Mentor Application Form : Surrey Training Hub

Name

*

Email

*

Phone Number

*

Practice

*

Please select the main area you work in *

NW Surrey
Guildford & Waverly
Surrey Downs
East Surrey

Eligibility criteria *

I am on the National Medical Performers List
I hold full registration and a licence to practise with the General Medical Council (GMC)
I am not subject to interim suspension under section 41A of the Medical Act 1983
I am working 3 or more NHS clinical sessions per week

How many NHS clinical sessions do you work each week in primary care?

Please confirm how many years' post-qualification you are?

*

Please let us know why you would like to be a GP Mentor?

*

Training requirements to ensure standardised approach. Please select your preference. *

Mentor Training (1st time)
Mentor Update Training (refresher)

Hold an existing mentoring qualification or similar? State: date obtained, awarding organisation

Describe any challenges you might encounter as a GP mentor; how might you approach these?

*

How many GP fellows/mentees could you support each month (1.5-2hrs/mentee)? *

1 mentee per month
2 mentees per month
3 mentees per month
4 mentees per month
Other (please specify)

Specify

*

I am aware my details will be processed by the Surrey Training Hub in order to facilitate and deliver the GP Mentor Scheme and will be processed in accordance with our Privacy Notice.

*GP mentors will be asked to sign a separate Memorandum of Understanding to acknowledge and agree to the Terms and Conditions as stipulated by NHSE/I, including changes in circumstances which may affect eligibility for this scheme.

*

I understand the mentor supplement will be paid following submission of a valid invoice and timesheet.

*

I understand I may occasionally be asked to provide feedback on this process, to support evaluation.

*

I understand sessions will be confidential and will be related to personal and professional career development, not clinical competence.

Name

*

Date

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