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NOTES FOR APPLICANTS

The application process and associated documentation has been produced in accordance with the NHS (Performers List) Regulations 2013. Any application submitted will be considered under the provision of these Regulations. Performers who appear on a Performers List should be aware of the requirements placed upon them by these Regulations. Your application should be made in person to the Operations Department of the NHSCB Local Area Team. Locality is determined as follows: The practice where you undertake the majority of the work which requires you to be on a performers list; If you are not attached to a practice, this is the address held by your registration body; If your registered address is outside England, but you wish to practice in England and are applying to join the NHS CBs national performers list, your application should be directed to : Cumbria, Northumbria and Tyne and Wear AT for performers whose address is in Scotland; Shropshire/Staffordshire AT for performers whose address is in North Wales; Arden, Hereford and Worcester AT for performers whose address is in South Wales; Wessex AT for performers whose address is in the Channel Islands; Merseyside AT for performers whose address is in Northern Ireland; and London North West AT for performers whose address is outside the UK.

Disclosure and Barring Service You will be required to provide a recent DBS Enhanced Disclosure Certificate, PIN for update or Fee and Form to enable a check to be undertaken. Applicants who cannot provide UK residency details for the last 5 years must undergo a Police Home Check. This can be arranged by contacting your Home Office or Embassy. If the document you provide is not in English, you will need to provide a translation that has been issued in the UK and signed by an official translator. Further information can be obtained from http://www.homeoffice.gov.uk/agencies-public-bodies/dbs/

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Documents Required to Support Your Application


The following documents should be brought along with you at the time of your application. (See also the requirements of the Disclosure and Barring Service). All Documents must be ORIGINALS (photocopies cannot be accepted). Passport or photo ID driving licence Your certificate of Full Registration with the GMC/GDC/GOC Your graduation certificate Your Vocational Training Certificate not applicable to Trainee applicants Or Certificate of Prescribed/ Equivalent Experience e.g. JCPTGP, PMETB or Evidence of Equivalency Ophthalmic Qualification Committee document OMPs only Recent Occupational Health Report - if available A detailed Curriculum Vitae of your complete work history Language Knowledge Certificate, OR alternative - if applicable A copy of your most recent appraisal/outcome statement - if available Work permit - if applicable Evidence of Membership of a recognised professional defence organisation at appropriate level Completed DBS form and appropriate fee if applicable, OR your current DBS Enhanced Disclosure Certificate if it was issued within the last 3 months, OR PIN for update service Additional Identity Documents will be required. See the DBS Checklist for details.

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SECTION 1: Personal details


1. Surname (This should be the name in which you are known by your registration body) 2. Forenames 3. Any other surname previously used (including Maiden Name) 4. Gender 5. Title 6. Date of Birth 7. National Insurance Number 8. UK Contact Address
(This should your home address which should be in local NHSCBs locality. If you are relocating and currently live in another part of the country, or abroad, please include details of your intentions, using Section 6 Additional information.)

Male /X

Female /X

Postcode 9. Private Telephone Number 10. Mobile Telephone Number 11. Preferred Contact Number 12. Email Address 13. GMC/GDC/GOC Registered Address (If different to UK Contact Address)

Postcode

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SECTION 1: Personal details (cont)

14. Please indicate in what capacity you wish to join the performer list Medical List GP Performer Salaried GP by practice Salaried GP by CCG GP Trainee Medical List GP Returner Scheme GP Retainer Scheme Armed Services Dental List Dental List Dental Locum Ophthalmic List Optometric Performer Ophthalmic Medical Practitioner Optometric Locum Optometric Trainee Yes ( ) 15. Nationality 15.1. Are you a full British Citizen or an EC National? If No go to next Question 15.2. Do you have evidence of entitlement to enter and work in the United Kingdom (e.g., settled status, spouse of a British Citizen?) If No go to next question. 15.3. Were you admitted to the United Kingdom as a doctor before 1st April 1985? If not, what is your immigration status please tick appropriately 15.4. Student 15.5. Visitor (including if you are taking the PLAB test) 15.6. Subject to work permit provisions 15.7. Self employment 15.8. Is there a time limit placed on your stay in the United Kingdom and if so what is this? Please give full details and state visa period or period of leave to remain No ( X )

