Medical Application Form

MEDICAL APPLICATION FORM

PLEASE COMPLETE ALL SECTIONS – Failure to do so may result in a delay in processing your application

(PLEASE USE BLACK INK)

Application for the post of:
Hospice Practitioner – Permanent Position – 1 day per week (2 clinical sessions) / Ref:
17/04 / Closing Date:
Friday, 24 February, 2017
Surname:
Dr.Ms.Miss.Mrs.Mr
Forenames:
Address for further correspondence:
Post Code:
Home Telephone Number:
Work Telephone Number:
E-mail address: / National Insurance Number:
Contact person in emergency:
Address:
Telephone Number:
Education: / School/College / Dates / Qualifications and dates
Secondary and Further / From / To
Professional qualifications, diplomas and training / College/University/Awarding body address: / From / To
Training and any qualifications currently being studied for: / College/University/Awarding body address: / From / To / Examination Date:

KW SF27 MEDICALAPP created 08/09/01 by EH/SO/AM reviewedJan 17 review Jan 20 1/7 PTO 

Are you registered with the GMC/GDC? Yes/No
with Licence to Practice
Provisional/Limited/Full (delete as applicable)

Registration No. ______

Expiry Date ______

/ Are you a member of the MDU/MPS? Yes/No
Membership No.______
Expiry Date ______
Failure by successful applicants to maintain professional registration will be deemed by Kirkwood Hospice to be a disciplinary matter.
Name and address of present employer (if applicable)
Period of notice required (if applicable): / Present post/title:
Current salary/wage:
Date appointed:
Brief description of current duties:
PREVIOUS EMPLOYERS
NAMES AND ADDRESSES / (MOST RECENT FIRST)
IF THIS INFORMATION IS INCLUDED IN AN ATTACHED C.V. IT IS NOT NECESSARY TO COMPLETE THIS PAGE
PLEASE EXPLAIN ANY CAREER GAPS.
HOSPITAL / PRACTICE / HOSPICE / GRADE / SPECIALITY / FROM
Date/Month/Year / TO
Date/Month/Year
Please state reason for leaving
Please read the person specification for the post carefully and indicate how you meet each requirement. Please continue on a separate sheet if necessary.

Publications (continue on a separate sheet if necessary)

Further Information (continue on a separate sheet, if necessary)

Please indicate your reasons for applying for this post. Applicants are invited to give a summary of their present post and any further information, e.g. details of any research or teaching experience they wish to have taken into account in support of their application and to list hobbies, spare time activities, interests, membership of voluntary organisation etc.
Who is your current Responsible Officer for revalidation? …………………………………………………..
What was the date of your last revalidation? ………………………………………………….
When is your next revalidation date due? …………………………………………………..
What was the date of your last revalidation ready appraisal? …………………………………………………..

Name, Address and Telephone Number of Three Referees (at least one of which should be relevant to your current/most recent post)

1 / 2 / 3
Where did you see the post advertised?

KW SF27 MEDICALAPP created 08/09/01 by EH/SO/AM reviewedJan 17 review Jan 20 1/7 PTO 

Do you hold a valid Driving Licence? Yes/No
Enter Endorsements (if any), offence code and number of points issued: / Are you a car owner? Yes/No
1. Are you a British Citizen or an EEA National? Yes/No
2. If no, do you have entitlement to permanent residency in the UK? Yes/No
3. If no, do you require a work permit to take up this post? Yes/No
4. What is the expiry date of your stay in the UK? ………………………………………….
DECLARATION STATEMENTS

1. I acknowledge that any appointment offered is subject to satisfactory medical clearance.
2. Applicants for posts at Kirkwood Hospice are exempt from the Rehabilitation of Offenders Act 1974. You are required to declare prosecutions or convictions, including those considered “spent” under this Act.

Please provide full details separately of any criminal offence, order binding you over or caution or details of any current proceedings which might lead to a conviction, an order binding you over or a caution, including approximate date, the offence, and the authority and country which dealt with the offence.

1. Have you ever been, or are you currently subject to any fitness to practice proceedings, investigations, suspension or been removed from the register by an appropriate licensing or regulatory body in the UK or any other country? Yes/No

