WhippsCrossUniversityHospital

NHS Trust

Medical Education Centre

Clinical Observer Course

Application Form

Please return completed form together with your CV and Cover Letter to Rebecca Fynn ()

Please complete this application form if you wish to apply for a place on the Clinical Observer Course. Before you complete the form please ensure that you have read through the wholeform before you start and please ensure that you read the accompanying guidance notes.

Please complete this application form in Black Ink or Typescript.

PERSONAL DETAILS
Title: Mr/Mrs/Ms/Miss/Dr etc: ……………………………………………………………………….
Surname/Family Name: …………………………………………………………………………..
Forenames: ………………………………………………………………………………………..

Full UK Address: ……………………………………………………………………………………..

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Postcode: ………………………………………………………………………………………….
Duration of Stay at this address:………………………………………………………………….
E-Mail Address: …………………………………………………………………………………
Home Telephone No: …………………………………………………………………………….
Mobile No: ……………………………………………………………………………………….
AREAS OF CLINICAL INTEREST
Please indicate below 3 preferences that you have for clinical specialties that you would wish your placement to be in. Please note that it may not be possible for you to be matched to your choices,although every effort will be made to accommodate one of these preferences.
  1. ………………………………………………………………………………………
2.……………………………………………………………………………………..
3. ……………………………………………………………………………………….
PLAB and IELTs STATUS
EXAM
/ DATE / DATE TO BE TAKEN/ SCORE / ORGANISATION OR
INSTITUTION
TO
/ FROM
PLAB 1
PLAB 2
IELTS

If your application is successful you will be asked to provide original evidence of your PLAB 1 and 2 passes, and IELTs Score.

PRIMARY MEDICAL QUALIFICATION AND ACADEMIC QUALIFICATIONS
Title of your Primary Medical Qualification:
Name of MedicalSchool/ University:
Country of Medical School/University:
Date Attended From:
Date Attend To:
ADDITIONAL ACADEMIC QUALIFICATIONS
Please list colleges and universities etc attended. You will be require to produce the originals of all examination certificates, professional qualifications certificates and professional registration details.
Place of Study
/ Qualification and Subject / DATE / COMMENTS
TO / FROM
CURRENT AND PREVIOUS EMPLOYMENT HISTORY
Please list details of all full-time and part-time work even if it was carried out overseas.
ORGANISATION OR
INSTITUTION
/ SPECIALITY & CONSUTLANT / DATE / COMMENTS
TO / FROM
DETAILS OF TWO REFEREES
Please provide the full names and addresses plus email addresses of two referees. One of which must be your last employer.
Referee 1
Name:
Address:
Email Address: / Referee 2
Name:
Address:
Email Address:
PREVIOUS CLINICAL ATTACHMENT HISTORY
ORGANISATION OR
INSTITUTION
/ SPECIALITY & CONSUTLANT / DATE / COMMENTS
TO / FROM
When, where and in what role did you last work as a Doctor?
……………………………
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ADDITIONAL INFORMATION
Please use the below space to add in supporting material, ie: Courses, Achievements, Future Plan etc.
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Provide a brief outline of how you feel this Course will help to meet your learning needs:
…………………………………………………………………………………………………….
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IMMIGRATION STATUS

How long have you lived in the UK? ………Years ………….. Months

Please tell us about your current immigration status in the section below.
Please indicate which of the following immigration categories apply to you, by ticking the appropriate box:
Tick which applies
Do you currently have refugee status within the UK □
Do you currently have ILR status (indefinite leave to remain) □
Do you currently have ELR status (exceptional leave to remain) □
Are you an EU National □
Are you a British Citizen □
Do you have a Highly Skilled Migrant visa □
None of the above apply □
If you have answered ‘none of the above’ what type of visa do you currently have:
……………………………………
What date does your current visa expire: ……………………………………

If your application is successful you will need to provide original evidence of your immigration status, along with your passport.

CRIMINAL RECORD DECLARATION
If your application is successful you will be asked to provide a Certificate of Good Standing, and to also complete a CRB (Criminal Records Bureaux) check via the Course.Your place on the course would also be subject to successful occupational health screening.
Please answer yes or no to the following question
(this information will be treated as confidential)
Have you been convicted of a criminal offence, been bound over or cautioned or are you currently the subject of any police investigations, which might lead to a conviction, an order binding you over or a caution in the UK or any other country?
Note: Applicants for positions in the NHS are exempt from the Rehabilitation of Offenders act 1974. You are required to declare prosecutions or convictions, including those considered ‘spent’ under this Act. / Yes/ No
If you have answered ‘yes’ to the above question please provide the details below of the criminal offence, including the date, and the authority and country that dealt with or will deal with the offence.
Have you undergone a recent CRB (Criminal Records Bureaux) check since you have been in the UK that you can provide original evidence of? / Yes/ No
If you have answered yes to the above questions please provide details of the date of
your most recent CRB check:
Signature: ………………………………….. Date: ………………………………

Equal Opportunities Monitoring Data

The Trust has an equal opportunity policy which aims to ensure that no applicant receives less favourable treatment on the grounds of ethnic group, nationality, gender, marital status, age, parenthood, sexual orientation, religion or disability. In order to assess the effectiveness of the policy and to assist in its development we would be grateful if you would please complete this form.

Do you consider yourself to have a disability? Yes or No
Do you have any specific needs in respect of a disability? Yes or No
If you have answered ‘yes’ to the above question please give details below, such as any particular equipment or facilities that your disability may require you to be provided with:
…………………………………………………………….
Ethnic Origin ( Please indicate by a tick in the appropriate box)
WhiteMixed
□British□White and Caribbean
□Irish□White and Black African
□Any other white background□White and Asian
□ Any other mixed background
Asian or Asian BritishBlack or Black British
□Indian□Caribbean
□Pakistani□African
□Bangladeshi□Any other Black background
□Any other Asian Background
Other Ethnic Groups
□Chinese□Any other ethnic group
Gender
□Male□Female
Marital Status
□Single□Married □ Divorced
□widowed□Common Law Partnership□other
Date of Birth:…………………………..
Place of Birth: ………………………….
Nationality: …………………………….
How did you become aware of this programme: …………………………………………..
Forenames:……………………………………Surname:……………………………………
(Please Print)(Please Print)

Thank you for answering these questions.

This Equal Opportunities Form needs to be returned along with your application.

DECLARATION
Please read each of the declarations below, and tick the box to indicate that you agree with each of the statements. Once you have completed the whole form, and ticked these final declarations please insert name and date below - this will be considered to be your signature.
• I certify that the information given on this form is correct and understand that any misleading or deliberate omissions will be regarded as grounds for withdrawal of an offer of a placement on the scheme, if my application is successful.
• I understand that the placement, if offered, is subject to occupational health clearance and confirmation of GMC proof of qualification.
• I accept that records will be kept of my application, and copies of appropriate paperwork, such as passport and visas, and if my application is successful records will be kept during and after my placement.
Please print name, signature and date:
Name
Signature
Date

Please return the requested documents only and no other documents at this stage.

Any application form returned without a CV and Cover Letter will NOT be considered.

It is not appropriate to enter on any part of the application form ‘refer to CV’.

Created by JoshiV Created on 14/11/2011 14:52:00- 1 -