Candidate Number (for office use only)

IN CONFIDENCE

NHS EDUCATION FOR SCOTLAND

APPLICATION FOR FOUNDATION VACANCIES

I wish to apply for
Please put an ‘X’ in the relevant box / FY2

Rank

My regional preference is:
(rank 1- 4 in order of preference with 1 being most preferred region):
Details of all the Scottish foundation programmes are available for information on our website www.nes.scot.nhs.uk/sfas. / North of Scotland / 01234
East of Scotland / 01234
South East of Scotland / 01234
West of Scotland / 01234
Personal details
Title / Surname / First name
Address
Town/City / Country
Postcode / Email
Home Tel / Mobile Tel

.

Relevant Professional Registration

You have to be eligible to register with the GMC to be able to work as a doctor in the UK and you will require Full GMC registration with a Licence to Practice.

Do you have or are you eligible for Full GMC registration?
Please enter an ‘X’ in the box / Yes / No
Do you hold a Licence to Practice
Please enter an ‘X’ in the box / Yes / No
GMC registration status
Please enter an ‘X’ in the box / Provisional / Full
GMC Number:
Name registered with GMC as:
Date of GMC registration or expected full registration:
Renewal date:
Are there currently any restrictions to your professional registration?
Please enter an ‘X’ in the box / Yes / No
If yes, please give reasons
Eligibility to work in UK

Some applicants may be considered before others on the basis of immigration status in accordance with employment regulations. Please note that if you are invited for interview you will be required to provide proof of your immigration status. With the introduction of the points based immigration system by the UK Borders Agency (www.ind.homeoffice.gov.uk), prospective applicants must ensure that they are aware of the changes in legislation and how this may impact on their eligibility to be considered for training posts if they are non UK or non EEA nationals.

Are you a UK, EC or EEA National?
Please enter an X in the box / Yes / No
If not, do you have a right to work in the UK that is not time limited?
Please enter an X in the box / Yes / No
Immigration Status
Expiry date of right to work currently held:
Please state any restrictions to your working status, e.g. no doctors/dentists in training
Language Skills

Please note that if you are invited for interview you will be required to provide proof of your language skills.

Was the language of instruction, clinical contact and examination of your undergraduate degree in English? Please enter an X in the box / Yes / No
If ‘No’, do you have demonstrable skills in written and spoken English at the required level to enable effective communication and medical or health topics with patients, colleagues and the public i.e. IELTS of at least 7.5 in every domain / Yes / No

If yes, please provide a breakdown of your IELTS scores below:

IELTS SCORES (if applicable)

Please indicate your overall score and your score for each subsection

Section / Score
Overall
Speaking
Listening
Reading
Writing

If no, please list the demonstrable skills in written and spoken English at the required level that have been acquired in the box below

Intermediate Life Support (ILS) / Advanced Life Support (ALS) Certification

Please note that if you are invited for interview you will be required to provide proof of your certification.

ILS / Yes / No / Date of Expiry
ALS / Yes / No / Date of Expiry
Less Than Full Time Working

The norm for flexible training will be based on two trainees slot-sharing at 50% each. Only in exceptional circumstances will alternative proportional allocations be possible.

Do you want to be considered for less than full time working?
Please enter an X in the box / Yes / No
Relevant Professional Qualifications

You must give details of your main medical degree below. Any other professional qualifications may be listed in the sections that follow further down.

Medical degree title: / Entry date to medical school:
Medical school / university address: / Medical school/university:
Date of qualification:
Post qualification experience:
List your Publications:
List your Presentations:
List your Audit / Research:
Key Statement

Using two cases that you have observed or have been involved with describe how the multidisciplinary team contributed to the care given to patients with similar clinical conditions, one within the hospital environment and one in the community environment. What were the challenges to effective team working in the community environment? How could you, as a hospital-based foundation doctor, contribute positively to the management of patients being discharged to the care of a community team? (maximum of 200 words)

Supporting Statement

Please give any further information you wish to provide in support of your application. (maximum of 200 words)

Present or most recent employment
Employer’s Name
Employer’s Address
Position held
Dates of Employment / To:
From:
Reason for leaving (if applicable)
Notice Period
Key Responsibilities and Duties
Employment History
Job Title / Employer / Date from / Date to
Gaps in Employment History

Please explain any gaps in your employment and give details with dates.

Date from: / Date to: / Reason
Completion of details

Closing date

The closing date for applications for this round is: 12 noon on Wednesday 9th April 2014

In order to be considered for this post you must submit a completed application by the closing date. Under no circumstances will late or incomplete applications be accepted. Your application must be downloaded and completed online (typed, not handwritten) then sent electronically to

Completing your application

Before submitting your application you should have:

·  Answered all of the mandatory questions in each section of the form.

·  Ensured that all details are true and accurate.

·  ensured that you have completed the key statements truthfully and to the best of your ability

Confirmation

I confirm that:

·  My standard of written and spoken English is sufficient to allow effective communication about medical issues with patients and colleagues, and can be demonstrated according to the criteria set out in the Person Specification form.

·  I have the right to work in the UK.