GP Locum Flexible Career Scheme

Dental Performer Dental Trainee

15.9. Please state your country of birth

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SECTION 2: Practice Details

16. If you are linked to a practice, please provide the full name and address. N.B. Trainees and Students should provide their training practice details

17. Practice Telephone Number 18. Practice Fax No 19. Practice email address 20. Level of Commitment Please indicate the basis you will be working in the practice. If not full time, state the number of sessions For guidance:1 Session = 4 hours and 10 minutes Full-time = 37 hours and 30 minutes per week Three-quarter time = up to 6 sessions, but not more than 25 hours per week This section is for Trainees and Students only 21. Date of Commencement 22. Expected end Date 23 Name of Approved Trainer D D D D M M M M Y Y Y Y Y Y Y Y

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SECTION 3: Professional details

24. Professional Council Number (e.g. GMC/GDC/GOC) 25. Date of First Registration 26. Date of Full Registration 27. GPs only

Registration

D D D

D D D

M M M

M M M

Y Y Y

Y Y Y

Y Y Y

Y Y Y

Date of Inclusion in GP Register (non Registrars) 28. Do you have a license to practise? Yes No

If you answered no to the above question please provide details and a supporting explanation

29. Please give details of your Professional indemnity/Insurance at a level commensurate with the performer list application 30. Ophthalmic Medical Practitioners only OQC Number 31. Date of Qualification D D M M Y Y Y Y

32. Please list all your primary, vocational and postgraduate qualifications Qualification Institution (give name & place) Date of Qualification

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SECTION 3: Professional details (cont)


33. Please list in chronological order all your professional experience:

Explain any gaps between appointments Explain any dismissals from posts Any additional supporting particulars Please use Section 6 Additional Information or continue on a separate sheet(s) as appropriate A period of locum work should be indicated with a statement indicating the period of locum work and the type of work undertaken every appointment should be listed. Where a period of locum work has been interrupted by a permanent or semi-permanent post this should be reflected accordingly. Leave of absence for matters such as maternity leave or study leave whilst in a permanent post do not need to be shown

List all Appointments held and if as a performer, indicate your status i.e. Principal, Non Principal, Locum or Trainee) Post Location and Specialty Start and finish date WT PT

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SECTION 3: Professional details (cont)

Performer List History


34. Have you at any time been on the Performers List of any Primary Care Organisation in England, Scotland or Wales?

Yes

No

If Yes, please provide the name(s) of the Responsible Officer and Primary Care Organisation, including contact name, telephone number and full address. 35. Dates of Inclusion on the Performers List 36. Have you been refused admission, conditionally included in, suspended from, removed or conditionally removed from any Primary Care List or equivalent list?

Start.... End.... Yes No

If you answered yes to the above question please provide details and a supporting explanation

37. Have you at any time during your career been subject to sanctions, conditions or suspensions imposed by your registration body, employer or other NHS body?

Yes

No

If you answered yes to the above question please provide details and a supporting explanation

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SECTION 3: Professional details (cont)


The provide the following information relating to assessments or appraisals

38. Please provide details of your current revalidation cycle e.g. 2012 2017 Appraisal No 1 2 3 4 5 If you have not undertaken appraisal, please provide the reasons for this: Appraisal Year Date of appraisal or grounds of exemption Organisation that undertook the appraisal Name of your appraiser

Please provide details of your compliance with the core CPD requirements of your professional body:

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SECTION 4: English Language Knowledge


All applicants must be able to give positive response to one of the following statements. If you cannot provide appropriate evidence, your application will be refused: 1. Do you have a certificate of graduation from a UK or Irish Republic Medical or Dental School or University Optometry Department If you answer YES, proceed to Section 5 2. Do you have a certificate of graduation from a recognised Medical or Dental School or University Optometry Department abroad which was taught in English If you answer YES, proceed to Section 5 3. Do you have proof of having worked in an English speaking environment in which communications were in English for at least 6 months within the last 2 years If you answer YES, proceed to Section 5 4. Do you have proof of having lived in a multilingual household in which a relative or carer used English as their primary form of communication 5. If you answer YES, proceed to Section 5 Yes No Yes No Yes No

Yes

No

6. Do you have certification of a recent pass of one at the appropriate level from a recognised institution (see following list of approved courses).

