NHS SCOTLAND

STRICTLY CONFIDENTIAL
To be retained by Medical Personnel
I am applying for:
POST REFERENCE NO
POST TITLE
SPECIALTY
CLOSING DATE FOR APPLICATIONS

Please note that receipt of applications will not be acknowledged.

Shortlisted candidates will be contacted within approximately two weeks of the closing
date.
Please email your completed application form in Word format to:
medical.personnel@nhslothian.scot.nhs.uk

Equal Opportunities Monitoring

We want to ensure that our job opportunities are open to all. The only way we can
ensure there is equal opportunity is to measure applications we receive. Therefore this
form asks you for your ethnic origin, gender, disability, religion, sexuality and age. The
information you provide in this part of the form is confidential and is not used in the
selection process. It will be separated from the rest of the form when we receive it.

1. You are:

Female Male

2. Do you consider yourself to work:

Full time Part time

3. Do you consider yourself, or have you ever considered yourself as transgender?

This could include considering or intending to undergo gender reassignment
surgery or not identifying with your assigned birth gender.

No Yes Prefer not to say

4. What is your date of birth?

______________________
5. Do you have a physical or mental health condition or disability that has a
substantial effect on your ability to carry out day to day activities or is expected to
last 12 months or more?

No Yes

If Yes, please describe here the nature of the disability and any special arrangements for
interview / work location:

Again, if Yes please tick if it is either of the following:

Learning disability Long standing illness

Mental Health Condition Physical Impairment
Sensory Impairment Other (please describe):

6. What is your ethnic group?

Choose one section from A to F, then tick the appropriate box to indicate your cultural
background
A) White Scottish Irish Other British
Other White Background

B) Mixed Any mixed background

C) Asian; Asian Scottish; Asian English; Asian .British:

Pakistani Indian Chinese
Bangladeshi Other Asian background

D) Black; Black Scottish; Black British

Caribbean African
Other Black background

E) other ethnic background

Any other background

F) Prefer not to answer

7. What is your religion?

A) Buddhism B) Christianity - Church of Scotland C) Hinduism

D) Judaism E) Islam F) Christianity - Roman Catholic

G) Christianity (other) H) Sikhism I) Other faith / belief

J) Prefer not to answer

8. What is your sexual orientation?
A) Bi Sexual B) Lesbian/Gay Woman C) Heterosexual (straight)

D) Gay Man E) Other F) Prefer not to answer

9. What is your marital status?

A) Married B) Single C) Widowed D) Not married

E) Other F) Separated G) Prefer not to answer

Disability Discrimination Act

The Disability Discrimination Act 1995 and Amended Regulations 2005 defines disability as
follows: any physical or mental impairment which has a substantial adverse effect on a
persons ability to carry out normal day to day activities. NHS Scotland is Positive About
Disabled People, and as such we provide job opportunities for disabled people. NHS
Scotland operates a Job Interview Guarantee (JIG), which means that if you have a
disability, and meet the minimum criteria outlined within the person specification, 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 guarantee scheme?

Yes No

Please specify any special requirements you require if attending for interview,
eg. Induction Loop, Wheelchair Access, Signer FORMTEXT

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,
eg. B, BE, C
Advert

Where did you initially hear about this vacancy:

BMJ (online)
BMJ (print)
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)
Global Medical Careers (www.globalmedicalcareers.com)
Word of mouth / referral
Social Media (eg twitter) (please specify)__________________
Career Fair (please specify)____________________________
Other (please specify) ________________________________
Personal Information (will not be viewed by panel at shortlisting)

SURNAME:

FIRST NAMES: TITLE: (Dr, Mr, Ms, etc.)

DATE OF BIRTH: PRESENT NATIONALITY:

ARE YOU AN EEA NATIONAL? Yes No

IF NO, DO YOU REQUIRE A WORK VISA? Yes No

If you are not an EEA National and do Not require a Work Permit please indicate and
attach supporting documentation of your immigration status:
____________________________________________________________

If you are not an EEA National, was your undergraduate training taught in English?