If yes, please provide full details separately of the nature of proceedings undertaken, or contemplated, including approximate date of proceedings, country where proceedings were undertaken and the name and address of the licensing or regulatory body concerned.
DISCLOSURE
If you are successful in your application for this post you will be asked to obtain a satisfactory disclosure from the Disclosure & Barring Service (DBS) prior to commencement in the post to check that you have no convictions that would render you unsuitable to work within a Hospice setting. The Hospice will also request checks and make referrals under the Protection of Vulnerable Adults Scheme (POVA).
I hereby declare that the information given on this form is true and understand that on appointment any misleading statements or deliberate omissions will be regarded as grounds for disciplinary action.
Signature Date
DATA PROTECTION ACT 1998
I give my consent to the information on this form being used for statistical analysis by Kirkwood Hospice.
Forms of unsuccessful candidates will be destroyed after six months.
Statement of Policy regarding fitness to practice proceedings by a licensing/regulatory body and relating to criminal investigations in the UK or overseas. (HSC 2000/019)
Registration with the General Medical Council or General Dental Council imposes on doctors and dentists the duty to provide a good standard of medical care for, and behave appropriately, towards patients. Kirkwood Hospice also has a duty to ensure that patients receive a good standard of medical care and ensure as far as possible the safety of patients. We therefore need to establish if you have been found guilty of a criminal offence, been bound over or cautioned or are currently the subject of proceedings which might lead to a conviction, an order binding you over or a caution, in the UK or any other country.
Applicants for posts at Kirkwood Hospice are exempt from the Rehabilitation of Offenders Act 1974. We expect that application forms will include a declaration by applicants declaring any previous or pending prosecutions or convictions, including those considered “spent” under this Act. This should also include a declaration of any cautions or bind-overs.
We also need to establish if you have been the subject of any fitness to practice proceedings in the past, or if any fitness to practice proceedings are being contemplated, by a licensing or regulatory body in the UK or another country and this is also reflected in the declaration.
This information will be treated in confidence and will not debar you from appointment unless the selection panel considers that it renders you unsuitable for appointment. In reaching such a decision we will consider the nature of the conviction/action, how long ago it took place and any other factors which may be relevant.
Failure to disclose a criminal offence, having been bound over or cautioned or that you are currently the subject of criminal proceedings which might lead to a conviction, an order binding you over or a caution, or fitness to practice proceedings undertaken or being undertaken by an appropriate licensing or regulatory body, may disqualify you from appointment, or result in summary dismissal/disciplinary action and referral to the General medical Council (General Dental Council) for consideration is such a discrepancy came to light.
If you would like to discuss what effect any previous convictions, police investigations or fitness to practice proceedings taken or being taken either in the UK or by an overseas licensing or regulatory body might have on your application, you may telephone the Administration Department on 01484 557900 for advice.

TO BE COMPLETED BY APPOINTING MANAGER

SHORTLISTING CRITERIA MET Yes/No / APPOINTMENT CRITERIA MET Yes/No

Equality & Diversity Data Collection Form

The Board of Trustees and Management Team of Kirkwood Hospice are committed to being open, honest and fair to all employees. We firmly believe that it is everyone’s right to be treated with dignity and fairness regardless of age, race, gender, religion or belief, sexual orientation, disability or marital status.

The data we collect will help us to monitor the diversity of our current workforce and to provide fair, open and honest treatment for our employees. The data will not be used for any other purpose.

Completing the questionnaire isn’t compulsory but by doing so you will be helping to make us a more accountable and transparent employer and to ensure we have sound information about the diversity of those who work for us to meet the requirements of the Equality Act now and in the future.

All data we have about employees is held securely and access is tightly controlled. In the case of your equality and diversity data, this will be held in a separate secure area of our database. Only those staff who are involved in maintaining the database and compiling statistics will have access to the data. The data will be used to generate statistical reports and undertake equality impact assessments.

Job Ref: Hospice Practitioner 17/04

Surname:

First Name(s):

Date of Birth: ______

Where did you see the vacancy advertised: ______

Place an  in the boxes using black ink.

Are you:MaleFemalePrefer Not To Answer 

Please choose one box below which most closely matches your ethnic background.

WhiteBlack or Black BritishMixed Group

BritishCaribbeanWhite & Black Caribbean

IrishAfricanWhite & Black African

Any other Any other BlackWhite and Asian

White background backgroundAny other Mixed

background

(Please specify below if you wish) (Please specify below if you wish) (Please specify below if you wish)

Asian or Asian BritishChineseOther background

IndianChineseOther

PakistaniAny other Chinese

Bangladeshi background

Any other Asian

background

(Please specify below if you wish) (Please specify below if you wish) (Please specify below if you wish)

Prefer Not To Answer 

PTO 

Disability

Are your day to day activities limited because of any health problem or disability which has lasted or is expected to last at least 12 months. Place an  in one box only.

Yes-limited Yes-limited a little No  Prefer not to answer 

Disability is legally defined as a ‘physical or mental impairment which has a substantial and long term adverse effect on a person’s ability to carry out normal day-to-day activities’. This can include “hidden” conditions such as mental health conditions, epilepsy or diabetes for example.

Sexual Orientation

Bisexual Gay Woman/LesbianHeterosexual/Straight 

Gay ManOther

Prefer not to answer

Which most closely matches your religion or beliefs?

BuddhistChristianHindu

JewishMuslimSikh

Prefer not to answerOtherI have no religious beliefs

(Please specify below if you wish)

Age Band:

Under 2525 to 3435 to 44

45 to 54over 54Prefer not to answer

Marital Status:

Married SingleDivorced

SeparatedCohabitingPrefer not to answer

If you have particular requirements in respect of any interview or selection test please give us details in the space below:

Name (in BLOCK CAPITALS): ______

The job that you have applied for: ______

Job Reference Number: ______

Details of particular requirements you might need:

If you have any questions or want to discuss your application in confidence, please contact Human Resources Administrator on tel: 01484 557900.

KW SF27 MEDICALAPPLY created 08/09/01 by EH/AM reviewed Oct 06 review Dec 06 1/7