Yes

No

(see note above)

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SECTION 4: English Language Knowledge (cont)


Table of Recognised Institutions and Pass/Score Required Awarding Body Cambridge University Certificate in English (ESOL) www.cambridgeesol.org London Chamber of Commerce Institute Examination (LCCIEB) www.lccieb.com National Open College Network NOCN www.nocn.org.uk Pitmans www.pitmanqualifications.com Trinity www.trinitycollege.co.uk Avalon/University of Bath www.bath.ac.uk/ubelt/ Linguarama www.linguarama.com International English Language Testing System www.ielts.org International English Language Testing System www.ielts.org Educational Testing Service www.ets.org Educational Testing Service www.ets.org Educational Testing Service www.ets.org Educational Testing Service www.ets.org Eutopia Medical Solutions www.eutopiamedical.com Title of Qualification Pass/Minimum Average Score

Business English Certificate (BEC) BEC Vantage

English for Business (EFB) NOCL Entry Level Certificate in ESOL Skills for Life Certificate in English Certificate in Integrated Skills in English (ISE I) English Language Assessment Linguarama English Test General International English Language Testing System

EFB Level 2

Entry 2

Achiever B2 *CEF Level B2 *CEF Level 2.5 2.0 7

International English Language Testing 6 System Academic Test of English as a Foreign Language 80 (TOEFL) Internet Based Test Test of English as a Foreign Language 200 (TOEFL) Computer Based Test Test of English as a Foreign Language 450 (TOEFL) Paper Based Test Test of English for International Communication (TOEIC) 660

Eutopia Certificate in Dental English 60% Language

* CEF: Common European Framework

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SECTION 5: Clinical References

You must provide details of two referees who have consented, if requested, to provide a clinical reference i.e. which relates to your clinical competence and abilities. The referees should be professional colleagues; one in your current role and one from your most recent post within the previous two years in which you have worked for 3 continuous months or more, at least one of which should not be someone with whom you have a financial or personal connection. If this is not possible because posts have been of shorter duration or you have worked as a locum with numbers of casual posts, you may include a referee from a frequently-held, recurrent post, for example. If you still have difficulty with identifying two referees, you may choose alternatives, but you are required to supply written reasons for this. Referee 1 Name Address

Telephone Number Email Address Relationship/ Capacity Known Length of Time Known

Referee 2 Name Address

Telephone Number Email Address Relationship/ Capacity Known Length of Time Known

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SECTION 6: Additional Information

Please provide any other information that the Commissioning Board may reasonably require to determine your application

Please continue any of the above information on a separate sheet if necessary

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SECTION 7: Declarations The NHS (Performers Lists) Regulations 2013


Under regulation 9, paragraph 2, all practitioners must make a declaration within 7 days if the practitioner: a. b. c. d. Is convicted of a criminal offence in the United Kingdom; is bound over following a criminal conviction in the United Kingdom; accepts a police caution in the United Kingdom; has accepted a conditional offer under section 302 of the Criminal Procedure (Scotland) Act 1995 (fixed penalty: conditional offer by procurator fiscal) or a compensation offer under section 302A of that Act (compensation offer by procurator fiscal) or agreed to pay a penalty under section 115A of the Social Security Administration Act 1992 (penalty as alternative to prosecution); has, in proceedings in Scotland for an offence, been the subject of an order under section 246(2) or (3) of the Criminal Procedure (Scotland) Act 1995 (admonition and absolute discharge) discharging the Performer absolutely; is convicted elsewhere of an offence which would constitute a criminal offence if committed in England and Wales; is charged in the United Kingdom with a criminal offence, or is charged elsewhere with an offence which, if committed in England and Wales, would constitute a criminal offence; is involved in any inquest as a person who falls within rule 20(2)(d) (entitlement to examine witnesses) or rule 24 (notice to person whose conduct is likely to be called into question) of the Coroners Rules 1984; is informed by any regulatory or other body of the outcome of any investigation which includes a finding adverse to the Performer; becomes the subject of any investigation by any regulatory or other body; becomes the subject of any investigation in respect of any current or previous employment, or is informed of the outcome of any such investigation which includes a finding adverse to the Performer; becomes the subject of any investigation by the NHS Business Services Authority in relation to fraud, or is informed of the outcome of such an investigation which includes a finding adverse to the Performer; becomes the subject of any investigation by the holder of any list which could lead to the Performers removal from the list; is removed or suspended from, refused inclusion in, or included subject to conditions in, any list; or becomes subject to a national disqualification.

e.

f. g.

h.

i. j. k.

l.

m. n. o.

