Please complete all information required within this pack

MEDICAL AND DENTAL APPLICATION FORM

PART A

Section 1: Personal Information

This section will not be used for short listing purposes but will be shared with the Assessment Panel if you are selected to attend interview.

Reference

MD/

Please quote on all correspondence

Location

Post Title

Closing Date

Title

Forename

Surname

Contact Details

Address

Post code

E-Mail

Telephone

Mobile

GMC/GDC Registration (Please insert a ( to indicate the correct details)

Professional Body:

General Medical Council

(GMC) (

General Dental Council

(GDC) (

Professional Registration Status:

Full (

Provisional (

Registration Number:

Name in which you are registered:

Do you hold a license to practise?

Yes (

No (

Are your details included on the GMC / GDC Specialist Register?

Yes (

No (

If yes, please state the following:

Specialty:

Sub-specialty:

If your details are not included on the GMC / GDC Specialist Register, please state the date you expect to be included:

Are your details included on the GMC GP Register?

Yes (

No (

Are there any restrictions to your professional registration?

Yes (

Please provide reasons on a separate sheet

No (

MEDICAL AND DENTAL APPLICATION FORM

PART B

Section 2: Employment Application Form

Reference:

MD/

Please quote on all correspondence

Candidate Reference:

xx

Office Use Only

Post Title:

Location:

Closing Date:

1. Medical Education, Other Degrees or Professional Qualifications, Undergraduate Awards, Prizes, Distinctions etc

Please detail qualifications obtained (please state if part qualified), membership of professional institutions.

Date From: Date To: Award, Degree, Prize

     

     

Reference

MD/

Please quote on all correspondence

Candidate Reference

xx

Office Use Only

2. Details of Current (or most recent) post

Job Title:

Specialty:

Grade:

Employer:

Location:

Dates employment started and

(if applicable) finished:

From:

To:

Was this role a research post?

Yes

No

If yes, are you on an on-call rota?

Yes

No

If yes, how often and at what grade?

What proportion of your time is spent on clinical work?

Role and Summary of Duties

     

Reference

MD/

Please quote on all correspondence

Candidate Reference

xx

Office Use Only

3. Other Previous Posts Held Since Graduation From Medical School

Please list in chronological order, starting with your most recent post. Please also include details of current, previous and future employment you know of together with details of your employer and a brief summary of your role. Provide reasons for any gaps in employment of more than four weeks. Please ensure that if you trained as a flexible trainee at any time during your training, this is clearly noted.

Dates Dates Post Held Employer

From To

Reference

MD/

Please quote on all correspondence

Candidate Reference

xx

Office Use Only

4. Clinical Competence

Please highlight below the competencies you have achieved that you feel are particularly relevant to this application, for example, procedures and to what level of competence, level of involvement in acute take, clinical courses attended. Please refer to the relevant person specification.

     

5. Commitment to Specialty

Please provide details as to what steps you have taken to show commitment to this specialty (for example, membership of societies, attendance at meetings, courses or exams undertaken, taster placements, specific electives, etc.)

     

Reference

MD/

Please quote on all correspondence

Candidate Reference

xx

Office Use Only

6. Audit, Research and Presentations

Please detail what audit and / or research work you have undertaken, including details of publications and presentations. Please specify to what extent you initiated the work, undertook and analysed it; if and how the audit loop was closed, type of meeting where any presentation took place and publication format and journal.

Please do not give names in presentation or publication citations but list title, journal/conference, date, volume and pages. Please indicate where in the authorship you are (for example, first, third author etc).

     

7. Teaching and Organisational Activity

Please provide details of your involvement in teaching activities (including when, how and formal/informal) and other work-related organisational activities (for example, rota co-ordinator, representative roles, including when and what this involved.)

     

Reference

MD/

Please quote on all correspondence

Candidate Reference

xx

Office Use Only

8. Leadership Involvement

Please detail dates, type and level (local / national; senior / junior; school / university) of any experience you have of leadership roles in either medical or non-medical fields, for example, team, organisation or group leader. Please, explain how this is relevant to your application.

     

9. Personal Achievements and Qualities

Please detail non-medical activities you have undertaken and how they demonstrate your personal qualities, for example, volunteer work, sporting & performance arts activities. Please specify dates, your role (member / leader) and the level (junior / senior: local / national). Please also highlight how these achievements and qualities enhance your approach to medicine.

