Remity Staffing – Doctor’s Application Form

Remity Staffing - Doctor's Application Form

Step 1

Step 2

Title*

Forename*

Surname*

Gender

Current Address*

Postal/ Permanent Address (as logged with GMC Register)

Current Post Code*

Registered Post Code

Tel No*

Email*

Date of Birth*

NI Number*

Next of Kin*

Contact No*

Relationship*

Name of Bank

A/C Holder name

Bank Address

Account Number

Sort Code

GMC Number*

Availability and Specialty

Grade*

Specialty*

Full Time

Part Time

Please give brief details of your planned career path in coming 5 years

Are you on the Specialist Register? If yes, I declare that I have made formal arrangements to be appraised regularly by a Medical Practitioner entered onto the Specialist Register and enclose a copy of my Letter of Entry. YesNo

Qualifications Please provide details of qualifications (please enclose copy certificates)

Basic

Date

Country

Higher

Date

Country

Appraisals - As required by the NHS, please detail below the formalarrangements you have made to be regularly appraised by a medical practitioner entered in the Specialist Register, in the case of general Practitioners the appraiser must be (or qualified to be) a GP Principal.

Name of Appraiser*

Date of appraisal*

Hospital/Practice where took place

GMC No. of the Appraiser

Date of Next Appraisal*

Date of Revalidation*

Professional Development (Annual Mandatory Trainings)

Mandatory Training YES/NO (If yes give date)*

ALS / ATLS / APLS Please specify If you have any, please specify date)*

Referees - Please provide details the referees covering employment History of last 5 Years

(Ref1) Name

(Ref1) E-mail

(Ref1) Specialty

(Ref1) Grade

(Ref1) Hospital

(Ref2) Name

(Ref2) E-mail

(Ref2) Specialty

(Ref2) Grade

(Ref2) Hospital

(Ref3) Name

(Ref3) E-mail

(Ref3) Specialty

(Ref3) Grade

(Ref3) Hospital

Criminal Convictions / Fitness to Practice PLEASE ANSWER YES / NO

Have you been convicted of a criminal offence, been bound over or cautioned, or are you currently the subject of a practice investigation, which might lead to a conviction, an order binding you over, or a conviction in the UK or any other country? YesNo

If yes, please provide details of the criminal offence, the order binding you over, the caution or details of any current proceedings which might lead to a criminal conviction, including approximate date, the offence and the authority and country that dealt with the offence. If applicable, include details of ‘Spent Convictions” in a separate envelope addressed to The Manager marked ’Private and Confidential’

NOTE: Applicants for posts in the NHS are exempt from the Rehabilitation of Offenders Act 1974.

Have you been, or currently been the subject to any ‘Fitness to Practice’ proceedings by an appropriate licensing or regulatory body in the UK or any other country? YesNo

Have you been suspended from duty with any organization or with the GMC? YesNo

If you have answered YES, to either of the above, please provide details of the nature of the proceedings undertaken, or contemplated, including approximate date of the proceedings, country where proceedings were undertaken and the name and address of the licensing or regulatory body concerned.

I declare that, if in the future, I am convicted of a criminal offence, bound over, or cautioned, under investigation by the GMC, the subject to ‘Fitness to Practice’ proceedings, or suspended from duty by any other employer or agency, I will inform Remity Staffing immediately.

Signed*

DrawType

Date*

Right to Work in the UK

What is your right to work in the UK? (lease tick appropriate)

Work Perm, Student Visa or HSMP Visa Expiry Date

Nationality

Expiry Date

Professional Indemnity*

Defense Body Name*

Policy Number

COVID-19 & Flu Vaccination Declarations

Under the current guidelines, every healthcare worker need to have annual flu vaccination and also at-least 2 jabs of COVID-19 Vaccination to work within NHS.

Did you receive Flu vaccination within last 12 months? If yes, please supply the date. If no please explain why.

Did you have your both COVID-19 Jab now? If Yes please supply the dates. If no please explain why and also when you going to have these.

Date of First Covid-19 Jab

Date of 2nd Jab

Please explain here, why you have not had your COVID-19 Jabs

Doctors Declaration - Please note that Remity Staffing may at its discretion change the format and wording of any CV provided by you to put in a form that is acceptable to trusts and hospitals. If you do not agree to Remity Staffing altering your CV in this way, please tick [ ] Please read the following statements and sign if you agree to all. 1. I understand I will be asked to sign a form declaring my good health and GMC Status at the start of every assignment 2. I agree for all my details, within the registration pack to be shared with approved third parties i.e Auditors and NHS clients. 3. I am willing for Remity Staffing to apply for a Criminal Records Bureau for “Disclosure” and, if requested, forward confirmation of such to any hospital where I may be assigned. 4. I will comply with the Department of Health guidelines; HIV/AIDS; MRSA; HEP ‘B’/’C’ (HSC 2000/20) 5. I will comply with all NHS regulations currently in place including regular health screening: data protection compliance/confidentiality, discrimination law and Health and Safety at Work Act 1974 6. I will act only on the instruction/direction of authorised/appropriate NHS trust/Health Authority personnel 7. I am willing, at the request of NHS trust, to work over Working Time Regulation guidelines and I agree to opt out of Regulation 5 of the Working Time Regulations 1998 8. I have received, read and understand the guidance in the Remity Staffing handbook and will fully comply with its requirements 9. I accept and will abide fully by the Terms of Engagement of Remity Staffing outlined in handbook 10. I will notify NISI Staffing IMMEDIATELY of changes to the above information 11. I confirm that I have received Remity Staffing’s agency ID Badge 12. I enclose a completed pre-employment health questionnaire and equal opportunities form 13. I declare that I will keep Remity Staffing informed of all the necessary arrangements to remain on the GMC License to Practice Register: 14. I declare that the information provided above is true and correct

Print full Name*

DOB*

Signature*

DrawType

Date*