1
Suite 28, 2nd Floor, Blackburn Business centre, Furthergate, Blackburn, BB1 3HQ
T: 0845 6440225 F: 01254 898909 Email:
Date: ………17/04/2019…………………………………..
Re: Application to register with Coben Medical Ltd
Thank you for your interest in registering with Coben Medical
Please find enclosed an application pack, which requests information and documentation, is required to obtain in order to place you with client governed by the PASA framework, and where applicable, the Care Standards Act 2000. I ask that you complete and return your fully completed registration pack and supporting documentation as soon as possible.
Please use the application checklist to ensure you enclose all the documents required to process your application as quickly as possible, as any missing information or document will delay Coben Medical being able to offer you work.
I look forward to receiving this form from you in the meantime please do not hesitate to contact me if I can be of any further assistance.
Yours sincerely,
Application Form: Doctors/GPs/Nurses
Personal Details
Title: First Name: Middle Name:
Last Name:
Other names: Maiden Name (if applicable):
Marital Status: Gender: Male Female
Date of Birth: / / Age:
Current Address:
City/ Town: Post Code:
Home Phone: Work Number:
Mobile Number:
Email Address: Preferred contact method:
National Insurance Number:
Miscellaneous Details
Type of registration:
GMC/ GDC Number:Registration Date
Renewal DateExpiry Date:
Right to Work:
Are you authorised to work in the UK: Yes No
Type of Visa: Work Permit HSMP Others(please specify:
Date of Issue of visa:Date of Expiry of visa:
Passport Number:Date of Issue of passport:
Date of Expiry of passport:
Professional Indemnity:
Do you have a professional indemnity cover: Yes No
If yes: MPS MDU Other (please specify)
Policy No:Renewal Date:
General Information:
Do you have your own transportYes No
If yes, type of transport:Driving licence: Yes No If yes Driving licence Number:
How did you hear about Coben Medical:
Coben Medical is committed to equal opportunities and none of the candidates are discriminated against with regards to race, sex, disability, age, colour, religion, national origin. In order to monitor the effectiveness of our equal opportunities policy, we request all applicants to provide the information indicated.
Please note: Ethnic minority questions are not about nationality, place of birth or citizenship. They are about colour and broad ethnic groups-UK citizens can belong to any of the groups indicated.
Please tick the appropriate category (one for your ethnic group and one for your sex)
A) White
English Scottish Welsh IrishAny other White background, please specify………………………………………………………..
B) Mixed
White and Black Caribbean White and Black AfricanWhite and Asian
Any other Mixed background, please specify………………………………………………………..
C ) Asian. Asian British, Asian English, Asian Scottish or Asian Welsh
Indian Pakistani Bangladeshi
Any other Asian background, please specify………………………………………………………….
D) Black, Black British, Black English, Black Scottish or Black Welsh
Caribbean African Any other Black background, please specify…………………………………
E) Chinese, Chinese British, Chinese English, Chinese Scottish, Chinese Welsh, or Other Ethnic Group
ChineseAny other background, please specify………………………………………………………………..
F) Sex
Male Female
Name: …………………………………………… Signed: …………………………………………………….
Date: ……………………………………………. Job Title: …………………………………………………..
Next of Kin
Name:
Relationship:
Address:
Post Code:
Telephone Number:
Bank Accounts:
We pay agency staff by BACS (automatic transfer), directly into their bank account. You will receive a fully detailed pay advise, and by using BACS, your money will be available in your bank account sooner, will not be held up in the post, and will not require you to go to your bank personally to pay your wages in.
Bank/Building Society name
Bank/Building Society address
Account holder nameAccount number
Bank/Building Society sort code
If the money is paid into a Building Society account, please state its’ reference number for Automated (BACS) payments.
Employment History (of the last 5 years)
Starting from Current or last employer:
1.) Employer Name:
Address:
County:Country:Post Code:
Telephone Number:Email address:
Start Date:End Date:To date
Title of Post:Grade:
Full TimePart time Main responsibilities:
2.) Employer Name:
Address:
County:Country:Post Code:
Telephone Number:Email address:
Start Date:End Date:To date
Title of Post:Grade:
Full TimePart time Main responsibilities:
3.)Employer Name:
Address:
County:Country:Post Code:
Telephone Number:Email address:
Start Date:End Date:To date
Title of Post:Grade:
Full TimePart time Main responsibilities:
4.) Employer Name:
Address:
County:Country:Post Code:
Start Date:End Date:To date
Title of Post:Grade:
Full TimePart time Main responsibilities:
5.) Employer Name:
Address:
Telephone Number:Email address:
County:Country:Post Code:
Start Date:End Date:To date
Title of Post:Grade:
Full TimePart time Main responsibilities:
Key Wording/ Grades:
Please tick only those areas where you want us to offer you work, for e.g. you have experience as a GP & SHO, but only want to be offered SHO work, tick only SHO. This would help us in finding you the right locum work for you.
