A-Z Hospitals NHS Trust (replace with your employer name)

Department of Health will be issuing new guidance relating to the monitoring of equality in April 2013. The equality and diversity sections within NHS Jobs application forms will be reviewed and updated when the new guidance is released. NHS MEDICAL & DENTAL APPLICATION FORM Please fill in the application form below. Do not type/write using only capital letters and please remember to check it carefully, as once the form has been submitted it cannot be changed. If you wish to apply on-line you can do so at www.jobs.nhs.uk. Please note that questions marked with an asterisk * are mandatory and therefore must be answered. APPLICATION FOR EMPLOYMENT WITH For Office Use Only Online Reference Number: A-Z Hospitals NHS Trust (replace with your employer name) APPLICATION FOR EMPLOYMENT Details entered in this part of the form will be held within HR systems of the recruiting organisation. Access to this information will be withheld from the shortlisting panel. Please do not type/write using only capital letters, as this could lead to your application being automatically rejected. Please use the appropriate mixture of capital and lowercase letters in standard written text. Job Reference Number Job Title Department Personal Details Title *Surname/Family Name *First Names Name in which you are registered with a professional body (if applicable) UK National Insurance No Address Medical_Application_Form v4b Page 1 of 25

*Postcode/ Zip code *Country Home Telephone Mobile Telephone Check this box if you wish to receive updates by text message? Work Telephone Preferred telephone number Home Mobile Work Email Address *Are you a United Kingdom (UK), European Community (EC) or European Economic Area (EEA) National? If you have answered no above, you must answer these questions: Please select the category that relates to your current immigration status. This status will be subject to checking before interview. Tier 1/HSMP Indefinite Leave to remain/enter Tier 2/HSMP Dependant / Spouse visa Clinical visa Tier 4 student Visitor Post Graduate Doctors and Dentists Tier 5 Temporary Workers Tier 5 Youth Mobility/ working holiday visa Refugee Other, please specify below ----------------------------------------------------------- Does your visa have a condition restricting employment or occupation in the UK? Please supply details of any visa currently held, including number, start/expiry dates and details of any restrictions. Visa No: Start Date: (DD/MM/YY) Expiry Date: (DD/MM/YY) Details of Restriction: Are you an NHS professional returning to practice? Medical_Application_Form v4b Page 2 of 25

APPLICATION FOR EMPLOYMENT Details entered in this part of the form will be held within HR systems of the recruiting organisation and will be made available to the short-listing panel. Job Reference Number Job Title Online reference number Department Education & Professional Qualifications Please list your University qualifications onwards in date order (most recent first). Please also indicate subjects currently being studied and the expected year of qualification. In the grade/result column for courses not yet completed, please state in progress.) All information disclosed on this application will be subject to verification. Subject/Qualification Place of Study Grade/result Year Relevant Training Courses Attended (Clinical, management and leadership, research, teaching, professional etc.) Please list courses you have attended over the past 3 years, in date order (most recent first). Please include courses in progress or approved for attendance in the near future and the expected date of completion. If you have completed a professional course which you believe to be relevant to this post, which falls outside of the 3 year limit, please include it. All information disclosed on this application will be subject to verification. Date Course Title Training Provider Duration Completed Medical_Application_Form v4b Page 3 of 25

Membership of Professional Bodies Include in this section any relevant professional registrations or memberships. If you are registered then please enter the relevant details below. All information disclosed on this application will be subject to verification. * Please indicate your Professional Registration status if relevant to this post: I have the relevant and current UK professional registration as required under the essential criteria of the person specification for this post I have the relevant and current UK professional registration and licence to practise as required under the essential criteria of the person specification for this post UK professional registration required and applied for UK professional registration and licence to practise required and applied for I do not have the relevant UK professional registration UK professional registration required but not yet applied for UK professional registration and licence to practise required but not yet applied for If professional registration is not required then go to Employment History If you are registered then please enter the relevant details below: UK Membership or UK Membership/ UK Professional Body Registration type Registration Number Expiry/Renewal Date If you are applying for a post that requires professional registration you are required to provide the following information: Are you currently the subject of a fitness to practise investigation or proceedings by a licensing or regulatory body in the UK or in any other country? Medical_Application_Form v4b Page 4 of 25

