GP Careers Champions

Thank you for applying to be a GP Champion.

This questionnaire will take <5 minutes to fill out and we will email you to confirm your participation in the scheme and outline what happens next.

If you have any further questions or would like a copy of our FAQs please email gpcareerschampions@gmail.com

Thank you,

Meg Rowlands & Anna Harrison

GP Leadership Trainees

South West Deanery

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* 1. Please enter any personal details you are happy to be contacted by

Name

Address

Address 2

City/Town

Post code

Email Address

Phone Number

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* 2. Please enter your main GP Surgery address (work address)

GP Surgery name

Deanery Patch (if known)

Address

Address 2

City/Town

Post Code

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* 3. What stage in your career are you at currently

GP Registrar (ST1-2)

GP Registrar (ST3+)

First 5 GP (please specify below if locum / salaried / partner)

>5 years post CCT (please specify below if locum / salaried / partner)

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* 4. What is your career background and do you have any particular interests? (eg background in sugery, GPwSI etc)

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* 5. Would you rather be a Champion to:

An Undergraduate

A Postgraduate (could be foundation trainee, out of training or doctor in other speciality)

Don't mind

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* 6. What level of support would you be happy to offer? (Tick as many as apply)

Offer Taster Experience in your surgery

Email advice / discussion

Telephone advice / discussion

Skype advice / discussion

Face - to - face meeting

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* 7. Do you feel you need any extra information or support to fulfil this role?

Yes

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* 8. Any other questions or comments about the GP Careers Champion scheme? We will answer these by return email.

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* 9. Please select to confirm your participation:

I understand and give my consent for my details to be stored on the GP Careers Champion database. I understand this information will not be shared with any other organisation.