum of 1 week)

Completion of two DOPS relevant to block

Completion of three TABs relevant to block

Completion of adequate number of clinical procedures as detailed in logbook

Unsatisfactory Pass Good Very Good 2BExcellent 1 2 3 4 3B5 1. History Taking & Physical Examination

2. Investigation and Management

3. General Medical Knowledge

4. Clinical Skills & Procedures

Unsatisfactory

0 Satisfactory

1 5. Professional Relationships

6. Attitude and Behaviour

End of Block Assessment Please total the marks awarded in areas 1-6 above to reach the overall mark

22 Please give details if any of 1-4 are unsatisfactory, or any of 5-6 are unsatisfactory: Where there are concerns regarding a student please contact Fiona Petrie f.petrie@abdn.ac.uk so we can provide any additional support to the student Please provide the student with some constructive feedback Signed - ……………………………………………………... Date - ……………………… (Specialty Tutor) Signed - ……………………………………………………... Date - ……………………… (Student)

Blue top copy to be returned to Fiona Petrie, MBChB office / Bottom yellow copy to be retained by student

GP BLOCK FORMATIVE ASSESSMENT

OUTCOME 1 : STUDENT AS SCHOLAR AND SCIENTIST

AREAS DESCRIPTOR CRITERIA STANDARDS

Apply biomedical scientific principals

Apply psychological

principals

Apply social science

principles

Apply the principles,

method and knowledge of

population health and

the improvement of health and

healthcare

Demonstrates knowledge of bioscientific,

psychological, social science

and population health

appropriate to level of training.

Uses all

educational opportunities

For evidence

check record of consultations

that have identified student

learning needs

Excellent knowledge of the scientific/first principal basis of disease presentation, investigation, management and prevention in the context of General Practice. Strong awareness of psychological and sociological concepts of health, illness and disease including their application to explain varied responses of individuals, groups or societies to illness. Fully aware of health inequalities, the strong links between occupation and health and the affects of poverty and affluence. Excellent knowledge of the medical and scientific literature, including its appraisal and the application of any findings clinically.

Excellent

Very good knowledge of the scientific/first principal basis of disease presentation, investigation, management and prevention as well as the importance psychological and sociological concepts of health, illness and disease in the context of General Practice. Very Good knowledge of how the health of a population can be measured and improved. Can critically appraise the medical and scientific literature and apply the findings clinically. Can formulate simple research questions and suggest appropriate methods to answer those questions.

Very Good

Good knowledge of the scientific/first principal basis of disease presentation, investigation, management and prevention as well as the importance psychological and sociological concepts of health, illness and disease in the context of General Practice. Good knowledge of how the health of a population can be measured and improved. Adequate knowledge of disease prevention. Starting to appraise the literature and be aware of issues relating to study design, skills incomplete.

Good

Adequate grasp of the scientific/first principal basis of disease presentation, investigation, management and prevention in the context of General Practice. Adequate knowledge of psychological and sociological concepts of health and of the concepts relating to the health of the wider population. Adequate awareness of the importance of disease prevention. Adequate evidence of background reading. Struggles to suggest research or audits that might be useful in practice.

Pass (Borderline)

Poor knowledge of the scientific basis of disease and its treatment. Poor grasp of psychological and sociological concepts of health. Poor knowledge of population based medicine. Poor awareness of audit and how it would be performed. Lack of knowledge of health inequalities, particularly the link between occupation and health. Generally poor knowledge overall. No understanding of how to appraise or apply knowledge from medical or scientific literature

Unsatisfactory

OUTCOME 2 : STUDENT AS A PRACTITIONER

AREAS DESCRIPTOR CRITERIA STANDARDS

Be able to carry out a consultation with a

patient

Diagnose and manage clinical presentations

Communicate

effectively with patients and

colleagues in a medical context

Provide immediate

care in medical emergencies

Prescribe drugs

safely, effectively and economically

Carry out practical procedures safely

and effectively

Use information effectively in medical

context

Demonstrates a level of

clinical competence

appropriate to level of training

For evidence

base this judgement on student record

of consultations,

observed consultations and reports

from colleagues

Outstanding clinical skills. Excellent at carrying out and presenting a consultation with constructive and imaginative discussion of findings. Able to provide a wide range of appropriate differential diagnosis and discuss how this might be narrowed down. Excellent communicator with patients and relatives, excellent rapport, easy manner and empathic. Aware of hidden agendas. Excellent patient feedback. Excellent knowledge of managing common GP emergencies. Excellent awareness of drug safety issues and how to prescribe effectively and economically in the community. Excellent awareness of risk in the context of General Practice.

Excellent

Very good clinical skills including carrying out a GP consultation and presenting it. Able to give some differential diagnosis. Very good communicator with both patients and relatives. Very Good knowledge of managing common GP emergencies, drug safety issues and how to prescribe effectively and economically. Good awareness of risks involved in practical procedures and how to minimise these. Generally uses the information to put patient’s presentation into context.

Very Good

Good clinical skills. Good ability to complete a GP consultation and present it with some discussion of likely diagnosis and management. Very occasional needs reminder of a structured communication plan. Good communicator and able to explain adequately and appropriately to patients. Some knowledge of drug safety issues. Performs practical procedures competently and safely. Good note keeping.

Good

Adequate clinical skills and/or ability to elicit & present history and examination. Sometimes unstructured consultations. Limited appreciation of differential diagnosis & management. Some problems with communication. Unaware of hidden agendas, more focused on the problem than the patient. Uses medical jargon. Difficulties in explaining problems. Limited awareness of drug safety issues. Needs help with procedures. Generally safe overall.