Note: The Rehabilitation of Offenders Act 1974 does not apply for the purpose of this declaration. Offences considered spent under that Act must be declared.

Under regulation 9, paragraph 4, a practitioner must make a declaration within 7 days if the practitioner is, has in the preceding 6 months been, or was at the time of the originating event, a director of a body corporate that: a. Is convicted of a criminal offence in the United Kingdom; b. is convicted elsewhere of an offence, which would constitute a criminal offence if committed in England and Wales; c. is charged in the United Kingdom with a criminal offence, or is charged elsewhere with an offence which, if committed in England and Wales, would constitute a criminal offence; d. is informed by any regulatory or other body of the outcome of any investigation which includes a finding adverse to the body corporate; e. becomes the subject of any investigation by any regulatory or other body;

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SECTION 7: Declarations The NHS (Performers Lists) Regulations 2013 (cont)


f. becomes the subject of any investigation in relation to fraud, or is informed of the outcome of any such investigation, which includes a finding adverse to the body corporate; g. becomes the subject of any investigation by the holder of any list which might lead to its removal from that list; h. is removed or suspended from, refused inclusion in, or included subject to conditions in, any list; i. is involved in an inquest as a person who falls within rule 20(2)(d) (entitlement to examine witnesses) or rule 24 (notice to person whose conduct is likely to be called into question) of the Coroners Rules 1984; or j. becomes subject to a national disqualification.
Note: Originating events are the events that gave rise to the conviction, investigation, proceedings, suspension, refusal to admit, conditional inclusion, removal or contingent removal took place

Do any of the twenty five circumstances listed apply? If Yes, please enter the appropriate identifying number(s) from the above list, and provide the information requested below

Yes

No

Please provide full details of any investigation or proceedings brought or about to be brought, including approximate dates, the nature of such investigations or proceedings and, where known, their outcome. If giving details of a body corporate you should also provide the name and registered office of the body corporate.

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SECTION 8: Undertakings
I Undertake: to provide the declarations and documents ,if applicable, required by Regulation 9 of the NHS Performer List Regulations 2013; to notify the NHSCB in writing within seven days of the occurrence of any events specified in Regulation 9 of the NHS Performer List Regulations 2013; to supply an enhanced criminal record certificate under Section 115 of the Police Act 1997 PIN Update or application form in respect of this performer list application and at any time, for reasonable cause if the NHSCB requests me to do so; to notify the NHSCB within seven days of any material changes to the information provided in the application until the application is finally determined, or at any time when my name is included in the list, including if there is any change in the circumstances of my working arrangements; to maintain adequate and appropriate indemnity arrangements which provide cover in respect of liabilities which may be incurred in carrying out the work as a performer at all times and to provide existence of such an indemnity arrangement to the Board on request; to give notice to the NHSCB within 28 days of any occurrence requiring a change in the information recorded about me on the Performer List and of any change to my private address. to notify the NHSCB at least 3 months in advance of my proposed date of withdrawl from the Performers List; to notify the NHSCB if I am included, or apply to be included, in any other list held by an equivalent body; to co-operate with an assessment by the National Clinical Assessment Authority if requested to do so by the NHS Commissioning Board; to co-operate with an assessment by the NHS Litigation Authority where appropriate and if requested to do so by the NHS Commissioning Board; to participate with the appraisal system provide by the NHSCB (excluding optometrists, Type 1 & Type 2 Armed Services GPs); where the relevant Part provides to the contrary and the appraisal is not conducted by the NHS, to provide a copy of the appraisal undertaken.

