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Applicant No.: (office use only)

NHS Scotland Medical Application Form

Notes to candidates

1 How to complete this form

Please complete the application form in full, as we do not accept curricula vitae (CVs).

Enter data in the non-shaded fields, adding a separate sheet if required. Additional guidance for applicants is included under section headings throughout this application form.

NB: There is no difference between the questions asked on this hard copy application, and those asked for online applications.

NHS Scotland’s application methods in order of preference: on-line application hard copy application by post

2 How we handle this information

All information collected and processed by NHSScotland is regarded as highly confidential, and is handled in line with the Data Protection Act. (Please note, however, that we are only responsible for handling of your information once we have received it.)

Part C (Education; Employment History) of this form will be used for the first stage of selection for interview.

If selected for interview, Parts A and B (Personal Details; Declarations) will be made available to those involved in the interview process.

Part D (Equality Monitoring) is confidential and will only be used for monitoring purposes.

NHS Scotland intends that recruitment practice will comply fully with our legal duties on equality. This will ensure that nothing in our recruitment process and practice will discriminate against, victimise or harass job applicants on the grounds of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation, and/or Trade Union membership or stewardship.

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Personal details will not be viewed at short-listing stage. Your full application (with the exception of Part D: Equality Monitoring data) will be viewed by the interview panel if you are invited to interview.

Part AApplication for (Job Title):

Vacancy Reference No.:(e.g. IRC1234)Applicant No.: (office use only)

Personal Details Title (Mr / Mrs / Miss / Ms / Dr / Prof)

Surname:

First Name:

Email: (for contact purposes)

AddressAddress Line 1:

Address Line 2:

Address Line 3:

Town:

County:

Post Code:

Phone Numbers Work Mobile:

Work:

Home:

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Where did you see the advert for this job?NHS Scotland job portal SHOW (www.jobs.scot.nhs.uk)

NHS Scotland Medical microsite (www.medicaljobs.scot.nhs.uk)

Doctors.net (www.doctors.net.uk)

NHSS internal iRecruitment portal

Vacancy bulletin

Job Centre Plus

Word of mouth / referral

Newspaper Please specify:Professional journal Please specify:Other website Please specify:Other Please specify:

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http://www.doctors.net.uk/

http://www.medicaljobs.scot.nhs.uk/

http://www.jobs.scot.nhs.uk/

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Part BApplication for (Job Title):


DeclarationsConvictions This post is exempt from the 1974 Rehabilitation of Offenders Act (Exclusions & Exceptions) (Scotland) Order 2003. This means that you must tell us about any previous convictions, classed as either “spent” or “unspent”.

If you are offered employment, any failure to disclose such convictions could result in dismissal or disciplinary action. Any information you give will be considered only in relation to the post for which this application form refers. Information will be verified by Disclosure Scotland for relevant posts.

I declare that I have:

No previous convictions

OR

Previous convictions, details of which are:

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Internal (NHS Scotland) candidates:

Please be aware that the information that you provide as part of your application will update your personal record on the electronic Employee Support System (eESS). If any information you have provided is found to be inaccurate, this will be investigated and may be addressed through the Board’s Disciplinary/Conduct policy, which may include dismissal.

ALL CANDIDATES, please read the following statements:

The details I have supplied in this application are, to the best of my knowledge, true and complete;

I understand that if appointed to this post, the information on this form will be kept as part of my personal record;

I authorise you to obtain references to support this application before any final job offer is made;

I understand that details of educational qualifications, membership of professional bodies, referee reports and immigration status may be verified through the establishments and individuals I have indicated;

I consent to my details being kept confidentially and used for specific and lawful purposes as specified in the Data Protection Act 1998 (as amended);

I declare that I have no previous convictions, or have identified any I have above.

Read, agreed & understood (tick box)

Signed:

Date:

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Part CApplication for (Job Title):


GMC/GDC RegistrationGMC GDC Professional Registration Status Full

Provisional Temporary

Registration number:Name in which you are registered:Do you hold a license to practise? Yes No Are you on GMC Specialist Register? Yes No If on register, please state the following:Specialty:Sub-specialty:If you are not on the register please state the date you expect to be included: Are there any restrictions (e.g. fitness to practise) to your professional registration?

Yes No

If yes please give reasons:

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Statutory Registration & Professional Membership detailsInclude in this section any other relevant professional registrations or membership. This information will be subject to a satisfactory check. Please continue on a separate sheet if necessary.

Category:e.g.MRCPMRCSStatutory RegistrationNon-Statutory RegistrationLicenseProfessional Membership

Type:

Date Received (month & year):

License / Registration / Membership Number:

Category: Type:



Category:

Type:



Category:

Type:

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CCTDate (or expected date) of CCT:Are you on GMC Specialist Register? Yes No Are you on GDC Specialist Register? Yes No Are you on GMC GP Register? Yes No If you have answered No to the question above, when do you expect to be included on the Register?