     

Reference

MD/

Please quote on all correspondence

Candidate Reference

xx

Office Use Only

10. Personal Statement in Support of Your Application

Please explain why you wish to apply for this post and highlight relevant experience and skills you have gained to date.

11. Referees and References

Your referees will include your present (or most recent) employer. Please identify below the person in your organisation (for current NHS staff this is your direct line manager) who is authorised to confirm your employment and the details given in your application. Please identify two other referees who may have closer knowledge of your skills, knowledge and abilities and who may offer opinion on your suitability for this post. Please note that references will be taken up for short listed candidates prior to interview.

Referee 1

(Present or current line manager / clinical supervisor)

Name and Title:

Position:

Address:

Email Address:

Telephone Number:

Mobile Number:

Reference 2

Name and Title:

Position:

Address:

Email Address:

Telephone Number:

Mobile Number:

Reference 3

Name and Title:

Position:

Address:

Email Address:

Telephone Number:

Mobile Number:

12. Advertising Sources

How did you find out about this vacancy? Please tick ( the relevant response.

Word of mouth (

Scotland’s Health on the Web Site(

Medical Microsite(

NHS Forth Valley Vacancy Site

(

Professional Journal (please specify)

Other (please specify)

MEDICAL AND DENTAL APPLICATION FORM

PART C

This section of the application will be removed prior to short listing but will be shared with the Assessment Panel at the interview stage.

Protection of Vulnerable Groups (PVG) Membership

PVG Registration Date:

PVG* Membership Number:

(16 digits)

Current PVG Membership Scope:

Children only ( Protected adults only (

Both (

Driving Licence

Do you have a full driving licence that allows you to drive in the United Kingdom?

Yes ( No (

Job Interview Guarantee (JIG) Scheme

NHS Forth Valley operates a Job Interview Guarantee scheme, 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 up this option, so please tick your preference if you are a disabled candidate.

Do you want to participate in the JIG Scheme?

Yes (

No (

Please state any specific requirements if attending interview (e.g. induction loop)

Eligibility to Work in the UK

Applicants should note that a Certificate of Sponsorship can only be issued to the successful applicant if the post:

· is included in the United Kingdom Shortage Occupation List; or

· meets the requirements of the resident labour market test.

Do you need to be sponsored under the Tier 2 (General) category of the UK points-based immigration system to take up this post?

Yes (

No (

Right to Work in the United Kingdom (Asylum and Immigration Act 1996)

NHS Forth Valley must check the right to work in the UK of all candidates appointed. If appointed, as part of our pre-employment checks, you must present original proof and a copy of your Right to Work in the UK. (See www.ukba.homeoffice.gov.uk/workingintheuk.)

Are you a United Kingdom (UK), European Community (EC) or European Economic Area (EEA) National?

Yes (

No (

Language Skills (Non-EEA applicants only)

Do you have demonstrable skills in written and spoken English at the required level (IELTS 7) to enable effective communication about medical and/or health topics with patients, colleagues and the public?

Yes (

No (

What evidence of English language proficiency do you have?

Please provide English language supporting information including dates, scores and sub-scores where relevant (e.g. IELTS)

Section 3: Declarations, Convictions and Applicant Signature

Post Reference

MD/

Please quote on all correspondence

Declaration Statements Regarding:

A - Any criminal offence, being bound over or cautioned, or current proceedings which might lead to a conviction, an order binding you over a caution and

B - Fitness to practice proceedings taken or being currently contemplated by a licensing / regulatory body.

If the answer is “Yes” to any question below, please provide details at point 11. Please note that you do not need to tell us about parking offences.

Please insert a ( in the relevant box to indicate your response

1. Are you currently bound over or have you ever been convicted of any offence by a Court or Court-Martial in the United Kingdom or in any other country?

No

Yes*

*If YES

Please provide details of the order binding you over and/or the nature of the offence, the penalty, sentence or order of the Court, and the date and place of the court hearing.

2. Have you ever received a police caution, reprimand or final warning?

No

Yes*

*If YES

Please include details of the caution, reprimand or final warning, including the date and reason administered.

3. Have you been charged with any offence in the United Kingdom or in any other country that has not yet been disposed of?

No

Yes*

You must inform us immediately if you are charged with any offence in the UK or in any other country after you complete this form and before taking up any position offered to you

*If YES

Please include details of the nature of the offence with which you are charged, date on which you are charged, and details of any on-going proceedings by a prosecuting body.