Pass (Borderline)

Inadequate clinical skills below the level expected at this stage in training. Poor case presentation. Little understanding of clinical problems. Poor communicator with poor explanations. Unsure or unaware of patients needs and/or concerns, missing the point of consultation. Poor feedback from patients. Rarely achieves consultation tasks. Some safety concerns regarding prescribing or practical procedures. Inadequate medical records.

Unsatisfactory

OUTCOME 3 : STUDENT AS A PROFESSIONAL

AREAS DESCRIPTOR CRITERIA STANDARDS

The graduate

will be able to behave according to ethical and legal principles

Reflect, learn and

teach others.

Learn and work

effectively within a multi-

professional team

Protect patients

and improve

care

Works effectively with all colleagues in the PHCT and beyond.

Acknowledges & respects the competencies of other team

members. Developed maturity,

professionalism and integrity in

general attitude,

behaviour and actions

For evidence base this on

own observations

and from other members of

the PHCT. Consider

attendance, honesty,

manners and dress (refer to Ethical Code

and Dress Code)

Excellent application of legal, moral, ethical and professional standards as outlined in the GMC’s guidance for students. Always seen as acting appropriately with regards to punctuality, honesty, dress and general behaviour. Interested in teaching. Self directed, showing strong sense of independence in learning, excellent ability to reflect on knowledge gaps and uses every opportunity to rectify these. Excellent team working skills and understands and respects the value of all the roles within the primary care team. Excellent feedback from all. Puts the patient at the centre of their healthcare. Understands their responsibility to raise any concerns about patient safety. Understands the professional framework in which medicine is practiced in the UK. Recognises own health needs.

Excellent

Very good application of the principles of legal, moral, ethical and professional. Always seen as acting appropriately with regards to punctuality, honesty, dress and general behaviour. Very good reflective practice with a commitment to learning. Needs little prompting towards learning resources etc. Very good team working skills and understands and respects the value of all the roles within the PCT. Very good feedback from all. Have been able and willing to get involved as placement progressed. Puts the patient at the centre of their healthcare. Very good awareness of issues relating to patient safety. Recognises own health needs.

Very Good

Good application of GMC guidance on student standards. Good team member, good attitude and feedback from others. Presents as honest and has a good professional behaviour towards patients and staff generally, but not exemplary eg with punctuality, dress and manner. Evidence of reflective practice and show awareness of knowledge gaps, occasional prompt required regarding learning. Basic understanding of the measures that can be put in place to improve patient safety eg audit and SEA. Recognises own health needs.

Good

Limited application of GMC guidance. Detached from day to day issues, seems disinterested. Lack of interaction with team members. Contributes little. Needs prompting about reflective practice and the importance of this. Perhaps minor concerns regarding honesty, punctuality, dress and/or manner. Lack of awareness of knowledge gaps at times but accepts guidance on rectifying these. Limited awareness of potential patient safety issues. Needs encouraged to look after their own health needs.

Pass (Borderline)

No grasp of GMC guidance. Lacks awareness of others in the team, exhibiting little interaction with them. Limited appreciation of other team member’s role and/or status. Lacks interest with little effort to get involved. No reflective practice observed. Dishonest, rude or inappropriate manner towards patients and/or staff. Inappropriately dressed for a medical student in contact with patients, no knowledge of Dress Code. Unacceptable professional behaviour. Inappropriate approach to problems. Unaware of limits in their medical knowledge and skill. Poor problem solving strategies. No awareness of clinical governance. Potential risk to patient safety. Evident personal health issues and limited desire to address these.

Unsatisfactory

Year 5 GP Tutor Formative Assessment Sheet

Student Name: Year 5 Practice: Tutor: Date: Block:

Unsatisfactory Pass

(Borderline) Good Very Good Excellent

1 2 3 4 5 Student as a

scholar

Student as a practitioner

Student as a professional

Strengths

Areas to address including any action points

Plan to take forward to further blocks and beyond

End of Block Assessment

Please total the marks awarded above to reach the overall mark

0B15 Tutor Signature:

Student Signature:

Date:

Date:

Green top copy to be returned to Fiona Petrie, MBChB office / Bottom yellow copy to be retained by student

Year 5 Psychiatry Attachment END OF BLOCK ASSESSMENT FORM

Student’s Name:

Tutor: Tutor Grade:

Please comment on the above student: Unsatisfactory Satisfactory Attendance Clinical Assistantship tasks Patient Contacts in Log diary Unsatisfactory Pass Good Very Good 4BExcellent 1 2 3 4 5B5 1. History Taking 2. Mental State Examination 3. Formulation, Treatment and Management Planning

4. General Knowledge of Psychiatry

Unsatisfactory

0

Satisfactory 1

5. Professional Relationships

6. Attitude and Behaviour

End of Block Global Assessment Please total the marks awarded in areas 1-6 above to reach the overall mark

1B22 Please give details relating to any borderline/unsatisfactory marks: Where there are concerns regarding a student please contact Fiona Petrie f.petrie@abdn.ac.uk Student Feedback – areas of strength/for development:

Signed - ……………………………………………………... Date - ……………………… ( Tutor) Signed - ……………………………………………………... Date - ……………………… (Student)

Blue top copy to be returned to Fiona Petrie, MBChB office / Bottom yellow copy to be retained by student