Foundation Training Have you been issued with a Certificate of Completion of Foundation Training?

Yes No

If you answered no, please detail why you do not have a Certificate of Completion of Foundation Training.

Do you have Portfolio evidence of achievement of your core training competencies?

Yes No

If you answered no, please detail why you do not have competencies.

Do you have a checklist of competencies achieved and countersigned by trainer?

Yes No

If you answered no, please detail why you do not have a checklist.

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Do you have evidence of having completed educationally approved posts?

Yes No

If you answered no, please detail why you do not have evidence of completing educationally approved posts.

Language skills (Non-EEA applicants only)Do you have demonstrable skills in written and spoken English at the required level (IELTS 7) to enable effective communication about medical and/or health topics with patients, colleagues and the public?

Yes No

What evidence of English language proficiency do you have? Please provide English language supporting information including dates, scores and sub-scores where relevant (e.g. IELTS)

NHS EmploymentAre you currently employed in NHS Scotland?

Yes No

Employment / Volunteering historyEnter details of your current, or most recent, employment. If a job supports the position you are applying for, please say more about it in your “Statement in Support of Application”.

Employer:

Start Date:

End Date:

Reason for Leaving:

Job Title:

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Location:

Notice Period:

Grade and Salary:

Description of Job Duties

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Employment / Volunteering historyAdd all previous periods of employment here. Please continue on a separate sheet if necessary.

Please include and give a brief explanation of any periods of unemployment.

Employer:

Start Date:

End Date:

Reason for Leaving:

Job Title:

Location:


Employer:

Start Date:

End Date:

Reason for Leaving:

Job Title:

Location:


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Employer:

Start Date:

End Date:

Reason for Leaving:

Job Title:

Location:


Employer:

Start Date:

End Date:

Reason for Leaving:

Job Title:

Location:


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Qualifications ACHIEVED (College / University)Please enter details of the colleges and universities which you have attended, as well as the qualifications received.

[NB: Qualifications gained at secondary school should be entered in the next section of the application form.]

Please continue on a separate sheet if necessary.

College or University:

Location:

Qualification:

Subjects:

Date Received:


Location:

Qualification:

Subjects:

Date Received:


Location:

Qualification:

Subjects:

Date Received:

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Professional degrees or qualifications, undergraduate awards, prizes, distinctionsDegree / qualification / award / prize /

distinctionAwarding Body Date

awarded

Qualifications CURRENTLY WORKING TOWARDS

Subjects Type of qualification

Grade anticipated

Date anticipated

Work-related training ACHIEVED (accredited or non-accredited)Course title Qualification or

accreditation Grade Achieved

(if applicable)

Work-related training CURRENTLY WORKING TOWARDSCourse title Qualification /

accreditationGrade

anticipated Date anticipated

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Statement in Support of ApplicationPlease tell us about your personal qualities, skills and attributes, experience and any major achievements, and show how they match those identified in the job description and person specification for this post. Please add a separate sheet if necessary.

As part of this statement you may wish to refer to any or all of the following:

Clinical Competencies Audit experience Teaching skills and experience Research skills and experience Presentations Publications and conferences attended Quality and risk management Service development Managing people Team work

Job Interview Guarantee (JIG) Scheme

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NHSScotland operates a Job Interview Guarantee, which means that if you have a disability and meet the minimum criteria outlined within the person specification for the post you are applying for, you will be guaranteed an interview. However, some disabled people prefer not to take this option, so please tick your preference if you are a disabled candidate.

Do you want to participate in the JIG Scheme?

Yes No

Please state any specific requirements if attending interview (e.g. induction loop)

Eligibility to work in the UKCandidates should note that a Tier 2 Certificate of Sponsorship can only be issued to the successful applicant if the post is either: included in the UK Shortage Occupation List; or meets the requirements of the resident labour market test.

Do you need to be sponsored under the Tier 2 (General) category of the UK points-based immigration system to take up this post?

Yes No

Right to work in the UK (Asylum and Immigration Act 1996)We must check the right to work in the UK of all candidates appointed. If appointed, as part of our pre-employment checks, you must present original proof and a copy of your Right to Work in the UK. (See www.ukba.homeoffice.gov.uk/workingintheuk.) Are you a United Kingdom (UK), European Community (EC) or European Economic Area (EEA) National?

Yes No

If you have answered “No” to the question above, please state the visa category under which you are legally entitled to work in the UK. What is the expiry date of your leave to remain in the UK?