4. Are you aware of any current police investigation in the United Kingdom or in any other country following allegations made against you?

No

Yes*

*If YES

Please include details of the nature of the allegations made against you, and if known to you, any action to be taken against you by the police.

5. Are you aware of any current NHS Scotland Counter Fraud Services investigations following allegations made against you?

No

Yes*

*If YES

Please include details of the nature of the allegations made against you, and if known to you, any action to be taken by Counter Fraud Services.

Post Reference

MD/

Please quote on all correspondence

6. Have you ever been investigated by the police, NHS Scotland Counter Fraud Services or other investigatory body resulting in a caution, conviction or dismissal from your employment?

No

Yes*

Investigatory bodies include:- Local Authorities, Customs and Excise, Immigration, Passport Agency, HMRC, Department of Trade and Industry, Department of Work and Pensions, Security Agencies, Financial Service Authority, Banks and Building Societies, Life Insurance Companies.

Please note, this list is not exhaustive.

* If YES

Please include details of the nature of the allegations made against you, and if known to you, any action to be taken by the Investigatory Body.

7. Have you ever been dismissed by reason of misconduct from any employment, office or other position held by you?

No

Yes*

*If YES

Please include details of the employment, office or position held, the date you were dismissed and the nature of the allegations of misconduct.

8. Have you ever been disqualified from the practice of a profession, or required to practice subject to specified limitations following fitness to practice proceedings, by a regulatory or licensing body in the United Kingdom or in any other country?

No

Yes*

*If YES

Please include details of the nature of the disqualification, limitation or restriction, the date, and the name and address of the licensing or regulatory body concerned.

9. Are you currently the subject of any investigation or fitness to practice proceedings by any licensing or regulatory body in the United Kingdom or in any other country?

No

Yes*

*If YES

Please include details of the reason given for the investigation and/or proceedings undertaken, the date, details of any limitation or restriction to which you are currently subject, and the name and address of the licensing or regulatory body concerned.

10. Are you subject to any other prohibition, limitation or restriction that means we are unable to consider you for the position for which you are applying?

No

Yes*

*If YES

Please include details of the reason given for the investigation and/or proceedings undertaken, the date, details of any limitation or restriction to which you are currently subject, and the name and address of the licensing or regulatory body concerned.

Post Reference

MD/

Please quote on all correspondence

11. If you have answered YES to any of the questions above, please use this space to provide details. Please indicate the number(s) of the questions you are responding to.

Applicant Signature

Reference

MD/

Please quote on all correspondence

Candidate Reference

xx

Office Use Only

Please read and sign and date this document below to confirm that you have read and understand the following statements:-

· I have completed all the relevant parts of the application pack and confirm the details supplied on my application are, to the best of my knowledge, true and complete.

· I understand that if appointed to this post, the information on this form will be kept as part of my Human Resources file.

· I authorise you to obtain my references to support this application and understand these are required prior to the interview stage.

· I understand that details of educational qualifications, membership or professional bodies and referee reports may be verified through the establishments and individuals I have indicated.

· I consent to my details being kept confidentially and used for the specific and lawful purposes as specified in the Data Protection Act 1998.

· I declare that I have no previous convictions, or have identified any I have above.

· I can confirm I have read, agree and understand this declaration

Signature :

(Electronic Signatures Accepted)

Name :

(Block Capitals)

Date:

MEDICAL AND DENTAL APPLICATION FORM

PART D

This section is confidential and will not be shared with the Assessment Panel.

Applicant Immigration Status – To Completed by all Applicants

Full name:

Post applied for:

Post Reference:

MD/

Please read all questions carefully and complete the necessary detail in full

Please use BLOCK CAPITALS and tick ( the appropriate responses

1.

Passport Expiry date

Day:

Month:

Year:

2.

Date of Entry to the UK

Day:

Month:

Year:

3.

Please indicate which Immigration Status applies to you:

O Own Visa StatusDependant Visa Status

(Spouse/Partner/Civil Partner of Visa Holder)

UK / EEA national

UK/EEA national

Tier 1 (General) Points Based

Tier 1 (General)

Medical Training Initiative

Tier 1 (Post Study Work)

Points Based

Tier 1 (Post Study Work)

Tier 2 Certificate of Sponsorship

(formerly Work Permits)

Tier 2 Dependant

National Identity Card

National Identity Card

Tier 4 (General Student)

n/a

Tier 4 (Student Visitor)

n/a

Refugee / Asylum

Refugee / Asylum

UK Ancestral Visa

UK Ancestral Visa

Romanian / Bulgarian Accession Card

Romanian / Bulgarian

Accession Card

Other – please specify:

4.

