APPLICATION FOR INITIAL APPOINTMENT TO THE RQIA LIST OF PART II MEDICAL PRACTITIONERS UNDER THE MENTAL HEALTH (NORTHERN IRELAND) ORDER 1986 Please complete electronically or legibly in block capitals using black ink otherwise this application form will be returned to you. Please refer to enclosed guidance notes Part A 1.0 Information about the Medical Practitioner Personal Details Title First Name Middle Names (if any) Surname (please indicate professional surname if different) Date of Birth GMC Registration Number Address Line 2 Town Postcode Telephone (home) Mobile/Preferred Number
Employment Details Substantive post Employer s Name Professional/Work Address Line 1 Professional/Work Address Line 2 Town Postcode Telephone E-mail Address Type of Appointment Please indicate type of appointment requested Locum Medical Practitioner Substantive Post Holder 2.0 Details of Previous Relevant Consultant Psychiatric Appointments (if required please use Continuation Sheet) Job Title Employers Name Employers Address Dates of Employment Comments:
Job Title Employers Name Employers Address Dates of Employment Comments: Job Title Employers Name Employers Address Dates of employment Comments: 3.0 Duration of Appointment Requested Requested duration of appointment e.g. 6 months/ 4 years *For locum medical practitioner, please indicate the effective dates from which appointment is required (max.12 months)
Part B 4.0 Classification of Medical Practitioner Please tick the appropriate box below. Comment (a) Working in an HSC trust as a consultant psychiatrist in mental health, learning disability, old age psychiatry, CAMHS or related specialism Yes (b) Working in an independent hospital as a consultant psychiatrist in mental health, learning disability, old age psychiatry, CAMHS or related specialism Yes (c) Working as a private medical practitioner (consultant psychiatrist) giving evidence or preparing reports or assessments for a court under Part III of the Mental Health (Northern Ireland) Order 1986 Yes OR Intending to give evidence or prepare reports or assessments for a court under Part III of the Mental Health (Northern Ireland) Order 1986 Yes
(d) Working as a consultant psychiatrist currently for the Mental Health Review Tribunal (Northern Ireland) or equivalent body in another jurisdiction (please state name of body) (e) Working as a sessional consultant psychiatrist for RQIA Yes Yes 5.0 Documents to be Supplied by the Medical Practitioner All relevant documents in relation to the medical practitioner as listed below should be enclosed. Please refer to the guidance notes for further information. It is the responsibility of the applicant to submit the required documentation to allow RQIA to assess the application for appointment to the list of Part II medical practitioners. Should the applicant fail to do so, RQIA may be required to refuse the application. Item Tick Comment 1. A fully completed application form 2. Evidence of appointment to the post of Consultant Psychiatrist in the specialism of mental health, learning disability, old age psychiatry, CAMHS or related specialism Or Evidence that you are or have had past relevant medical experience as a consultant psychiatrist, within the last four years (in one of the specialisms above) completing applications for and/or renewal of detention/ guardianship of patients, under Part II of the Mental Health (Northern Ireland) Order 1986
Or Evidence of working as or intending to work as a private medical practitioner giving evidence or preparing reports or assessments for a court under Part III of the Mental Health (Northern Ireland) Order 1986 Or Evidence of working as a consultant psychiatrist currently for the Mental Health Review Tribunal (Northern Ireland) or equivalent body Or Evidence of appointment as a sessional consultant psychiatrist for RQIA. 3. Evidence of a valid Certificate of Specialist Training (CST) and/or be on the Specialist Register of GMC 4. Evidence of satisfactory participation in continuing professional development, including demonstration of registration with and provision of Continuing Professional Development (CPD) Good Standing Certificate from the Royal College of Psychiatrists or equivalent body within your last academic year (please state name of body) 5. Evidence of certificates demonstrating completion of GAIN e-learning modules 1-4 on the Mental Health (Northern Ireland) Order 1986 within the last two years
6. If a medical practitioner working within an trust, a reference from the medical director, or the medical director s authorised nominee, who can be an associate medical director or a clinical director 7. If a medical practitioner working in an independent hospital, a reference from the medical director, or the medical director s authorised nominee, who can be an associate medical director or a clinical director 8. If an independent medical practitioner giving evidence to or preparing reports or assessments for the court under Part III of the Mental Health (Northern Ireland) Order 1986, a reference from the Medical Practitioner s Responsible Officer under The Medical Profession (Responsible Officers) Regulations (Northern Ireland) 2010 9. If Part II duties are not indemnified as part of a contract of employment, applicants must provide a copy of their current insurance certificate of indemnity, with a recognised medical defence organisation, or similar body, providing adequate cover to undertake work in respect of the functions of the Mental Health (Northern Ireland) Order 1986
