Core Element G (Domain 4)

Domain 4: Maintaining Trust

Each year you are asked to consider any Health issues experienced since your last appraisal. As part of Appraisal Form 3, you are asked to complete a Health Statement.  Additionally, you may wish to complete a reflective template as well, which can be found at the bottom of this page.

Completion of Health Statement (declaration) is required for every appraisal

Good medical practice requires all doctors to:

  • Show respect for patients (para 53-55)
  • Treat patients and colleagues fairly and without discrimination (para 56-64)
  • Act with honesty and integrity (para 65-80)

GMC (2013) Good Medical Practice, [Online], Available:

"Issues" on Form 4

When the appraiser drafts the Form 4 summary, any Health issues declared in the Health Statement will get flagged automatically as "issues".

If the appraiser deems the issue(s) as resolved and no further action is required, they can overwrite "issues" on your Form 4 to "Resolved".

The three statuses in relation to the self declarations are:

  • "Issues" - a declaration has been made of an incident which requires discussion with appraiser
  • "No issues" - declaration made with no incidents raised
  • "Resolved" - declaration made with incident(s) which was discussed with appraiser at appraisal, who has deemed the issue resolved and does not need to be flagged for RO's attention.

Related Documents

Structured Reflective Template - HEALTH | File Size: 93.5 KB | Date Updated: 11/03/2015

Document designed for electronic completion

This page was last updated on: 15/05/2015