Have you ever been removed from the register or have conditions or undertakings been made on your registration by a fitness to practise committee or the licensing or regulatory body in the UK or in any other country? If applicable, please provide details of any conditions, undertakings or restrictions currently applied to your professional registration. In your current or any previous employment, have you had restrictions placed on your clinical practice as part of the revalidation process? Employment History Please record below full details of all your continuous employment history, beginning with your current or most recent employer and working backwards chronologically. If there are any gaps in your employment please ensure a full explanation is given at end of the Employment History section. IMPORTANT: If you are currently working within an NHS organisation but through an agency, please ensure you name the agency as your employer and not the NHS organisation you are currently contracted to. Please confirm what you believe to be your effective start date of continuous NHS service. If you have not been employed by the NHS, please state N/A Months since most recent employment ended (if applicable) Medical_Application_Form v4b Page 5 of 25

Current (or Most Recent) Employment (Reference always required) Start Date Employer Name Full Postal Address End Date Contract Duration (months) Type of Business Name of Educational or Clinical Supervisor Email Your Post Title Grade Specialty Hospital/Base Post/Zip Code Job Title Telephone Current Basic Salary Sub-Specialty (if applicable) Permanent Fixed Term Ad Hoc Contract Current Contract NHS Locum Agency Locum Sessional GP Type Rotational Post with NTN OOH GP Salaried GP Other (please state): Reason for leaving (if applicable) Description of your duties and responsibilities Medical_Application_Form v4b Page 6 of 25

Previous Employment Please record below the details of your previous employment, not including your current or most recent post which has been provided above. If required, please provide additional information regarding your employment history within the Supporting Information section. Please explain any gaps in employment in the section below. Previous Employer 1 Start Date Employer Name Full Postal Address Type of Business Name of Educational or Clinical Supervisor Email Your Job Title Grade Specialty Hospital/Base End Date Post/Zip Code Job Title Telephone Sub-Specialty (if applicable) Contract Duration (months) Contract Type Reason for leaving Permanent Fixed Term Ad Hoc Contract NHS Locum Agency Locum Sessional GP Rotational Post with NTN OOH GP Salaried GP Other (please state): Previous Employer 2 Start Date Employer Name Full Postal Address End Date Post/Zip Code Contract Duration (months) Medical_Application_Form v4b Page 7 of 25

Type of Business Name of Educational or Clinical Supervisor Email Your Job Title Grade Specialty Hospital/Base Contract Type Reason for leaving Job Title Telephone Sub-Specialty (if applicable) Permanent Fixed Term Ad Hoc Contract NHS Locum Agency Locum Sessional GP Rotational Post with NTN OOH GP Salaried GP Other (please state): Previous Employer 3 Start Date Employer Name Full Postal Address Type of Business Name of Educational or Clinical Supervisor Email Your Job Title Grade Specialty Hospital/Base End Date Post/Zip Code Job Title Telephone Sub-Specialty (if applicable) Contract Duration (months) Contract Type Permanent Fixed Term Ad Hoc Contract NHS Locum Agency Locum Sessional GP Rotational Post with NTN OOH GP Salaried GP Other (please state): Medical_Application_Form v4b Page 8 of 25

Reason for leaving Previous Employer 4 Start Date Employer Name Full Postal Address Type of Business Name of Educational or Clinical Supervisor Email Your Job Title End Date Post/Zip Code Job Title Telephone Contract Duration (months) Grade Specialty Hospital/Base Contract Type Reason for leaving Sub-Specialty (if applicable) Permanent Fixed Term Ad Hoc Contract NHS Locum Agency Locum Sessional GP Rotational Post with NTN OOH GP Salaried GP Other (please state): Previous Employer 5 Start Date Employer Name Full Postal Address Type of Business End Date Post/Zip Code Contract Duration (months) Medical_Application_Form v4b Page 9 of 25

