SAS Registration form

west midlands deanery

SECTION1: PERSONAL INFORMATION
Title: Dr Mr Mrs Miss Ms Sir / Gender:Please SelectFemaleMale
Surname/Family name:
Forename:
Name in which you are registered with a
Professional body if different from above: / DOB:
Contact Details

Home Address:

/

Work Address:

Email Address:
Please note MOST Deanery communications will be via email so you must provide an active email address which you check regularly and you must inform the Deanery of any change.
Telephone Numbers:
Home:
Mobile:
Work:
May we contact you at work?Please SelectNoYes
Right to Work in the United Kingdom
Are you a United Kingdom (UK), European Community (EC) or European Economic Area (EEA) National? / Please SelectNoYes
If not, do you have entitlement to enter and work permanently in the United Kingdom
(i.e. Indefinite Leave to Remain – free from immigration control?) / Please SelectNoYes
Are you on a dependents visa?
if you have answered YES please complete the Partner/Civil Partner/Spouse status section / Please SelectNoYes
If you have selected no to both of the above please mark with a cross those boxes below that define your immigration status and complete start and expiry date of your permit:
Personal Status
Nationality (Please indicate the Country pertaining to your Nationality: /
Please tick the appropriate box: / Status / Start Date / Expiry Date
Highly Skilled Migrant Programme (dates of endorsement stamp in passport) / /
Points based system – with endorsement “no employment as a doctor in training” / /
Points based system – no endorsement regarding “employment as a doctor in training” / /
Permit Free Training/Postgraduate doctor or dentist / /
Refugee in the UK / /
Work Permit/Tier 2 / /
Tier 4 / /
UK Ancestry / /
Student visa holder / /
Other immigration categories i.e. Overseas government employees, Innovators etc. / /
if Other than above, please specify the immigration category (max 50 words):

Partner/civil partner/spouse status
Please complete this section if you have answered YES to *“Are you on a dependent visa”
Nationality (Please indicate the Country pertaining to your Nationality): /
Please tick the appropriate box: / Status / Start Date / Expiry Date
Partner/civil partner or spouse of UK/EEA citizen / /
Non EEA national partner/civil partner or spouse of EEA citizen exercising a treaty right / /
Partner/civil partner or spouse of HSMP holder / /
Partner/civil partner or spouse under the Points based system – with endorsement “no employment as a doctor in training” / /
Partner/civil partner or spouse under the Points based system – no endorsement regarding “employment as a doctor in training” / /
Partner/civil partner or spouse of student visa holder – student visa holder must have 12 months or more leave to remain / /
Partner/civil partner or spouse of other immigration categories i.e. refugees, work permit holders, Overseas government employees, Innovators etc. / /
If other than above, please specify the immigration category (max 50 words):

SECTION 2: EDUCATION & QUALIFICATIONS
Include in this section all relevant qualifications.
Primary Medical Education
Qualification:
/
Date of qualification:
/
Medical School/University:
/
Fellow/Member of Royal College
Name of Royal College:
/
Qualification:
/
Date of qualification:
/
Are you registered with the GMC?
/
Please SelectNoYesIf yes please provide Registration number:
Membership of Professional Bodies:

Name of Body:

/ Type of Membership:
/ Date Obtained:

Are you on the Specialist Register?

/ Please SelectNoYesIf yes please provide Registration year:
Specialty:

Further Postgraduate Qualifications (most recent first)

Subject/Qualification (including grade/result) / Year obtained / Place of Study

SECTION 3: EMPLOYMENT

Current employment details
Name of NHS Trust /
Name of Primary NHS Trust /
Name of Secondary NHS Trust /

Specialty

Please indicate your specialty (most applicable)
Anaesthesia
Medicine: / Please SelectAllergyAudiology MedicineCardiologyClinical GeneticsClinical NeurophysiologyClinical Pharmacology & TherapeuticsDermatologyEndocrinology & Diabetes MellitusGastroenterologyGeneral (Internal) MedicineGenitourinary MedicineGeriatric MedicineHaematologyImmunologyInfectious DiseasesMedical OncologyMedical OphthalmologyNeurologyNuclear MedicinePaediatric CardiologyPalliative MedicinePharmaceutical MedicineRehabilitation Medicine / Further optionsRenal MedicineRespiratory MedicineRheumatologySport & Exercise Medicine
Pathology: / Please SelectChemicalChemical PathologyHistopathologyMedical MicrobiologyVirology
Obstetrics & Gynaecology
Ophthalmology
Psychiatry / Please SelectChild and Adolescent PsychiatryForensic PsychiatryGeneral PsychiatryOld Age PsychiatryPsychiatry of Learning DisabilityPsychotherapy
Public Health
Radiology / Please SelectClinical OncologyClinical Radiology
Surgery / Please SelectCardiothoracic SurgeryGeneral SurgeryNeurosurgeryOral and Maxillofacial Surgery (OMFS)OtolaryngologyPaediatric SurgeryPlastic SurgeryTrauma and Orthopaedic SurgeryUrology
Paediatric & Child Health
Other: (please state /

