To Be Retained by Medical Personnel

CANDIDATE ID No. ______

POST TITLE : ______

STRICTLY CONFIDENTIAL

To be retained by Medical Personnel I am applying for: POST REFERENCE NO POST TITLE SPECIALTY CLOSING DATE FOR APPLICATIONS Please note that receipt of applications will not be acknowledged. Shortlisted candidates will be contacted within approximately three weeks of the closing date.

Equal Opportunities Monitoring

We want to ensure that our job opportunities are open to all. The only way we can ensure there is equal opportunity is to measure applications we receive. Therefore this form asks you for your ethnic origin, gender, disability, religion, sexuality, marital status and age. The information you provide in this part of the form is confidential and is not used in the selection process. It will be separated from the rest of the form when we receive it.

1. You are: Female  Male 

2. Do you wish to work: Full time  Part time  3. Do you consider yourself, or have you ever considered yourself as transgender? This could include considering or intending to undergo gender reassignment surgery or not identifying with your assigned birth gender.

No  Yes  Prefer not to say 

4. What is your date of birth?

5. Do you have a physical or mental health condition or disability that has a substantial effect on your ability to carry out day to day activities or is expected to last 12 months or more? No  Yes 

If Yes, please describe here the nature of the disability and any special arrangements for interview / work location:

Again, if Yes please tick if it is either of the following:

Learning disability  Long standing illness  Mental Health Condition  Physical Impairment  Sensory Impairment  Other (please describe):

1 CANDIDATE ID No. ______

POST TITLE : ______

6. What is your ethnic group? Choose one section from A to F, then tick the appropriate box to indicate your cultural background A) White Scottish  Irish  Other British  Other White Background 

B) Mixed Any mixed background 

C) Asian; Asian Scottish; Asian English; Asian .British: Pakistani  Indian  Chinese  Bangladeshi  Other Asian background 

D) Black; Black Scottish; Black British Caribbean  African  Other Black background 

E) other ethnic background Any other background 

F) Prefer not to answer 

7. What is your religion?

A) Buddhism  B) Christianity - Church of Scotland  C) Hinduism 

D) Judaism  E) Islam  F) Christianity - Roman Catholic 

G) Christianity (other) G) Sikhism  H) Other faith / belief 

I) Prefer not to answer  J) No Religion 

8. What is your sexual orientation?

A) Bi Sexual  B) Lesbian/Gay Woman  C) Heterosexual (straight) 

D) Gay Man  E) Other  F) Prefer not to answer 

9. What is your marital status? A) Married  B) Single  C) Widowed  D) Not married 

E) Other  F) Separated  G) Prefer not to answer 

POST TITLE : ______

Disability Discrimination Act

The Disability Discrimination Act 1995 and Amended Regulations 2005 defines disability as follows: “any physical or mental impairment which has a substantial adverse effect on a person’s ability to carry out normal day to day activities”. NHS Scotland is “Positive About Disabled People”, and as such we provide job opportunities for disabled people. NHS Scotland operates a Job Interview Guarantee (JIG), which means that if you have a disability, and meet the minimum criteria outlined within the person specification, you will be guaranteed an interview. However, some disabled people prefer not to take this option, so please tick your preference if you are a disabled candidate.

Do you want to participate in the guarantee scheme?

Yes No

Please specify any special requirements you require if attending for interview, eg. Induction Loop, Wheelchair Access, Signer FORMTEXT

Driving Licence (see Job Description - only complete if a driving licence is essential)

Do you have a driving licence? Yes No If yes, which categories are you entitled to drive, eg. B, BE, C

Please give dates you will not be available for interview

Advert

How did you find out about this vacancy:

BMJ (online) BMJ (print) BDJ NHS Scotland job portal SHOW (www.jobs.scot.nhs.uk) NHS Scotland Medical Microsite (www.medicaljobs.scot.nhs.uk) Doctors.net. (www.doctors.net.uk) Word of mouth / referral Unknown Other (please specify) ______

POST TITLE : ______

Personal Information (will not be viewed by panel at shortlisting)

SURNAME:

FIRST NAMES: TITLE: (Dr, Mr, Ms, etc.) DATE OF BIRTH: PRESENT NATIONALITY:

ARE YOU AN EEA NATIONAL? Yes No

IF NO, DO YOU REQUIRE A WORK VISA? Yes No

If YES, please circle your current immigration status: Tier 1, Tier 2, Tier 4, Visitor Visa, Other ______

Start Date______Expiry Date ______

If you are not an EEA National and do Not require a Work Visa please indicate and attach supporting documentation of your immigration status: ______

If you are not an EEA National, was your undergraduate training taught in English?

