Gloucestershire

Family Health Services

FP16 OPT (GOS)

Return this form to:-

Contracts Team

Gloucestershire FHS Shared Services

. Victoria Warehouse

The Docks

Gloucester

GL1 2EL

Tel: 01452 300222

APPLICATION FOR INCLUSION ON
THE OPHTHALMIC OR SUPPLEMENTARY LIST

(please note you can only be on one Supplementary List in England at any one time)

1.  PERSONAL DETAILS OF THE OPTOMETRIST

Surname / ______
Previous Surname
Forenames / ______

Gender / Male / Female
Title / Mr / Mrs / Miss / Ms / Dr
Date of Birth / ______
Present Private Address / ______
______
______
______
Present telephone No. / ______
Mobile No (optional) / ______
Email Address / ______
Remember to tell us if your address or telephone numbers change

I am applying to join the *CONTRACTOR LIST / SUPPLEMENTARY LIST

- *Please delete as appropriate

2.  OPHTHALMIC QUALIFICATIONS

Please list your ophthalmic qualifications

Qualification / Institution (Give Name & Place) / Date of Qualification

OPTOMETRIST:

I declare I am a fully registered Ophthalmic Practitioner, included in the General Optical Council Opticians Register / YES / NO
Registration number in the Opticians Register / ~
Date of First Full Registration (Day / Month / Year)

CORPORATE OPTICIAN:

I declare the company is a fully registered Corporate Optician included in the General Optical Council Corporate Opticians Register / YES / NO
Registration number in the Opticians Register / C / O
Date of First Full Registration (Day / Month / Year)

OPHTHALMIC MEDICAL PRACTITIONER:

I declare I am a fully registered Ophthalmic Medical Practitioner, included in the Medical Register / YES / NO
Registration number in the General Medical Register
Date of First Full Registration (Day / Month / Year)
Ophthalmic Qualifications Committee Number
Date of First Full Registration (Day / Month / Year)

3.  PROFESSIONAL EXPERIENCE

3.1)  Please detail experience in chronological order, with reference to the following:

  1. indicate the type of experience in the first column i.e. general practice (optometrist, dispensing optician, ophthalmic medical practitioner), hospital appointment other
  2. for locum work indicate the area in which you worked, in the second column. Alternatively for hospital appointments please state the appropriate Trust.
  3. starting and finishing dates of each appointment

Please also provide an explanation of any gaps between appointments, plus additional supporting particulars, including an explanation as to why you were dismissed from any post.

It is not necessary to list every appointment. Entries such as “locum optometrist in general practice from April 1998 to date” are acceptable.

Comprehensive Curriculum Vitae will suffice.

Position

/ Responsible Authority / Start Date / End Date

4. REFEREES

4.2  Please supply names and addresses of two referees who are willing to provide clinical references in respect of two recent posts (where possible and which should include the current post) as an ophthalmic medical practitioner or optician which lasted three months without a significant break, and where this is not possible, a full explanation and alternative referees.

Recent is defined as posts within the last five years.

Where your working pattern is a series of short-term locum positions, references may be accepted from any other clinician who can comment objectively on your clinical abilities. If this is the case the reference should be from a clinician with whom you have done separate periods of work over a twelve month period, amounting to at least 13 weeks.

Name
Address
Position Held by referee
Dates worked with referee
Name
Address
Position Held by referee
Dates worked with referee

5.  TYPE OF PRACTICE

5.1)  What type of application do you intend to submit?

Optometrist/Sole Trader
Ophthalmic Medical Practitioner

Corporate Optician - For Corporate Opticians please complete Annexe A
Partnership

5.2) Name and address of principal contractor (if you intend working at more than one branch of the same body corporate please give details of both)

1.______2.______
______
______
______
______

5.3)  Names of deputies, directors, or employees regularly engaged in the provision of general ophthalmic services at this address and whether their name is included in the ophthalmic List

1.______2.______
______
______
______

5.4) Days and hours of attendance

Monday ______Monday ______
Tuesday ______Tuesday ______
Wednesday ______Wednesday ______
Thursday ______Thursday ______
Friday ______Friday ______
Saturday ______Saturday ______
Sunday ______Sunday ______

5.5) Will patients be seen by appointment only? Yes No

Note: A separate application form must be completed for each body corporate.

6.  CRIMINAL CONVICTIONS

If you answer yes to any of the following questions please give details at the end of this section in the space provided, including approximate dates of where the investigation or proceedings were or are to be brought, the nature of that investigation or proceedings, and any outcome. (Please use a separate sheet of paper if necessary)

Answering YES to any of the following questions does not automatically preclude applications from inclusion in the Ophthalmic List

Note:

i. Please note that the Rehabilitation of Offenders Act 1974 does not apply to general practitioners for the purpose of the following questions. Offences considered “spent” under that Act must be declared.

ii. Matters dealt with by a fixed penalty ticket need not be declared..

Please delete as appropriate

6.1. Have you any criminal convictions

Or

Have you been bound over following a criminal conviction

Or

Have you accepted a police caution in the United Kingdom

6.2 Have you been convicted elsewhere of an offence, or what would constitute a criminal offence if committed in England or Wales, or been the subject of a Penalty, which would be the equivalent of being bound over or cautioned?

Or

Are you currently the subject of any proceedings that might lead to such a conviction, which has not yet been notified to the PCT?