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http://www.ukba.homeoffice.gov.uk/workingintheuk

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Driving Licence (see Job Description - only complete if a driving licence is essential)Do you have a driving licence? Yes No If yes, which categories are you entitled to drive?(e.g. B, BE, C)

Protecting Vulnerable Groups (PVG) Scheme detailsInclude in this section details of PVG Scheme membership, if applicable. This information will be subject to a satisfactory check. (See guidance notes)

PVG Scheme Membership Number:

PVG Joined Date:

PVG Regulatory Group: Children Adults Both

ReferencesOur pre-employment screening includes taking up references and, where appropriate, health and fitness for work, criminal records, immigration status, qualifications and professional registration.

Please give details, including titles and correct style of address, of three professional referees who have consented to be approached. They should be people qualified to comment on your medical ability and experience for this appointment. The named referees should include at least one referee from your current (or most recent) employer.

Please identify below the person in your organisation (this is normally your direct line manager or educational supervisor) who is authorised to confirm your employment and the details given in your application. Please also identify a second referee who may have close knowledge of your skills, knowledge and abilities, and who may offer opinion on your suitability for this post (e.g. supervisor or previous employer).

You should not use family members or friends. Your referees should cover a minimum three-year period, so please provide details on a separate sheet of more than two referees if necessary.

Name of referee (1):

Referee’s job title:

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Referee’s address and postcode:

Referee’s telephone number:

Referee’s e-mail address:

In what capacity is this reference being provided? (e.g. employment; academic etc)













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Part DApplication for (Job Title):


Equality Monitoring: Confidential The collection, monitoring and analysis of equality data is a key part of NHSScotland’s recruitment process. The data will be used to make sure that recruitment to NHSScotland can show that we continue to meet the requirements of the UK’s Equality Act 2010.

This part of the application asks some personal questions relating to:

Gender Disability Ethnic Group Nationality Religion and Belief Sexual Orientation Gender Reassignment Marriage and Civil Partnership Maternity

Answering these questions is entirely voluntary. Your answers are held in strict confidence, and do not get sent to the people involved in making recruitment decisions.

This part of the application also asks some questions that relate to your potential employment with NHSScotland. Please answer all of the questions in this section that are relevant to you.

Date of birthGender Male Female Prefer not to say

Have you, are you or do you plan to undergo gender reassignment (changing sex)? Yes No Prefer not to say

Do you have a condition / disability that has lasted / may last, 12 months or more? No Prefer not to say Yes If yes, please select this

condition/disability:Deafness or partial hearing loss Blindness or partial sight loss

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Learning disability (for example Down’s Syndrome) Learning difficulty (for example dyslexia) Developmental disorder (for example Autistic Spectrum Disorder or Asperger’s Syndrome)

Physical disability Mental health condition Long-term illness, disease or condition Other condition (please write in) Are your day-to-day activities limited because of this condition / disability? Yes, limited a little Yes, limited a lot No Prefer not to say

What is your ethnic group?Choose ONE from section from A to F, then tick ONE box which best describes your ethnic group or backgroundA: WhiteScottish Irish Other British Gypsy Traveller Polish Other

B: Mixed or Multiple Ethnic Group (please write in):

C: Asian; Asian Scottish; Asian British:Pakistani, Pakistani Scottish or Pakistani British Indian, Indian Scottish or Indian British Bangladeshi, Bangladeshi Scottish or Bangladeshi British Chinese, Chinese Scottish or Chinese British Other (please write in)

D: African:African, African Scottish or African British Other (please write in)

E: Caribbean or Black: Caribbean, Caribbean Scottish or Caribbean British Black, Black Scottish or Black British Other (please write in)

F: Other Ethnic Group: Arab, Arab Scottish or Arab British Other (please write in)

Prefer not to say

What is your nationality?

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What religion, religious denomination or body do you belong to?None Church of Scotland Roman Catholic Other Christian Muslim Buddhist Sikh Jewish Hindu Pagan Prefer not to say Another (please write in)

Which of the following options best describes how you think of yourself?Heterosexual / straight

Gay / Lesbian Bisexual

Other Don’t know Prefer not to say

What is your legal marital or same-sex civil partnership? Married Civil partnership None of these Prefer not to say

Are you on maternity leave/pregnant at the time of application of completing this form?Yes No Prefer not to say

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Personal Information: Confidential This part of the application also asks some questions that relate to your previous, current or potential employment with NHSScotland. Please answer all of the questions in this section that are relevant to you.

Birth Name or Maiden NameKnown As SurnameNational Staff ID (FOR NHS SCOTLAND EMPLOYEES) / Payroll NumberPublic Body Member? Yes No

Retain/Reserve Member? Yes No

NHSS Continuous Service DatePersonal E-mail AddressDate available to start if offered postReckonable Service Years (enter completed years only)Reckonable Service Months (enter completed months only)Reckonable Service Employers (enter valid employer names only, comma separated)

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