T06 Scope support and review agreement — Blank form
2026 digital edition · Dr Naeem Aziz DGM FRCP · 1 min read
Print this blank worksheet and complete it privately. Responses are not collected by the website. Do not include identifiable patient information. This is a planning aid, not an official application form.
Blank reusable form
Read with chapter 9
Agree the clinical activity and support before a new arrangement starts. Record immediate advice separately from mentoring; use the review discussion in chapter 9. Use the form for a new activity or a genuine clarification of responsibilities; it is not a recurring permission test for established SAS autonomy.
Activity and authorised scope
Define setting, responsibility and exclusions, including what is not changing.
Clinical support
Name the supporting role, availability, method of contact and expected response arrangement.
Discussion and escalation
Distinguish optional peer advice, required supervisory approval and urgent escalation. Specify which decisions the doctor can make and implement.
Absence and failed contact
Record cover and what happens when planned support is unavailable.
Time and service arrangements
Confirm the job-plan implications for the doctor and supporting colleagues.
Evidence and review
Identify observation, feedback, review date and the triggers for an earlier review.
Approval and change control
Record participants, authorising role, agreed date and who can amend or pause the arrangement.