The Research Passport

RESEARCH PASSPORT
INFORMATION TO SUPPORT ISSUING AN HONORARY RESEARCH CONTRACT
Research Passport forms can be obtained from NHS R&D offices.
Please use the guidance notes attached when completing the form
Section 1 Details of Researcher To be completed by researcher
1. Surname: / Forename(s): / Prof/Dr/Mr/Mrs/Miss/Ms
Address:
Tel: Email:
2. Professional registration details (if applicable):
3. Current employer, place of study or, if no employer, research sponsor:
4. Post or status held:
Section 2 Details of Research Passport To be completed by researcher
5. Type of Research Passport:
Five-year: YES/NO If yes, complete the details in the Appendix
Project-specific: YES/NO If yes, complete the project title and dates below
Project Title:
Start and end date required for honorary research contract:
Are you working with staff children vulnerable adults interventional
Please tick as appropriate
6. Location of research:
NHS organisation(s): / Dept(s): / Supervisor/ Manager in NHS organisation:
Section 3 Suitability of Researcher To be completed by researcher
7. Have you ever been refused an honorary research contract? YES/NO
Have you ever had an honorary research contract revoked? YES/NO
If yes why?
Section 4 Suitability of ResearcherTo be completed by person responsible for ensuring researcher is suitably experienced and qualified
8. Name: / Job title:
Organisation: / Department:
Email:
I am satisfied that the above named individual is suitably qualified to undertake responsibilities and duties in association with all research activities for which they are responsible.
Signed: / Date:
Section 5 Pre-employment checks To be completed by the HR department of the researcher’s employer
9. Has a CRB disclosure that reveals no convictions or other police information been obtained in the last 6 months? YES/ NO
If yes, please provide details
Date of disclosure:
Type of disclosure: Standard/ Enhanced (delete as applicable)
Organisation which requested disclosure:
Additional checks obtained in disclosure e.g. PoCA:
Contact in employer’s HR for further details:
10. I am satisfied that the pre-employment checks described below have been carried out with regard to the above-named employee:
  • Employment screening: two verified references, verification of permission to work in the UK, exploration of gaps in employment , ID with photograph
  • Occupational health screening
  • Evidence of professional registration
  • Evidence of qualifications
An occupational health certificate should be provided, indicating the screening conducted.
Signed:
PRINT: / Date:
Section 6 This section should be signed by NHS HR, only if additional occupational health checks are required.
I am happy that the above named individual is fit to carry out duties in association with their research activity in accordance with the additional occupational health screening required for this post. Written evidence of the health checks conducted has been provided to the researcher.
Signed:
PRINT: / Date:
Section 7 Instructions to applicants:
Please indicate which of the following documents are attached to this Research Passport:
Current curriculum vitae (including details of qualifications, training and registration)
CRB disclosure (if question 9 is answered Yes)
Appendix with list of project titles and reference numbers
Occupational health certificate
Declaration Form
Please send the completed form and original documents to: R&D Directorate or Department. [address]
The completed form and original documents will be returned to you.
Section 8For Office Use Only: NHS R&D office must countersign and date photocopies
CV reviewed? Y/N
Details of relevant qualifications Y/N Training Y/N Registration details Y/N/NA
CRB disclosure reviewed? Y/N
Appendix reviewed? Y/N
Occupational Health Certificate reviewed? Y/N
Approved by R&D Director/Manager? Y/N
Signed:
PRINT: / Date
Date Honorary Research Contract issued:

Passport Appendix. List of Projects and amendments

Name………………….

Date……………………

For a five-year passport, please list research projects with which you are currently involved:

Title /
Dates

Add additional projects to be covered by this Research Passport:

Title /
Dates
/ Office use only. NHS R&D signature

Amendments to the Research Passport (please state what these are, e.g. they might be a change in name or employment details, or moving into a new area of work). Please check with the NHS organisation if you are unsure whether you will need a new Research Passport

Date / Old Details / New Details / Office use only. NHS R&D signature
For office use only: A photocopy of the appendix should be retained whenever any amendments or additions to the appendix are made.