Name of Educational or Clinical Supervisor Email Your Job Title Grade Specialty Hospital/Base Contract Type Reason for leaving Job Title Telephone Sub-Specialty (if applicable) Permanent Fixed Term Ad Hoc Contract NHS Locum Agency Locum Sessional GP Rotational Post with NTN OOH GP Salaried GP Other (please state): Previous Employer 6 Start Date Employer Name Full Postal Address Type of Business Name of Educational or Clinical Supervisor Email Your Job Title End Date Post/Zip Code Job Title Telephone Contract Duration (months) Grade Specialty Hospital/Base Contract Type Sub-Specialty (if applicable) Permanent Fixed Term Ad Hoc Contract NHS Locum Agency Locum Sessional GP Rotational Post with NTN OOH GP Salaried GP Other (please state): Medical_Application_Form v4b Page 10 of 25

Reason for leaving Please add additional employers/information on a separate sheet. Gaps in Employment Please provide in this section explanations for any gaps in your employment history (chronologically, most recent first). For any gaps in employment of 6 months or more over the past 5 years, please include contact details for your professional mentor or educational supervisor, who can verify the reason for the gap and if necessary provide you with an appropriate reference for the period not worked. Medical_Application_Form v4b Page 11 of 25

Skills and Experience Elements of this section may not apply to you or the post for which you are applying. Please be reassured that your application will only be measured against the essential and desirable criteria set down in the published person specification. If you have nothing to insert in a specific (specialist) section, please state not applicable and the detail of that section will be hidden on the form. Declaration of Practical Experience (Relevant to the Post Applied for) This should refer to verifiable Log Book/Portfolio Evidence which will need to be presented by all appointed candidates (most recent first please) Number of Recorded Procedures or Interventions Completed Under Senior Independently Supervision Please briefly describe the extent of your proficiency and experience in the procedures highlighted above, along with any particular clinical skills/experience/special interests you possess that you may wish to highlight. In the context of this post, in reflecting on your own skills and abilities, are there any areas where you might seek further development and support? Medical_Application_Form v4b Page 12 of 25

Teaching If applicable, please briefly describe both formal and informal teaching you may have undertaken, the main topics taught, your audience (numbers and composition) and which teaching methods you have used. If you have attended formal training or courses on teaching, please identify them here, and include any feedback you may have received about your teaching skills. Do you hold any particular qualifications in Teaching? Management of Change If applicable, please briefly describe changes (including audits and quality improvement projects) you may have personally undertaken over the past 5 years and wish to highlight. Include the aim and outcome, whether you led the change independently or worked under the supervision of a senior. Description of Change Date (most recent first please) Aim & Measure of the Change Conclusions/Actions Of the change/audits/projects you have undertaken, which has been of most value, and why? Describe the impact of a change initiated by you on wider members of your team. Medical_Application_Form v4b Page 13 of 25

Research If applicable, briefly describe any research projects you have undertaken over the past 5 years, the research aim and outcome, whether you initiated and led the research independently or worked under the supervision of a senior. Project Title Date (most recent first please) Aim of Research Conclusions/Actions Please summarise your main learning point from an effective audit/quality improvement project you have undertaken Do you hold any particular qualifications in Research? Publications in Peer Reviewed Journals (Top 6) Date and Category of Publication (most recent first please) Journal Publication Title Authors Date and Category of Publication (most recent first please) Journal Publication Title Authors Date and Category of Publication (most recent first please) Journal Medical_Application_Form v4b Page 14 of 25

Publication Title Authors Date and Category of Publication (most recent first please) Journal Publication Title Authors Date and Category of Publication (most recent first please) Journal Publication Title Authors Date and Category of Publication (most recent first please) Journal Publication Title Authors Presentations (Top 6) Title Type (local/national/regional/international) Year obtained (most recent first) Medical_Application_Form v4b Page 15 of 25

Prizes or other academic distinctions Awarding Body Description and Purpose of Award Year obtained (most recent first) Management and Leadership Experience Please highlight experience you may have which is relevant to this post, not necessarily limited to professional activities. Team Working Describe situations where you have been involved in working in a team, not necessarily limited to professional activities. Medical_Application_Form v4b Page 16 of 25

Supporting Information In this section you need to demonstrate that you have read the published person specification and how you meet the essential and (where relevant) desirable criteria for this particular post, if this has not been fully covered in the previous sections. Please include your reasons for applying and take the opportunity to highlight your particular talents and strengths, (what you feel you can personally offer what is unique to you what sets you apart from your peers). Please DO NOT include personal details or duplicate information already provided elsewhere in your application. Additional Personal Information Preferred Employment Type Full Time Part Time Job Share Secondment Flexible Hours Medical_Application_Form v4b Page 17 of 25

