Personal Details
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Mobile(*)
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Select date(*)
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Do you have any special learning needs? Will you require extra time for examinations?(*)
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Employment Details
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Witness/Supervisor Details
Main Witness/Supervisor Name(*)
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Commitment to the course
What times are you available for live online classrooms/webinars?

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Please confirm you are aware you must have access to a computer and internet access to view the online tutorials/video recordings
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As this course is online, do you believe you are capable of self-directed learning?
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Please confirm you are aware you are required to watch online video tutorials
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Out of 10 what rating would you give your motivation to learn online?

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Have you considered how you will meet the online learning requirements and make time to complete your record of experience? Please explain in no more than 100 words.
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To complete your Record of Competence you require access to range of patient groups. Please tick which patient groups you will have access to.

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Learning Preferences
What is your most preferred learning style?

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What is your least preferred learning style?

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Please upload the required documents or email them to [email protected]
Your GDC Registration
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Your main witness/supervisor’s GDC Registration
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NEBDN Contract
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