Specialism / Less than 6months / More than 6months / 1-2 years / 2+ yearsAnaesthetics
GP
ARV
Cardiology Adult
Paediatrics
Cardiothoratic Surgery
Casualty
ACLS
ATLS
PALS
ALS
BLS
FMA
Chiropody
Dermatology Gastro
Geriatric
ENT Surgery
Endocrinology & Diabetes Mellitus
Family Planning
Gastroenterology
Geriatrics
Genito-urinary medicine
General Medicine
HIV
ICU
Internal Medicine
Nephrology
Neurology
Neonatal
Neuro Surgery
MT
Cytogenetics
Cytology
Haematology
Immunohaematology
Microbiology
Toxicology
Urinanalysis
Virology
Obs & Gyne
Ophthalmology
Oral Surgery
Orthopedy
Paediatrics
General
Surgery
Pathology
Plastic Surgery
Psychiatry
General
Forensic
Old Age
Rheumatology
Surgery
TB
Urology
Grade of Agency Worker:
SHO Oral Hygienist
MORegistrar
Senior RegistrarSMO
PMOConsultant
DentistDental Therapist
Others (Please specify)
Available for: Part-time Full- time Locum :Weekends :
Available from:To:
Preferred location for work:
Rehabilitation of Offenders
Declaration Regarding Doctors’ Fitness to Practice Proceedings by a Licensing / Regulatory Body & Relating to Criminal Investigations in the UK or Overseas. Statement of criminal convictions & Police Check Clearance.
Rehabilitation of Offenders Act 1974
By virtue of the Rehabilitation Act 1974 (Exemptions) (Amendments) Order 1986, the provisions of section 4.2 of the Rehabilitation of Offenders Act 1974 do not apply to any employment which is concerned with the provision of health services and which is of such a kind as to enable the holder to have access to persons in receipt of such services in the course of his/her normal duties. Applicants are therefore not entitled to withhold any information about convictions, which for other purposes are, the ‘spent’ under provision of the Act, and in the event of employment, and failure to disclose such convictions could result in disciplinary action including dismissal being taken by the Health Authority. You are therefore required to declare all criminal convictions of cautions. Any information given will be completely confidential and will be considered only in relation to an application for positions to which the order applies and will not debar from appointment unless the selection panel considers that it renders you unsuitable for employment Your answer to the following question should include any ‘spent’ convictions. This may or may not affect your application.
Part One: Convictions, Findings against you and Disciplinary Action
1. In the last five years, have you had any cases considered, heard and concluded against you by any of the following:
a) The General Medical Council?
b) Any other professional regulatory licensing body within the UK?
c) A professional regulatory or other professional licensing body outside the UK?
Yes No
Comments:______
2. Are there any cases pending against you with any of the following organisations:
a) The General Medical Council?
b) Any other professional regulatory licensing body within the UK?
c) A professional regulatory or other professional licensing body outside the UK?
Yes No
Comments:______
3. In the past five years, have there been any disciplinary actions taken against you by your employer or contractor – either in the UK or Outside – that have been upheld?
Yes No
Comments:______
4. In the past five years, has your employment or contract ever been terminated or suspended – in the UK or outside – on the grounds relating to your fitness to practise (conduct, performance or health)?
Yes No
Comments:______
Part two: Professional Obligations
5. I accept the professional obligations placed upon me in paragraphs 58 to 57 of Good Medical Practice.
DOH Circular (88/9) Protection of Children requires us to carry out checks on police records for agency staff whose assignments will give them substantial access to children.
Do you agree that such checks may be made, concerning you, if required? Yes No
I……………………………………………………………(print name) hereby declare that the information given here is true.
Signature______Date______
Name (in Capitals)______
Training
The National Framework Locums Contract requires each locum doctor to have received adequate training in the following prior to working for an agency. Please forward the training certificates on to your recruitment consultant.
