JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
RTW Needs Analysis Form
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Name
*
Your answer
Age
*
Your answer
Gender
*
Your answer
Year of GP Qualification
*
Your answer
About your current situation...
*
I am currently off work
I am about to go off work
I have recently returned to work
Other:
Length of time out of work/anticipated if not yet returned...
*
0-3 months
4-6 months
7-9 months
10-12 months
13-18 months
19-24 months
2+ years
Length of time out of work/anticipated if not yet returned...
*
0-3 months
4-6 months
7-9 months
10-12 months
13-18 months
19-24 months
Other:
Previous position held before career break e.g. Locum, Salaried, Partner, Trainee?
*
Your answer
How many sessions did you work in your previous role (as above)?
*
Your answer
Did you undertake any other roles? (OOH, Managerial role, GPwSI)?
*
Your answer
If you did any other roles (as above), how many sessions did you take?
*
Your answer
Reason for being out of work e.g. parental leave, working abroad, other specialty, sick leave, other work, career break, retirement, other - please specify.
*
Your answer
How motivated are you to return to your previous role? (please rate your responses using the number system provided).
*
extremely unmotivated
1
2
3
4
5
6
7
8
9
10
extremely motivated
How supported do you feel returning back to work? (please rate your responses using the number system provided).
*
unsupported
1
2
3
4
5
6
7
8
9
10
fully supported
How self-confident do you feel returning back to work? (please rate your responses using the number system provided).
*
no self-confidence
1
2
3
4
5
6
7
8
9
10
extremely self confident
How confident do you feel keeping up to date with professional administration on returning? (please rate your responses using the number system provided).
*
no self-confidence
1
2
3
4
5
6
7
8
9
10
extremely self confident
How confident do you feel being clinically up to date on returning? (please rate your responses using the number system provided).
*
no self-confidence
1
2
3
4
5
6
7
8
9
10
extremely self confident
How confident do you feel being up to date with local events/pathway/guideline changes on returning? (please rate your responses using the number system provided).
*
no self-confidence
1
2
3
4
5
6
7
8
9
10
extremely self confident
How confident do you feel using the computer system on returning? (please rate your responses using the number system provided).
*
no self-confidence
1
2
3
4
5
6
7
8
9
10
extremely self confident
Have you seriously thought about leaving general practice while off? (please rate your responses using the number system provided).
*
very seriously
1
2
3
4
5
6
7
8
9
10
not at all
Do you have any sources of professional support while off e.g. mentor or a peer network, if so what?
*
Your answer
Do you have any planned process to help your transition back into practice? (e.g. Keeping In Touch days/induction/named buddy)
*
Your answer
Are there any barriers making your return more difficult e.g. health problems, childcare, financial?
*
Your answer
What are your biggest worries about returning to work e.g. workload, not being up to date, appraisal, stigma?
*
Your answer
Is there anything else you would like to share/would find useful regarding the process of coming back into work?
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