·  I will be eligible for Full registration and hold a licence to practice with the GMC on 6th August 2014

Declaration

I understand that any employment offered to me by an NHS employer will be subject to satisfactory clearances and subject to the information provided on my application form or any related documents being correct. Any offer of employment may be dependent on pre-employment screening to review and confirm the details of my application. Any false or misleading information provided by me on my application form or any other related document may result in any employment being terminated. I confirm that I have fairly and honestly completed this application by myself, without significant help or input from other sources.

I understand that all of the information I have provided, with the exception of the Monitoring Information, may be used by NHS Education for Scotland to progress my application for a training place.

Please enter an X in the box

Yes / No
I agree with the above declaration
I do not agree with the above declaration

Once your application has been submitted it cannot be changed.


References

Please provide details for two senior medical staff who have been involved with your clinical training and who have agreed to provide references. Your referees must be either practising hospital consultants or GPs, and must have valid email addresses. If you are currently working, one of your referees must be from your current employer. Referees will be contacted in the event that you are selected for interview.

Referee 1

Surname/family name / First name
Job title
Address
Town/City / County/State
Postcode/Zip / Country
Email

Referee 2

Surname/family name / First name
Job title
Address
Town/City / County/State
Postcode/Zip / Country
Email
Monitoring Information

As Public Sector Employers, NHS organisations are required to collect details about an applicant's age and gender. This information is collected to fulfil that obligation and is used for monitoring purposes only; any information given in this section will not affect short-listing or interviews.

Age

Date of birth (dd/mm/yyyy)

Gender (Please enter an X in the box)

Male
Female
Transgender Male
Transgender Female
I do not wish to disclose my gender

Race Relations (Amendment) Act 2000

As Public Sector Employers, NHS organisations are required to collect details about an applicant's ethnicity. This information is collected to fulfil that obligation and is used for monitoring purposes only.

Ethnic origin

I would describe my ethnic origin as (Please enter an X in the box)

Scottish
Irish
Any other White background
Other British
Any mixed background
Pakistani
Indian
Bangladeshi
Chinese
Any other Asian background
Caribbean
African
Any other Black background
Prefer not to answer
Any other background


Employment Equality Regulations 2003

In order to comply with these regulations NHS Employers are monitoring sexual orientation and religion/belief in applications. Please answer the following questions:

Sexuality

I would describe my sexuality as (Please enter an X in the box)

Bisexual
Gay Man
Heterosexual
Lesbian/Gay Woman
Other

Belief

Please indicate your religious belief (Please enter an X in the box)

Christianity – Church of Scotland
Christianity – Roman Catholic
Christianity - Other
Islam
Judaism
Hinduism
Sikhism
Buddhism
Other faith/belief
No religion (none)
Prefer not to answer

Disability Discrimination Act 1995

The Disability Discrimination Act protects disabled people. This includes people with long-term health conditions. If you tell us that you have a disability we can make reasonable adjustments to where you work and your work arrangements.

NHS organisations welcome applications from disabled people.

Disability

Do you consider yourself disabled as set out under the Disability Discrimination Act? / Yes
No
Do you wish to be considered under the Guaranteed Interview Scheme if you meet the minimum criteria as specified in the person specification? / Yes
No
N/A
If you have a disability, do you need any special arrangements to enable you to attend for interview? / Yes
No
N/A
If so, please give details

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
Sensory impairment
Mental health condition
Learning disability/difficulty
Long-standing illness
Other

Criminal Records Declaration

You are applying for a post involving access to persons in receipt of health services, therefore your offer of employment will be subject to a satisfactory disclosure from Disclosure Scotland. Failure to reveal information relating to any convictions could lead to withdrawal of an offer of employment.

You are required to declare both unspent and previously spent convictions under the acts described below.

This post is considered a "regulated activity" within the terms of the Protection of Vulnerable Groups (Scotland) Act 2007, and appointments made after 20 July 2010 may be subject to registration (currently under government review) with the Independent Safeguarding Authority (ISA). For further information, please refer to the relevant website - Independent Safeguard Authority

Rehabilitation of Offenders Act 1974

The Rehabilitation of Offenders Act helps rehabilitated ex-offenders back into work by allowing them not to declare criminal convictions to employers 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.

Before you can be considered for appointment with the NHS, we need to be satisfied about your character and suitability.

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, 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. Please answer the following question:

Unspent Convictions

Do you have any current or pending court convictions, cautions, warnings or reprimands? / Yes
No
If so, please give details including dates:

Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975

In order 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. These include positions where there is access to patients in the course of normal duties. 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, cautions, warnings and reprimands 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. A check will be made with the Criminal Records Bureau.

In addition to information provided above on unspent convictions, please answer the following question:


Previous convictions

Have you at any time received or had pending a court conviction, caution, warning or reprimand? / Yes
No
If so, please give details:

As 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 disclosure from the Criminal Records Bureau. Failure to reveal information relating to any convictions could lead to withdrawal of an offer of employment.

Fitness to practise

Are you currently the subject of any investigation or fitness to practise proceedings by any licensing or regulatory body in the United Kingdom or in any other country? / Yes
No

If so, please give 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.

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