Trainings / Completed / Not Completed / In processGeneral Healthcare
Fire Safety
Health and Safety (requirements of the 1974 & 1999 Acts)
Moving, lifting and Manual Handling
COSHH
RIDDOR
Infection Control
Basic Life Support
Mental Health Act
Mental Healthcare - as well as the above
Handling Violence and Aggression
Manual Handling
Lone Worker Training
Risk Incident Reporting
Caldicott Protocols
Training in Complaints Handlings
Clinical Governance
Data Protection
Continued Professional Development
Please List below details of any relevant course completed (please enclose copy certificates)
Course Name / Location / Date / Additional Information
Professional References:
These must be from your last two jobs and referees must usually be a supervising consultant or in the case of a consultant the medical director of the department or hospital or in case of GP , trainer or practice manager and also the locum jobs done by you which has had a duration of 14 days or more:
Name of referee:Company Name:
Position:Start Date:End Date:
Address:
Country:Post Code:
Telephone Number:Fax:
Mobile Number:Email:
Name of referee:Company Name:
Position:Start Date:End Date:
Address:
Country:Post Code:
Telephone Number:Fax:
Mobile Number:Email:
Name of referee:Company Name:
Position:Start Date:End Date:
Address:
Country:Post Code:
Telephone Number:Fax:
Mobile Number:Email:
Checklist:
As per NHS PaSA we would need you to supply us with the following documents to make you complaint:
Current Curriculum VitaeApplication Form (form enclosed)
Terms and Conditions (form enclosed)
Please sign one copy and return, the second copy is for your records
Passport (validated copy only with clear photo)
Performers list (current)
MDU/MPS Insurance (valid up to date)
Proof of Eligibility to work in UK (copy of stamp, visa in passport with clear photo)
Two Passport sized photographs
Proof of Address (2 items, i.e. copy of driving license, utility bills, marriage or birth certificate)
Professional Registration Certificates (copy)
Training (copy of any mandatory training completed in the last 12 months)
CRB Disclosure in My Locum’s name (form enclosed)
Medical Questionnaire (form enclosed)
Proof of Immunity for Hep B (Laboratory report)
Proof of Immunity for Rubella (Laboratory report)
Proof of Immunity for TB (Laboratory report)
Proof of Immunity for Varicella (Laboratory report)
Proof of Immunity for Hep C, if engaging in Exposure prone procedures (Laboratory report)
Latest References x 2
Appraiser’s Details (form enclosed)
Coben Medical Registered in England No. 7585597
1
Suite 28, 2nd Floor, Blackburn Business centre, Furthergate, Blackburn, BB1 3HQ
T: 0845 6440225 F: 01254 898909 Email:
Terms and Conditions of MembershipThese conditions constitute a legally binding agreement between you (the temporary worker) and Coben Medical Ltd. It is a condition of Membership that you should read and fully understand. We will be pleased to clarify any points you do not understand
In this agreement
“Staff” means a temporary worker.
“Client” means the party to whom the services are provided.
Coben Medcial Limited trading as Coben Medcial is referred to as “The Agency”
“Assignment” means from time to time, any activity which the client seeks the services of a staff from the agency.
“Booking” means the agreement for the provision of services by an identified staff.
MyLocum Role
The Agency will endeavour to find suitable assignments for the candidate in accordance with and subject to the terms and conditions. The staff is not obliged, to accept any Assignment offered to him or her by the client.
The Agency shall not be in obligation to provide any minimum period of assignments to the staff. The suitability of the staff in respect towards the assignment is entirely up to the discretion of the client. The Agency shall also be entitled to review the suitability of the candidate from time to time before and during an assignment.
Staff Responsibilities
The staff promises and hereby confirms to the Agency that the details supplied to the Agency on his/her behalf are full and accurate in all materials respects. The names of two most recent referees, relevant qualifications, registration certificates and current insurance certificates where applicable, will be provided by the staff to the Agency prior to the Assignment commencing. The staff will take originals of all the above documents and passport/.work permit to every Booking and show them to the Client. The Agency reserves the right to submit all, or any part of, information contained in references to the Client.
Staff must ensure that you maintain registration with the professional body at all times when you are engaged on an Assignment. Failure to do so means that the Client shall not be obliged to pay you for work done while you were not fully registered.
Staff must ensure that throughout any Assignment you have full professional insurance and/or indemnity cover in force at all times. Staff must not jeopardize cover by being in breach of any condition of your insurance and /or indemnity scheme.
The staff must inform the Agency of any situation which has resulted in his/her suspension or dismissal from any Hospital, Health Authority, SocialServicesDepartmentetc., and of any complaints made against the staff to the staff’s professional body.
It is the staff’s responsibility, if not a UK resident, to ensure that he/she meets all the requirements of the UK to allow such individuals to undertake work in the UK throughout each Assignment.
The staff agrees to inform the Agency in writing of his/her health status, and of any unusual symptoms in relation to special concerns raised by Clients or identified by The Department of Health from time to time. The staff agrees to inform the Agency of any restrictions imposed by law upon the staff which would affect work undertaken.
The Agency does not accept responsibility for any personal injury or damage sustained by the staff whilst on the premises or property of any Client, whilst acting on the instructions of any Client, or whilst travelling to or from the premises or property of any Client.
Appointments and Engagements
The staff will provide the services in a professional manner with reasonable care and skill and to the best of his/her ability.
The staff agrees with the Agency to observe throughout each Assignment the reasonable directions of the Client in connection with the provision of the services (including any such directions as to the hours during which the services are to be provided and the standard and type of dress of the staff) and to provide the services under the supervision and control of the Client and in accordance with the Terms of this part of the Agreement and with the Terms of the Agreement between the Agency and Clients in respect of the services.