References Please provide the names and full contact details of the people who have agreed to supply references. References must include at least two positions with separate employers and, as a minimum, cover a period of three years employment and/or training history, where this is possible. Referees will be required to comment on your competence, personal qualities and suitability for the post. This may be your line/department manager, or someone in a position of responsibility for any work experience or placement undertaken. In the case of medical and dental staff, it must be a clinical/supervisor/clinical tutor. If you are a student or trainee this should include a teacher/tutor at your education institution. If you have not been in employment for a considerable amount of time but have had previous employment, then you should seek one reference from your last known employer and a personal reference from a person of standing within your community such as a doctor, solicitor or MP. Where it is genuinely not possible to obtain references from any of the sources outlined above, you must provide contact details of two personal acquaintances who would be willing to give a reference. Personal acquaintances must not be related to you, or have any financial arrangement with you. Please note that all reference requests will be followed up and verified through the organisation s human resources department or other relevant recruitment function. For medical posts you must provide a minimum of three references. Referees will be approached prior to interview, unless you indicate otherwise below. Referee 1 Type of Reference Employer Educational Personal Title *Surname/Family name *Relationship First Name Job Title *Address *Post Code/ Zip Code Telephone Email *Can the referee be contacted prior to interview? *Country Fax Medical_Application_Form v4b Page 18 of 25

Referee 2 Type of Reference Employer Educational Personal Title *Surname/Family name *Relationship First Name Employer name Job Title *Address *Post Code/ Zip Code Telephone Email *Can the referee be contacted prior to interview? Referee 3 *Country Fax Type of Reference Employer Educational Personal Title *Surname/Family name *Relationship First Name Employer name Job Title *Address *Post Code/ Zip Code Telephone Email *Can the referee be contacted prior to interview? *Country Fax Medical_Application_Form v4b Page 19 of 25

If you have applied to us within the last 3 months in the same grade and specialty, are you happy for us to use the references from your earlier application? Declarations The information in this form is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if employed by the organisation. Where applicable, I consent that the organisation can seek clarification regarding professional registration details. I agree to the above declaration Signature Name Date Where did you see this vacancy advertised? NHS Website Local Newspaper Search Engine British Medical Other Website Journal National British Dental Journal Newspaper Health Service Journal Hospital Doctor Doctor Therapy Weekly Nursing Times GP Nursing Standard Other Professional Journal Jobcentre Plus Radio Other Medical_Application_Form v4b Page 20 of 25

MONITORING INFORMATION NHS organisations recognise the benefits of having a diverse workforce and therefore welcome applications from all sections of the community. In addition to this, under the provisions of the Equality Act 2010, all NHS organisations are required to demonstrate that their recruitment processes are fair and that they are not discriminating against or dis advantaging anyone because of their age, disability, gender reassignment status, marriage or civil partnership status, pregnancy or maternity, race, religion or belief, sex or sexual orientation. Therefore a series of questions need to be raised in order to ascertain who is applying for each position and to ensure that no one is being unfairly discriminated against or disadvantaged. This section of the application form will be detached from your application form and will not be used as part of the selection process nor will it be seen by anybody who is interviewing you. The information collected is only used for monitoring purposes in an anonymised format to assist the organisation in analysing the profile and make up of individuals who apply, are shortlisted for and appointed to each vacancy. In this way, they can check that they are complying with the Equality Act 2010. Equality Act 2010 The Equality Act 2010 protects people against discrimination on the grounds of their age and sex. * Please state your date of birth * Please indicate your gender Male Female I do not wish to disclose this Equality Act 2010 The Equality Act 2010 protects people who are married or in a civil partnership. * Please indicate the option which best describes your marital status Married Single Civil partnership Legally separated Divorced Widowed I do not wish to disclose this Medical_Application_Form v4b Page 21 of 25