10. If employed by a HSC trust (or independent hospital) please provide a copy of the most recent AccessNI Enhanced Disclosure Certificate. If an AccessNI Enhanced Disclosure check was not undertaken on taking up current employment, applicants should submit relevant documents as required in Section 5, item 11 (below) 11. For medical practitioners not employed by a trust or independent hospital, an AccessNI Enhanced Disclosure application form with Part B, D, E, F and G only completed and; Valid identification documents (3 or 5) as per AccessNI guidance document, together with AccessNI Fee payment of 33 to RQIA Cheque (provide number): Or BACS remittance advice (provide reference): 12. If an applicant is applying to the list of medical practitioners from outside Northern Ireland they are required to submit a copy of their most recent Disclosure and Barring Service (DBS) (previously CRB) Certificate.
6.0 Information Required Under The Rehabilitation of Offenders (Exceptions) Order (Northern Ireland) 1979 Have you ever been convicted of a criminal offence? Yes No If yes, please provide details Please note: All Part II Medical Practitioners must inform RQIA without delay inform RQIA if they: have accepted a caution from the police or been criticised by an official inquiry they have been charged with or found guilty of a criminal offence another professional body has made a finding against their registration as a result of fitness to practise procedures. If they are suspended by an organisation from a medical post, or have restrictions placed on their practice. Are you aware of any prosecutions outstanding or any pending court action against you? Yes No If yes, please provide details Are you currently subject to any criminal investigation? Yes No
If yes, please provide details Where an applicant or appointee is cautioned or charged with any criminal offence, other than a parking or speeding offence, without aggravating circumstances, he/ she should report the matter at once to the RQIA Directorate of Mental Health and Learning Disability and Social Work. The applicant or appointee should keep RQIA informed of the progress and the outcome of the case. Convictions for some offences including motoring offences, need not necessarily be regarded as incompatible with continuing to provide services under Part II of the Mental Health Order 1986. In such cases the Appointment Panel will review the appointment and decide if any further action is required.
7.0 Declaration of being subject to any current fitness to practice proceedings with professional regulatory body Please indicate if you are subject to any current fitness to practice proceedings with your professional regulatory body Yes No If yes, please provide details
8.0 Details of Referee Title First Name Surname Address Line 1 Address Line 2 Town Postcode Email Address Telephone Occupation Capacity in which known to you - medical director of trust; - medical director of independent hospital; - responsible officer
9.0 Declaration of Medical Practitioner Applying to be Appointed to the RQIA List of Part II Medical Practitioners I understand that it is an offence to knowingly make a statement which is false or misleading in a material respect and hereby confirm that all information in respect of this application is, to the best of my knowledge and belief, correct and complete. I am aware that it is my responsibility to inform RQIA of any information that is relevant to my application, and to update this information accordingly. I understand that if applying as a private medical practitioner or in circumstances where an AccessNI Enhanced Disclosure check was not undertaken as part of my current contract of employment in a trust or independent hospital, an Enhanced Disclosure Check must be obtained, before my application can be progressed. I am aware that spent convictions may be disclosed and I consent to the check being made. I have knowledge and understanding of my legal responsibilities in relation to carrying on the functions of the Mental Health (Northern Ireland) Order 1986 and other relevant standards set by professional bodies and standard setting organisations. Should it be required, I will undertake up-date training to ensure I have the necessary knowledge and skills to carry out my functions. I will maintain registration with my relevant professional regulatory body and adhere to its Code of Professional Conduct. I declare that I am of the opinion that I am physically and mentally fit to carry out the duties of a Part II medical practitioner under the Mental Health (Northern Ireland) Order 1986 Name Signature Date
Continuation Sheet