Relevant information regarding present employment

Current Grade:
/ Please SelectAssociate SpecialistSpecialty DoctorStaff Grade / If other: (please specify)
Length of time in current grade: / Years: Months: / Old ContractNew Contract
Work Status: / Please SelectFull TimeLess Than Full Time / Total Number of PAs:
On-Call Commitments: / Yes1st on:2nd on:
No
Weekend On-Call / Please SelectNoYes / Frequency: (1 in…)
What level of seniority do you consider to be: / Please SelectJunior ConsultantJunior SpRMiddle GradeSenior ConsultantSenior SpRSHO
Duration as SAS Doctor / Years: Months:
First substantive UK post / Date:Grade: Specialty:
Hospital:
Accredited training taken in the UK at the SHO level: / YesNo Years: Months:
Accredited training taken in the UK at the Specialist Registrar level: / YesNo Years: Months:
Do you work independently? / Please SelectNoYes
Do you have a clinical supervisor? / Please SelectNoYes(if yes) Name of Supervisor:
What level of supervision? / Please SelectDirectDistance
Previous employment history
Previous UK posts
Please list all further medical employment from most recent employment history.
Post 1
Employer name: /
Address: /
Post Title: / / Grade:
Specialty: / / Current Level:
Post 2
Employer name: /
Address: /
Post Title: / / Grade:
Specialty: / / Current Level:
Post 3
Employer name: /
Address: /
Post Title: / / Grade:
Specialty: / / Current Level:

Section 4: Personal Development

Study Leave Budget
Have you been able to access full study leave entitlement in the last year? / Please SelectNoYes / Study leave days per year:
Have you been able to access your full study leave allowance entitlement in the last year? / Please SelectNoYes
Level of study leave allowance supplied by trust in the last year: Please Select£500£600£700£800£900£1000
Other:
Have you ever been denied a study leave request? / Yes No Reason:
Are you aware of extra funding from the Deanery? / YesNo
Do you know your SAS doctor Rep/Clinical Tutor is? / Yes No
Do you have your annual appraisal regularly? / YesNo Last Appraisal Date:

SECTION 5: EQUALITY AND DIVERSITY mONITORING FORM

This part of the registration form will NOT be used to shortlist candidates for interview.
As public/private partnership sector employers, healthcare organisations are required to collect details about an applicant’s age, disability, ethnicity, gender, religious beliefs and sexual orientation. This is to ensure they meet their statutory requirements and to encourage the recruitment of a diverse workforce that represents the communities they serve. This information is collected to fulfil that obligation.
Our workforce profile data is collected against categories which are determined through the National Census of the UK population. The categories on this form reflect those which the Office for National Statistics advise are likely to be used in the next, 2011, census.
In order to monitor and ensure successful development of our policy, all applicants for posts are requested to complete the Equality and Diversity Monitoring information detailed below.
Date of birth:
Your gender – are you?
/ Male: / Female: / Transsexual/Transgender
Your age:
/ 16-25 / 26-35 / 36-45 / 46-55 / 56 and over
I would describe my ethnic origin as (please note this question does not refer to your Nationality/Country of origin).
White:
English
Other British
Irish
Other white background (please describe) /
Black or Black British:
African
Caribbean
Other black background (please describe) /
Asian or Asian British:
Indian
Pakistani
Bangladeshi
Chinese
Other Asian background (please describe) /
Mixed (dual heritage):
Asian and White
Black African and White
Black Caribbean and White
Other Asian background (please describe) /
Other ethnic group:
Arab
Gypsy
Irish Travellers
Romany
Other ethnic group (please describe) /
What is your religion or belief?
No religion/
Belief / Christian / Buddhist / Hindu / Jewish / Muslim / Sikh
Other religion (please describe)
Other belief (please describe)
If you consider yourself to be disabled, please specify:
Communication / Mental Health
Hearing / Mobility
Learning / Physical
Visual / Other
Please give further details below if you wish:

SECTION 6: Fitness to PractiSe

Are you currently bound over or have you ever been convicted or the subject of any offence or charge by a
Court or Court-Martial in the United Kingdom orin any other country?NoYes
If you have indicated yes, please email the details including dates to
Section 7: DECLARATION
The information in this section is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the Registration form will be grounds for rejecting this application or subsequent dismissal if in post and/or employed by the organization.
Where applicable I consent that the organization can seek clarification regarding professional registration details.
I confirm that I have a legal right to work in the UK and if this registration/application is successful, I undertake to produce the appropriate documentary evidence to prove this, prior to commencing work in the post.
I agree to the above declaration:
By submitting registration and application details the applicant understands that the information he/she provides may be used by postgraduate deaneries and employing organisations. Key personal information, including monitoring data will not be made available.
The registrar understands that the data will be recorded and processed on secure information technology systems by authorised recruiting staff in order to process and monitor appointments as well as to produce aggregated recruitment statistics.
The West Midlands Workforce Deanery may share information with any other organisations involved in the planning management and delivery of training and during employment. The applicant consents to the recording and processing of personal data in this way in accordance with the Data Protection Act 1998
In the interest of continual service improvement the West Midlands Workforce Deanery may wish to forward the details of this registration to external bodies for statistical analysis. All information released would remain anonymous in accordance with the Data Protection Act. If however you do not wish your registration to form part of this analysis please contact the PMDE team by e mail at
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