6.3 Have you ever been the subject of an investigation by one of the following, where the outcome was adverse?: -

By any licensing, regulatory or other body into your professional conduct or performance any where in the world

Or

By the NHS Counter Fraud Services

6.4  Are you currently the subject of any investigation:-

By any licensing, regulatory or other body into your professional conduct or performance anywhere in the world

Or

By any current or former employer into your professional conduct or performance anywhere in the world

6.5 Have you ever been refused admission or conditionally included in, removed or contingently removed from, or are you currently suspended from any Primary Care Trust (or equivalent body in Wales, NI and Scotland) list?

6.6 Please detail limitations imposed by the Home Office which restricts your ability to work in any specific capacity in England and Wales.

6.7 If the ophthalmic medical practitioner or optician is not in the Health Authority/Primary Care Trust ophthalmic lists, the name of any Health Authority/Primary care Trust in whose dental, medical, pharmaceutical, supplementary or services list he is included, or from any of whose lists he has been removed or contingently removed or is currently suspended, or to any of whose lists he has been refused admission or conditionally included, with an explanation as to why, and particulars of any outstanding or deferred application for inclusion in the ophthalmic list, or any other list of a Health Authority/Primary Care Trust, with the name of the Health Authority/Primary Care Trust in question.

Supplementary Questions:

Have you been in the preceding six months, or were you to your knowledge at the time of the event needing declaration, a director of a body corporate

(Membership of a body corporate is considered to be somebody who is a director or has been a director of a company i.e. pharmaceutical supplier, pharmacy, dental practice, medical equipment supplier etc.)

If yes to the above question please complete 2.7 to 2.14 below.

If no to the above question please proceed to Section 3 of this form.

2.1)  Has the body corporate any criminal convictions in the United Kingdom

Or

Is the body corporate currently the subject of any proceedings that might lead to such a conviction?

2.2)  Has the body corporate been convicted elsewhere of an offence, or what would constitute a criminal offence if committed in England and Wales, or been the subject of a penalty which would be the equivalent of being bound over or cautioned?

Or

Is the body corporate currently the subject of any proceedings that might lead to such a conviction?

2.3)  Has the body corporate ever been the subject of an investigation by one of the following, where the finding was adverse? :-

By any licensing, regulatory or other body into its professional conduct or

performance any where in the world

Or

By any current or former employer into its professional conduct or performance any where in the world

Or

By the NHS Counter Fraud Services?

2.4)  Is the body corporate currently the subject of any investigation:-

By any licensing, regulatory or other body into its professional conduct or

performance any where in the world

Or

By any current or former employer into your professional conduct or performance any where in the world

Or

By the NHS Counter Fraud Services?

2.5)  Is the body corporate currently the subject of any Primary Care Trust (or

equivalent body in Wales, NI and Scotland) investigation that could lead to

its removal from their list?

2.6)  Has the body corporate ever been refused admission or conditionally included

in, removed or contingently removed from, or is it currently suspended from any

Primary Care Trust (or equivalent body in Wales, NI and Scotland) list?

2.7)  If you are a Director of any Body Corporate that is included in any list of any Primary Care Trust, or equivalent lists, or which has an outstanding application (including a deferred application) for inclusion in any list of any Primary Care Trust, or equivalent lists, please give the name and registered office of any such body, and details of the Primary Care Trust or equivalent body concerned.

______

2.8)  Please confirm whether you are, or were in the preceeding six months, or are to your knowledge at the time of the originating events a director of a body corporate, details of any Primary Care Trust list or equivalent list for which that body has been refused admission, conditionally included, removed, contingently removed or from which you are currently suspended, with an explanation as to why.

______

If you have answered yes to any of the preceding questions please give details below, including approximate dates, of where the investigation or proceedings were or are to be brought, the nature of that investigation or proceedings, and any outcome. (Please use a separate sheet of paper if required)

7.  DECLARATION

7.1 I declare that I am a registered optometrist, included in the General Optical Councils Opticians Register in the name shown at the beginning of this form. Pre-Registered Opticians waiting for GOC registration to be approved also need to sign this declaration.

7.2 I apply to join Gloucestershire Ophthalmic list.

7.3 If my application is granted, I agree

·  To notify the Primary Care Trust within 7 days of any changes to the information provided in the application until the application is finally determined.

·  To Serve under, and be bound by, the terms of service from the time being in operation in the PCT Area.

·  To notify the Primary Care Trust whenever I change my permanent home address

·  Consent to the Primary Care Trust requesting from any employer or former employer, licensing, regulatory or other body in the United Kingdom or elsewhere, information relating to a current investigation, or an investigation where the outcome was adverse, by them into the optician.

·  Consent to a Criminal Record Bureau (CRB) check being carried out by the PCT. If you have previously completed a CRB check in the last 6 months please provide a copy of the disclosure and another check will not need to be carried out.

7.4 I declare that this information is correct

Signature ______

Full Name ______

Date ______

You must enclose the following items:

·  Annual Registration Certificate/Renewal slip with receipt with the General Optical Council/Ophthalmic Qualifications Committee.

·  All other Certificates relating to your qualifications

·  Current Optical Indemnity Certificate

·  CRB Disclosure if issued within the last six months

·  For UK citizens, your UK birth certificate or passport

·  For non UK citizens, your passport (a birth certificate is not acceptable)

·  IELTS Certificate - only applicable to citizens of EEA countries whose first language is not English and were trained in countries other than the UK or Republic of Ireland.

In all cases original certificates must be provided to Gloucestershire FHS Shared Services

PLEASE ENSURE THIS FORM IS COMPLETED FULLY

PLEASE RETURN THIS FORM TO FHS CONTRACTS TEAM, FHS SHARED SERVICES, VICTORIA WAREHOUSE, THE DOCKS, GLOUCESTER, GL1 2EL.

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