Date period of entry to UK (Visa expiry) / leave to remain ceases

Day:

Month:

Year:

Please attach copies of the following documentation (originals will be checked at interview): Passport (personal details) Visa (if applicable). Original letters from the Home Office / UK Border Agency / Immigration and Nationality Director (if applicable).

7.

I confirm that the information provided on this form is to the best of my knowledge correct.

I understand that failure to provide appropriate evidence on request will mean my application cannot be considered further.

SIGNATURE:

DATE:

Equality Monitoring

Post Reference

MD/

Please quote on all correspondence

The collection, monitoring and analysis of equality data is a key part of NHS Forth Valley’s recruitment process. The data will be used to make sure that recruitment to NHS Forth Valley can show that we continue to meet the requirements of the UK’s Equality Act 2010.

This part of the application asks some personal questions relating to:

· Gender

· Disability

· Ethnic Group

· Nationality

· Religion and Belief

· Sexual Orientation

· Gender Reassignment

· Marriage and Civil Partnership

· Maternity

Answering these questions is entirely voluntary. Your answers are held in strict confidence, and will not be sent to the Assessment Panel at any stage in the recruitment process.

This part of the application also asks some questions that relate to your potential employment with NHS Forth Valley. Please answer all of the questions in this section that are relevant to you.

1.Date of birth

2.Gender

Male

(

Female

(

Prefer not to say

(

3. Have you, are you or do you plan to undergo gender reassignment (changing sex)?

Yes

(

No

(

Prefer not to say

(

4. Do you have a condition / disability that has lasted /may last 12 months or more?

No

(

Prefer not to say

(

Yes

(

If yes, please select this condition/disability:

Deafness or partial hearing loss

(

Blindness or partial sight loss

(

Learning disability (for example Down’s Syndrome)

(

Learning difficulty (for example dyslexia)

(

Developmental disorder (for example Autistic Spectrum Disorder

Or Asperger’s Syndrome)

(

Physical disability

(

Mental health condition

(

Long-term illness, disease or condition

(

Other condition (please write in)

(

5. Are your day-to-day activities limited because of this condition/disability?

Yes, limited a little

(

Yes, limited a lot

(

No

(

Prefer not to say

(

6. What is your ethnic group?

Choose ONE from section from A to F, then tick ONE box which best describes your ethnic group or background

A: White

Scottish

(

Irish

(

Other British

(

Gypsy Traveller

(

Polish

(

Other

(

B: Mixed or Multiple Ethnic Group (please write in):

C: Asian; Asian Scottish; Asian British:

Pakistani, Pakistani Scottish or Pakistani British

(

Indian, Indian Scottish or Indian British

(

Bangladeshi, Bangladeshi Scottish or Bangladeshi British

(

Chinese, Chinese Scottish or Chinese British

(

Other (please write in)

D: African:

African, African Scottish or African British

(

Other (please write in)

E: Caribbean or Black:

Caribbean, Caribbean Scottish or Caribbean British

(

Black, Black Scottish or Black British

(

Other (please write in)

F: Other Ethnic Group:

Arab, Arab Scottish or Arab British

(

Other (please write in)

Prefer not to say

(

7. What is your nationality?

8. What religion, religious denomination or body do you belong to?

None

(

Church of Scotland

(

Roman Catholic

(

Other Christian

(

Muslim

(

Buddhist

(

Sikh

(

Jewish

(

Hindu

(

Pagan

(

Another (please write in):

(

Prefer not to say

(

9. Which of the following options best describes how you think of yourself?

Heterosexual / straight

(

Gay / Lesbian

(

Bisexual

(

Other

(

Prefer not to say

(

10. What is your legal marital or same-sex civil partnership status?

Married

(

Civil partnership

(

None of these

(

Prefer not to say

(

11. Are you on maternity leave at the time of completing this form?

Yes

(

No

(

Prefer not to say

(

Thank you for your interest in working with NHS Forth Valley. Your application will be acknowledged within two working days of receipt.

Strictly Confidential