Staff, in providing the subcontracted services, accepts posts with one or more Clients on the understanding that the staff work in that post or posts as the Agency’s subcontractor. If a staff accepts any such post, or any part thereof, or any extension of that post through another agency he/she will be liable to recompense the Agency immediately, upon demand, for any losses that the Agency may suffer as a consequence of this action.
The staff shall immediately inform the Agency if he/she is offered a permanent or temporary appointment with any Client as a result of being introduced to any Client by the Agency.
Working Hours
In compliance with the implementation of the Working Time Regulations, working time should not exceed 48 hours per week (averaged over a period of 17weeks) and Coben Medical recommends this practice. However, Members may wish to waive this right, and should indicate their preference by ticking Yes/No in the box provided below. Staff can change their chosen option by giving appropriate notice. Working time shall include only the period of attendance at each individual assignment through Coben Medical
Yes, I may wish to work for more than 48 hours a week.
No, I do not wish to work for more than 48 hours a week.
Ionising Radiation
There is a requirement for certain medical practitioners to be in possession of a certificate (the Popumet certificate) to administer radiation.
Do you hold the Certificate in Ionising Radiation? Yes No
AIDS / HIV infected healthcare workers
I confirm that I am aware of the Department of Health’s current guidelines on AIDS/HIV infected healthcare workers and agree to abide by these recommendations. Yes No
Clothier Clearance (Beverly Allit Report)
I confirm that I am aware of the Department of Health’s guidelines and agree to abide by these recommendations Yes No
Incomplete Assignments
Staff shall forthwith notify both the Agency and the Client of any actual or anticipated inability to provide the services (whether by lateness, illness or otherwise) during the hours for the provision of the services.
The staff may be asked to end an Assignment with a Client due to unsatisfactory work at any time. The Agency shall not be liable to pay the staff for any period worked if the termination under this condition is either within four hours of the commencement of an Assignment of seven hours or more or within two hours where the Assignment is of a lesser period.
A Client may cancel an Assignment at short notice, and in such circumstances the Agency cannot accept responsibility or liability for any loss or expense which may be suffered by the Locum as a result of such a cancellation.
Payment
The staff shall keep a full and accurate record of the hours worked by him/her in the provision of the services to the Client in each week or part week of each Assignment. Timesheets must be submitted on a weekly basis, to be received by the Monday following the end of the week in question, in order that payment can be made via BACS into the Locum’s bank account.
Staff will be paid at the rate in force at the time of Booking. At times, these rates may be varied without prior notice.
Staff and Agency agree that accommodation charges, meals and telephone services, together with travel expenses, where arranged, will not be the responsibility of the Agency and will be settled directly between the staff and the Client.
The Agency, will pursuant to Inland Revenue Regulations, deduct PAYE and National Insurance contributions from all earnings of the Staff in each Assignment.
Staff and the Agency agree that the Agency shall be entitled to deduct from any monies payable to the Staff hereunder or from any other payment due to the Staff from the Agency, all sums which may be due from the Staff to the Agency howsoever incurred or arising.
Other than in accordance with applicable legislation Staff are not entitled to payment: (a) in respect to pension; or (b) for time not spend on an assignment (whether as a result of illness, holiday including bank holidays or any other reason.)
The Agency will be under no obligation to contribute to any other benefits (i.e. Holiday pay, paid sick leave) or provide any Insurance in respect of Assignments accepted nor any workplace supervision in connection with it. The Staff will indemnify the Agency and keep it indemnified against the cost and financial consequences of and occasioned by any and all claims against the Agency.
Data Protection
Personal information provided by you ("Your Data") is collected and, used within the provisions of the Data Protection Act 1998. Personal data that is exempt from notification under the Data Protection Act 1998 is also processed. Your Data will be collected and retained in a database. This will be facilitated and managed by MyLocum. It will be used to analyse and evaluate the information provided by you. It will be used for staff administration, advertising, marketing & public relations, accounts & records, consultancy & advisory services. Your Data will be disclosed to MyLocum for the administration of your application and will be used to provide you with the service you registered for - to find you permanent or temporary work. Only current authorised MyLocum employees will have access to this data. The accuracy and completeness of Your Data submitted is entirely your responsibility.
Law
These Conditions of Membership are governed by the law of EnglandWales and are subject to the exclusive jurisdiction of the courts of England and Wales.
Signed………………………………………………………………………
Date …………………………………………
Members Name…………………………………………………………………………
………………………………………………………………………………..
If you have any queries regarding these conditions, please contact Coben Medical for further explanation. Please forward the signed copy to the above address.
EQUAL OPPORTUNITIES AND DISCRIMINATION POLICY