Tyne & Wear NHS Library & Knowledge Services

Registration Form Dr/Mr/Mrs/Miss/Ms/ First names (Please print clearly): Family name (Please print clearly): Other

Full Work address: (Student term time address) Home address:

Post code: Post code:

E-mail address/es:

Work phone: Home: Bleep no: Mobile phone no:

Work fax no: Term time phone no:

SECTION A: TO BE COMPLETED BY NHS STAFF

Job title: Leaving date Area of interest or (if known): study (optional) Supervising Consultant ( for Junior doctors/ clinical observers etc): EMPLOYER DETAILS (Please circle the Newcastle Hospitals PCT Trust that applies to you): North East Ambulance Health Care City Hospitals Sunderland Northumberland Care Trust South Tyneside PCT Gateshead Health NHS Trust Northumberland, Tyne and Wear NHS Trust Sunderland Teaching PCT Gateshead PCT North East Strategic Health Authority Sunderland Teaching PCT - CSA Health Protection Agency Northumbria Healthcare NHS Trust Other (please specify): Newcastle PCT

SECTION B: TO BE COMPLETED BY FULL TIME STUDENTS ON PLACEMENT

TYPE OF STUDENT: (Delete or state ) College/University: Medical / Nurse / Other …………………………..

Course title:

Placement ends: Date of graduation/course end:

SECTION C: ALL USERS MUST SIGN BOX BELOW I agree to abide by the Libraries’ Rules and regulations. I agree to this information being held on the joint library management system, and agree that it may be shared between the NTW NHS LKS. All information will be kept confidential in accordance with the Data Protection Act 1998, and will be stored for use by the Northumberland, Tyne and Wear NHS Library & Knowledge Services only.

Signature: Date: OFFICE USE ONLY Barcode Number: Workbase: Staff Group:

Staff member who processed form Date processed