Yes No

If not, please attach your English language examination certificate.

__________________________________________________________________________

YOUR PERMANENT ADDRESS:

Post Code: Telephone number:

*Address for correspondence (if different from above):

Post Code:

E-mail: ..............................................................................................

*Your daytime telephone number, or number on which a message may be left:

*(Please ensure this Address and Telephone No. are where you can be contacted
after the closing date)
 Registration Information:

Are you a member of the Protection of Vulnerable Groups Scheme (PVG) YES / NO

If YES, please state membership number:

Please state your GMC / GDC Number:

Please state type of registration: Provisional Limited Full

Do you have a License to Practice? YES / NO

Are you on the GMC Specialist Register? (if applicable) YES / NO

Are you on the GP Register? (if applicable) YES / NO

If you are not on the Specialist Register please state the date you Date:
expect to be included:
DECLARATION STATEMENTS (See Annex A)

Note (1) The Rehabilitation of Offenders Act 1974 provides for many people
who have been convicted of certain criminal offences the opportunity to have no
need to refer to these convictions or the circumstances relating to them in the course
of their daily lives. Certain convictions can, therefore, be regarded as spent after
the lapse of a period of years under the terms of the Act. The National Health
Service employment for which you are applying is excluded in the provisions of the
Act unless otherwise stated in the job description. If the post is excluded you are
required not to withhold information about cautions, charges or convictions which for
other purposes are spent under the provisions of the Act. In the event of
employment, any failure to disclose such convictions could result in dismissal or
disciplinary action by your employer. Any information given, however, will be
completely confidential and will be considered only in relation to the post for which
this application form refers.

I declare that I have:

(a) No previous convictions

(b) Previous convictions details of which are given overleaf

Note (2) To the best of your knowledge have you been or are you currently
subject to any fitness to practise proceedings by an appropriate licensing or
regulatory body in the UK or any other country?

(a) No

(b) Yes

If yes please provide details on a separate sheet of paper of the nature of

proceedings undertaken or contemplated, including approximate date of
proceedings, country where proceedings were undertaken and the name and
address of the licensing or regulatory body concerned.

Note (3) Relevant details from this form will be retained as part of your
employment records if you are appointed. This information will be used for personnel
administration and planning the work of your employer. In accordance with the Data
Protection Act 1998, copies of personnel records may be obtained by contacting the
Directorate of Human Resources.
DECLARATION

I DECLARE THAT, TO THE BEST OF MY KNOWLEDGE, THE INFORMATION

CONTAINED IN THIS FORM IS ACCURATE AND I CONSENT TO DETAILS BEING
RETAINED CONFIDENTIALLY AND USED FOR SPECIFIC AND LAWFUL
PURPOSES IN CONNECTION WITH THE DATA PROTECTION ACT 1998.

Signature:.Date:.

Please print your name if you do not have an electronic signature.

WE ARE COMMITTED TO PROMOTING EQUAL OPPORTUNITIES

ANNEX A

STATEMENT OF POLICY REGARDING FITNESS TO PRACTISE

PROCEEDINGS BY A LICENSING/REGULATORY BODY AND
RELATING TO CRIMINAL INVESTIGATIONS IN THE UK OR
OVERSEAS

Registration with the General Medical Council or General Dental Council imposes on
doctors and dentists the duty to provide a good standard of medical care for, and to
behave appropriately, towards patients. NHS Employers also have a duty to ensure
that patients receive a good standard of medical care and ensure as far as possible
the safety of patients. We therefore need to establish if you have been found guilty of
a criminal offence, been bound over or cautioned or are currently the subject of
proceedings which might lead to a conviction, an order binding you over or a caution,
in the UK or any other country.

Applicants for posts in the NHS are exempt from the Rehabilitation of Offenders Act
1974. Application forms will include a declaration for applicants to complete declaring
any previous or pending prosecutions or convictions, including those considered
spent under this Act. Forms will also include a declaration of any cautions or bind
overs.

