Absence Declaration

This check is to ensure that your current training and expected Completion of Training date remain on schedule (if applicable).
Name GMC Grade/Year

Since your last review can you confirm if you have had any significant periods of absence during your training period.

Significant absence is defined as either

a) a period of continuous absence that exceeds 10 consecutive working days/shifts
b) a series of absences that when combined exceed a period of 15 working days/shifts

Please tick relevant box below 

No, I have not had any period or periods of significant absence as defined above
Yes, I have had a period or periods of absence that have exceeded the definitions above
If you have answered YES to the above, please provide further details below and continue on separate sheet if required:

Please provide dates and duration of

Total Number of
ALL Absences including Type e.g.
Days
Sick Leave, Maternity Leave etc

Signed (Trainee) Date / /

Signed (Educational Supervisor) Date / /

A period or periods of significant absence may have an impact on your training and your ability to complete your training programme or may result in an
amendment to your expected CCT date. Any changes required will be discussed and agreed with you in conjunction with your Training Programme Director
and Deanery staff.
For Deanery Use Only:
Period Covered - Note this should be the same as ARCP/RITA dates Dates From To
Database Updated Yes Initials

V6 – updated 23/11/2010