Equality Act 2010 The Equality Act 2010 protects people against discrimination on the grounds of their race which includes colour, nationality, ethnic or national origin. * Please indicate your ethnic origin Asian or Asian British Bangladeshi Indian Pakistani Any other Asian background Black or Black British African Caribbean Any other Black background Mixed White & Asian White & Black African White & Black Caribbean Any other mixed background White British Irish Any other White background Other Ethnic Group Chinese Any other ethnic group I do not wish to disclose this Equality Act 2010 The Equality Act 2010 protects bisexual, gay, heterosexual and lesbian people from discrimination on the grounds of their sexual orientation. * Please indication the option which best describes your sexual orientation Lesbian Gay Bisexual Heterosexual I do not wish to disclose this Equality Act 2010 The Equality Act 2010 protects people against discrimination on the grounds of their religion or belief, including a lack of any belief. * Please indicate your religion or belief Atheism Buddhism Christianity Hinduism Islam Jainism Judaism Sikhism Other I do not wish to disclose this Medical_Application_Form v4b Page 22 of 25

Equality Act 2010 The Equality Act 2010 protects disabled people - including those with long term health conditions, learning disabilities and so called "hidden" disabilities such as dyslexia. If you tell us that you have a disability we can make reasonable adjustments to ensure that any selection processes - including the interview - are fair and equitable. * Do you consider yourself to have a disability? I do not wish to disclose this information Please state the type of impairment which applies to you. People may experience more than one type of impairment, in which case you may indicate more than one. If none of the categories apply, please mark other. Physical impairment Learning Disability/Difficulty Sensory impairment Long-standing illness Mental health condition Other If you have a disability, do you wish to be considered under the guaranteed interview scheme if you meet the minimum criteria as specified in the person specification? Medical_Application_Form v4b Page 23 of 25

Rehabilitation of Offenders Act 1974 The Rehabilitation of Offenders Act (as amended) helps rehabilitated ex-offenders back into work by allowing them not to declare criminal convictions after the rehabilitation period set by the Court has elapsed and the convictions become spent. During the rehabilitation period, convictions are referred to as unspent convictions and must be declared to employers. The NHS aims to promote equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of race, gender, marital status, religion or belief, disability, sexual orientation and age. The NHS undertakes not to discriminate unfairly against applicants on the basis of a criminal conviction or other information declared. If you are applying for a post involving access to persons in receipt of health services, your offer of employment may be subject to a satisfactory criminal record check. Failure to reveal information relating to any convictions could lead to withdrawal of an offer of employment. Individuals applying for positions which involve regulated activity are required to have an enhanced criminal record check and, where appropriate to the role, this check will also include any information which may be held against the barred lists for working with children and/or adults. The full definition of regulated activity is defined in the Safeguarding Vulnerable Groups Act 2006, as amended by the Protection of Freedoms Act 2012 which came into force on 10 September 2012. Are you currently bound over, or do you have any unspent convictions issued by a Court or Court Martial in the UK or any other country? If yes, please supply details below; Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 To protect certain vulnerable groups within society, there are a number of posts within the NHS that are exempt from the provisions of the Rehabilitation of Offenders Act 1974 (as amended). As the post you have applied for falls within this category, it will be exempt from the provisions of the Rehabilitation of Offenders Act by virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975. Applicants for such posts are not entitled to withhold any information about convictions or other relevant criminal record information which for other purposes are spent under the provisions of the Act. If you are successful with this application, any failure to disclose such information could result in dismissal or disciplinary action. Any information provided will be confidential and will be considered only in relation to posts to which the Order applies. Medical_Application_Form v4b Page 24 of 25

All individuals applying for positions which involve regulated activity are required to have an enhanced criminal record check and, where appropriate to the role, this check will also include any information which may be held against the barred lists for working with children and/or adults. The full definition of regulated activity is defined in full under the Safeguarding Vulnerable Groups Act 2006 (as amended by the Protection of Freedoms Act 2012) which came into force on 10 September 2012. 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? If YES, please include 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. Please note: you do not need to tell us about parking offences. Are you currently bound by any barring decision made by the Independent Safeguarding Authority (ISA) from working with children? Are you currently bound by any barring decision made by the Independent Safeguarding Authority (ISA) from working with vulnerable adults? Relationships If you are related to a director, or have a relationship with a director or employee of an appointing organisation, please state the relationship: Medical_Application_Form v4b Page 25 of 25