Yes No

If not, please attach your English language examination certificate. Eg IELTS ______

YOUR PERMANENT ADDRESS:

Post Code Telephone numbers

*Address for correspondence (if different from above):

Post Code: Fax No. e-mail:

*Your daytime telephone number, or number on which a message may be left:

*(Please ensure this Address and Telephone No. are where you can be contacted after the closing date)

POST TITLE : ______

Registration Information:

Are you a member of the Protection of Vulnerable Groups Scheme (PVG) YES/NO (which was introduced by Disclosure Scotland in February 2011)?

If YES please state 16 digit membership number:

Please state your GMC / GDC Number:

Do you have a License to Practice? YES/NO

Are you on the GMC/GDC Specialist Register? (if applicable) YES / NO

If so which specialty/specialties?

Are you on the GP Register? (if applicable) YES / NO

If so please state the date you completed your GP Training

If you are not on the Specialist Register please state your expected CCT date

POST TITLE : ______

DECLARATION STATEMENTS (See Annex A)

Note (1) The Rehabilitation of Offenders Act 1974 provides for many people who have been convicted of certain criminal offences the opportunity to have no need to refer to these convictions or the circumstances relating to them in the course of their daily lives. Certain convictions can, therefore, be regarded as “spent” after the lapse of a period of years under the terms of the Act. The National Health Service employment for which you are applying is excluded in the provisions of the Act unless otherwise stated in the job description. If the post is excluded you are required not to withhold information about convictions which for other purposes are “spent” under the provisions of the Act. In the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action by your employer. Any information given, however, will be completely confidential and will be considered only in relation to the post for which this application form refers.

I declare that I have:

(a) No previous convictions

(b) Previous convictions – details of which are given overleaf

Note (2) To the best of your knowledge have you been or are you currently subject to any fitness to practise proceedings by an appropriate licensing or regulatory body in the UK or any other country?

(a) No

(b) Yes

If yes please provide details on a separate sheet of paper of the nature of proceedings undertaken or contemplated, including approximate date of proceedings, country where proceedings were undertaken and the name and address of the licensing or regulatory body concerned.

Note (3) Relevant details from this form will be retained as part of your employment records if you are appointed. This information will be used for personnel administration and planning the work of your employer. In accordance with the Data Protection Act 1998, copies of personnel records may be obtained by contacting the Directorate of Human Resources.

POST TITLE : ______

DECLARATION

I DECLARE THAT, TO THE BEST OF MY KNOWLEDGE, THE INFORMATION CONTAINED IN THIS FORM IS ACCURATE AND I CONSENT TO DETAILS BEING RETAINED CONFIDENTIALLY AND USED FOR SPECIFIC AND LAWFUL PURPOSES IN CONNECTION WITH THE DATA PROTECTION ACT 1998.

Signature:…………………………………………………………….Date:………………

NB Canvassing of NHS Highland, directly or indirectly, or providing false information with regard to this application, shall disqualify the candidate from such appointment, or if discovered after appointment, may lead to dismissal.

“WE ARE COMMITTED TO PROMOTING EQUAL OPPORTUNITIES”

POST TITLE : ______

ANNEX A

STATEMENT OF POLICY REGARDING FITNESS TO PRACTISE PROCEEDINGS BY A LICENSING/REGULATORY BODY AND RELATING TO CRIMINAL INVESTIGATIONS IN THE UK OR OVERSEAS Registration with the General Medical Council or General Dental Council imposes on doctors and dentists the duty to provide a good standard of medical care for, and to behave appropriately, towards patients. NHS Employers also have a duty to ensure that patients receive a good standard of medical care and ensure as far as possible the safety of patients. We therefore need to establish if you have been found guilty of a criminal offence, been bound over or cautioned or are currently the subject of proceedings which might lead to a conviction, an order binding you over or a caution, in the UK or any other country.

