Central and North West London NHS Foundation Trust

Non-Executive Director Application Form2017

Please read the ‘Guidance on completing the application form’ section of the Application Pack which should help you complete this application form

Part 1: Your personal details

Surname
Forenames
Title
Home address
Postcode
Home contacts / Phone / Mobile
Fax No. / Email
Business Address
(if applicable)
Postcode
Work contacts / Phone / Mobile
Fax No. / Email
Which address would you prefer for correspondence? (add an X where relevant)
Home / Business
Preferred e-mail address
Your current Job Title

Part 2: How you found out about this post

(add an X where relevant)

Local Newspaper / Which one
National Newspaper / Which one
Website / Which one
From Appointments Commission
Word of Mouth
Other / Please give details

Part 3: Previous NHS or other Dept. Of Health posts held(add X where relevant)

Have you held any other chair or non exevutive positions in the past 3 years?
No / Yes

If yes, please give details:

Board / Post / Dates

Part 4: Conflicts of interests

Do you have any business of personal interests that might be relevant to the work of the Trust and which could lead to a real or perceived conflict of interest were you to be appointed? (Failure to disclose such information could result I an appointment being terminated.) add an X where relevant
No / Yes

If yes, please give details:

Part 5: References

Name / Name
Address / Address
Postcode / Postcode
Tel. No. / Tel. No.
E-mail / E-mail
How do you know him/her? / How do you know him/her?
May we contact them before interview?(add X where relevant)
No / Yes

Part 6.1: Evidence that you have the expertise required to be a Non-Executive Director

Please give specific evidence of your expertise and experience to show how this meets the requirements. You must complete sections 1, 2 and 3. Please restrict your responses to no more than 300 words on each section. Where relevant, please give brief information about the organisation so we can judge its size and complexity. Please give details of your experience and key achievements.

Section 1: Please complete this section
Essential expertise: Senior/board level experience in a large and complex organisation. Please give evidence of your level of decision making responsibility in each key role
Section 2: Please complete this section
What can you offer to the Trust in the role of a Non-Executive Director? What key knowledge, skills and experience can you bring?
Section 3: Please complete this section
Have you had any previous interest in, worked or supported mental/community health or related areas? Have you ever been engaged in activities supporting social inclusion?

Part 6.2: C.V.

Please include a brief, up to date cv (no more than 2 sides of A4) outlining your employment history, any relevant voluntary work, public service or other experience, together with any relevant professional, academic or vocational qualification. Your CV will be used to assist the assessment of your expertise.

Part 7: Declaration

I confirm that to the best of my knowledge and belief, the information in this form is complete and correct. I further confirm that I have considered and understood the criteria for disqualification from appointment (which are set out in the guidance notes) and that I do not fall within any of the descriptions of persons specified in those criteria. I understand that if I am appointed and the information I have provided is subsequently found to be untrue then my tenure of office may be terminated. I confirm that I meet the criteria laid out in the CQC Fit and Proper Persons regulations.

Name
Date

Part 8: Declaration to determine independence of Non-Executive Directors

I confirm that I have read the Code of Governance for Foundation Trusts () and understand the role of Non-Executive Directors to follow and adhere to the supporting principles and code provisions.

Name
Date

PLEASE NOW COMPLETE THE MONITORING/DIVERSITY INFORMATION ON THE FOLLOWING PAGES AND THEN EMAIL YOUR COMPLETED FORM TO

CLOSING DATE: 24 September2017

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 disadvantaging 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 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

Equality Act 2010

The Equality Act 2010 protects bisexual, gay, heterosexual and lesbian people from discrimination on the grounds of their sexual orientation.

* Please indicate 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 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 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

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? /  Yes  No
 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?
 Yes No