Witness Form

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Witness Form

Name(Required)

First Last

GDC Number(Required)

Professional Role(Required)

Practice Name(Required)

Telephone Number(Required)

Email(Required)

Enter Email Confirm Email

I confirm that I understand my overall responsibility for supporting the learner whilst acting as the Named GDC Supervising Registrant.(Required)

I confirm

Date(Required)

Learner Details

Name(Required)

First Last

Provider Name(Required)

Witness's Relationship to the Learner(Required)

Delegation of Witness Responsibilities

Delegation of Witness Responsibilities(Required)

Will responsibility for workplace observations be delegated/shared? If Yes complete the Additional Witnesses section. If No Continue to submission.

Yes

Additional Witnesses

Name

First Last

GDC Registration Number

Professional Role

Relationship to the Learner

Telephone Number

Enter Email Confirm Email

Delegation Details

Please specify the delegated responsibilities (e.g. competent to complete any/all topics, or specific treatments/procedures only).