Applicants for posts in the NHS are exempt from the Rehabilitation of Offenders Act 1974. Application forms will include a declaration for applicants to complete declaring any previous or pending prosecutions or convictions, including those considered “spent” under this Act. Forms will also include a declaration of any cautions or bind overs.

We also need to establish if you have been the subject of any fitness to practise proceedings in the past, or if any fitness to practise proceedings are being contemplated, by a licensing or regulatory body in the UK or another country and this is also reflected in the declaration.

This information will be treated in confidence and will not debar you from appointment unless the selection panel considers that it renders you unsuitable for appointment. In reaching such a decision we will consider the nature of the conviction/action, how long ago it took place and any other factors which may be relevant.

Failure to disclose a criminal offence, having been bound over or cautioned or that you are currently the subject of criminal proceedings which might lead to conviction, an order binding you over or a caution, or fitness to practise proceedings undertaken or being undertaken by an appropriate licensing or regulatory body, may disqualify you from appointment, or result in summary dismissal/ disciplinary action and referral to the General Medical Council [General Dental Council] for consideration if such a discrepancy came to light.

If you would like to discuss what effect any previous convictions, police investigations or fitness to practice proceedings taken or being taken either in the UK or by an overseas licensing or regulatory body might have on your application, you may contact us and ask to speak to a Senior Medical Staffing Officer in confidence, for advice.

STRICTLY CONFIDENTIAL

POST TITLE : ______

PLEASE COMPLETE ALL BOXES IN BLOCK CAPITAL LETTERS OR TYPESCRIPT

1. Are you on the GMC Specialist Register, if not what is your CCT date? (consultant posts only)

Please state specialty: ______2. Details of current (or most recent) post:

Grade: Specialty: (state if Locum)

Date of Appointment: From: To:

Current Salary: Period of Notice Required:

Employer/Hospital:

Duties:*

Is this a research post ? () YES NO

If yes give further details including funding body

If you are on an honorary contract, give details including grade of post

*Please note this section is expandable if you require more space

3. EMPLOYMENT HISTORY Details of previous posts held since Medical School/Dental School. Include grade of post, if you held a NTN or VTN number note of duties, place of employment and details of any research posts held (including funding body), Start with your most recent employment first and work down the page. If a job supports the position applied for, please say more about it in your Application Support Statement. 9 CANDIDATE ID No. ______

POST TITLE : ______

Job Title Employer From To Reason for leaving

*Please note this section is expandable if you require more space

POST TITLE : ______

Please note all sections below are expandable if you require more space 4. Medical education, professional qualifications, postgraduate medical training, including experience in research or academic medicine Dates Qualifications obtained, membership of professional institution, etc. From To

Name of Medical/Dental School

Clinical Experience

Teaching Experience

Research and Audit Experience

POST TITLE : ______

Staff Management

Team Working and Interpersonal Skills

POST TITLE : ______

5. Any other relevant educational of professional qualification and undergraduate awards or special projects – give details and dates: Qualification Details Dates

6. Reasons for applying - Please say why you are interested in this appointment and indicate the relevance to the job and/or training programme of your medical training and previous experience.

POST TITLE : ______

7. Publications (Please exclude your name when listing your publications so that your application remains anonymised for short listing purposes)

8. Future Plans

POST TITLE : ______

PROFESSIONAL REFEREES Please give details, including titles and correct style of address, of at least TWO professional referees who have consented to be approached. They should be people qualified to comment on your medical ability and experience for this appointment. The named referees should include at least one referee from your current (or most recent) employer who should be a Clinical Line Manager ie Clinical Lead/Clinical Director/Medical Director. You should not use family members or friends. Our pre- employment screening also includes, where appropriate, health and fitness for work, criminal records, qualifications and professional registration. Note that references will be requested only if invited to interview.

PLEASE USE BLOCK LETTERS NAME NAME NAME

DESIGNATION DESIGNATION DESIGNATION

ADDRESS ADDRESS ADDRESS

Tel No:- Tel No: Tel No:

Fax No:- Fax No:- Fax No:

E-mail:- E-mail:- E-mail:

Relationship: Relationship: Relationship:

If you do not wish your present employer to be contacted please write NO in the box

Declaration: I hereby declare that the information given here is true. I further declare that should the situation change with regard to police investigations, criminal convictions or fitness to practise while applying for or appointed to this post, I will provide full details to the Medical Staffing Recruitment Team

Declaration : YES I agree to the above