We also need to establish if you have been the subject of any fitness to practise
proceedings in the past, or if any fitness to practise proceedings are being
contemplated, by a licensing or regulatory body in the UK or another country and this
is also reflected in the declaration.

This information will be treated in confidence and will not debar you from
appointment unless the selection panel considers that it renders you unsuitable for
appointment. In reaching such a decision we will consider the nature of the
conviction/action, how long ago it took place and any other factors which may be
relevant. If you fail to provide the full information on a separate sheet of paper as
requested in the application form your application will not proceed to shrotlisting or
interview.

Failure to disclose a criminal offence, having been bound over or cautioned or that
you are currently the subject of criminal proceedings which might lead to conviction,
an order binding you over or a caution, or fitness to practise proceedings undertaken
or being undertaken by an appropriate licensing or regulatory body, may disqualify
you from appointment, or result in summary dismissal/ disciplinary action and referral
to the General Medical Council [General Dental Council] for consideration if such a
discrepancy came to light.

If you would like to discuss what effect any previous convictions, police investigations
or fitness to practice proceedings taken or being taken either in the UK or by an
overseas licensing or regulatory body might have on your application, please contact
Jenny McCusker, HR Manager Medical and Dental on 0131 465 7735 in confidence
for advice.
If you are appointed, due to the nature of your employment you must advise your line
manager, or HR manager, of details of criminal charges and/or convictions incurred
during employment or since your offer of appointment. NHS Lothian will view the
disclosure of such information as sympathetically as possible and endeavour to
accommodate any restrictions imposed on your ability to carry out the full range of
your duties. Where, however, the behaviour that led to the charge and/or conviction of
yourself is considered to significantly affect your ability to perform your duties,
particularly where there is trust involved, the NHS Lothian Management of Employee
Conduct (Disciplinary) Policy may apply.

Failure to disclose such information at any stage may lead to disciplinary action being
taken.
 NHS LOTHIAN

STRICTLY CONFIDENTIAL

PLEASE COMPLETE ALL BOXES IN BLOCK CAPITAL LETTERS

OR TYPESCRIPT

1. Are you on the GMC Specialist Register, if not what is your CCT date?
(consultant posts only)

2. Details of current (or most recent) post:

Grade: Specialty:
(state if Locum)

Date of Appointment: From: To:

Employer and address (please state if employed by an Agency):

Duties:

Is this a research post ? () YES NO

If yes give further details including funding body

If you are on an honorary contract, give details including grade of

post
3. Details of previous posts held since Medical School. Include grade of post, if you held
a NTN or VTN number note of duties, place of employment and details of any research
posts held (including funding body):
____________________________________________________________________________
4. Medical education, professional qualifications, postgraduate medical training,
including experience in research or academic medicine
Dates Qualifications obtained, membership of
professional institution, etc.
From To

Name of Medical School

Qualifications obtained
(state if part qualified),
membership of Professional
Institutions, etc.

Clinical Experience

Teaching Experience
Research and Audit
Experience

Staff Management

Team Working and

Interpersonal Skills
5. Any other relevant educational of professional qualification and undergraduate awards or
special projects give details and dates:

6. Reasons for applying - Please say why you are interested in this appointment and indicate
the relevance to the job and/or training programme of your medical training and previous
experience.

(Please append any further information on a separate sheet)

7. Publications

8. Future Plans
PROFESSIONAL REFEREES
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. You should not use family members or friends.
Our pre-employment screening also includes, where appropriate, health and fitness for work, criminal
records, qualifications and professional registration. Note that references will only be taken up for
Preferred Candidates following interview.

PLEASE USE BLOCK LETTERS

NAME NAME NAME

POSITION POSITION POSITION

ADDRESS ADDRESS ADDRESS

Tel No:- Tel No: Tel No:

Fax No:- Fax No:- Fax No:

E-mail:- E-mail:- E-mail:

Please email your completed application form in Word format to:

medical.personnel@nhslothian.scot.nhs.uk