I am a GP, Optometrist, Dental Trainee undertaking Vocational Training and Undertake: not to perform any primary care services, except when acting for and under the direction of my approved trainer to withdraw from the Performers List if I fail to complete my Vocational Training to provide on completion of my training, satisfactory evidence to the NHSCB that I have completed my training

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SECTION 8: Undertakings (cont)

I Declare That: I am in good health and know of no health issues which could impact on my performance. I am a fully registered with my Professional Registration Body with a Licence to Practise in the name shown at the beginning of this form. The information given in this application form, including any continuation sheets, is true and complete I agree to provide the declarations and documents, if applicable, as required by Regulations. I will inform the Commissioning Board if I change my private address and private telephone number and any change in my employment arrangements or name (e.g. as a result of change in marital status). to the NHSCB requesting from any employer, former employer, licensing, regulatory or other body in the United Kingdom or elsewhere, information relating to a current investigation, or an investigation, where the outcome was adverse, by that employer or body regarding myself or any body corporate of which I am or was a director and to the disclosure of such information by that person or body; to the disclosure of information in accordance with Regulation 9. to the disclosure of information to the NHSCB in relation to my appraisal and revalidation history which includes release of appraisal and revalidation documentation.

I Consent:

I Understand: that my failure to comply with the requirements outlined in this declaration that I have agreed to abide by may result in conditions being placed upon my name on the NHSCB Performers List or may result in removal of my name from the List.

Name: (please print) Signature: Professional Registration Number: Date: D D M M Y Y Y Y

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SECTION 9: Equal Opportunities


The Equality Act 2010 requires all public sector organisations to ensure they eliminate discrimination and advance equality of opportunity. The act outlaws discrimination based on nine protected characteristics: race, sex, disability, age, sexual orientation, religion or belief, gender re-assignment, marriage and civil partnership, pregnancy and maternity. Monitoring of access to the performers list will assist the NHSCB to address any potential of discrimination. We would request that you complete this form, however, this is not a mandatory requirement. The information you provide will be treated in the strictest confidence and will be used for monitoring and reporting access to and removal from the NHSCB Performers List. It will be stored electronically with restricted access to named staff. Your data will not be shared by others. The information you provide will be removed from storage twelve months after you are removed from the performers list, or twelve months from the notification that your application has been rejected. What is your ethnic group 1 ? Ethnic origin categories are not about nationality, place of birth or citizenship. They are about the group to which you as an individual perceive you belong. Please choose one section and then tick one box to best describe you ethnic origin. White English Irish

Welsh Scottish Northern Irish Gypsy or Irish Traveller Other White background Any other mixed background
White and Black African

Mixed/multiple ethnic groups White and Black Caribbean White and Asian Asian/Asian British Indian Bangladeshi Any other Asian background

Pakistani Chinese


Yes/No

Black/ African/ Caribbean/ Black British African Caribbean Any other Black/African/Caribbean background Other ethnic group Arab Any other ethnic group

Do you consider yourself to be a disabled person? If Yes, please describe the nature of your disability.

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OCCUPATIONAL HEALTH QUESTIONNAIRE


THIS DOCUMENT SHOULD BE PLACED IN A SEALED ENVELOPE MARKED PRIVATE & CONFIDENTIAL AND RETURNED FOR THE ATTENTION OF THE RO (________________) AREA TEAM. YOU WILL BE REQUIRED TO UNDERGO TESTING FOR BLOOD BORN VIRUSES AT YOUR OWN COST.

Surname:

First Name:

Date of birth:

Profession: Doctor/Dentist/Optometrist (delete as appropriate) Street Address: Town/City: Phone No: 1. County: E-mail Address: YES/NO (delete as appropriate) Postcode:

Have you lived or worked in a country other than the UK, European countries, New Zealand, USA and Canada?

If YES, which countries? Dates: YES/NO (delete as appropriate)

2.

Do you have any health issues that may affect your ability to undertake the duties of your role?

If YES, please give details.

3. Infectious diseases: 3.1. Tuberculosis Have you lived continuously in the UK for the last 5 YES/NO (delete as appropriate) years? If NO, please list all the countries that you have lived in or visited for more than 4 weeks over the last 5 years: Do you have reason to believe that you may have been exposed to tuberculosis? Have you had TB?

YES/NO (delete as appropriate) YES/NO (delete as appropriate)

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3.2. HIV/AIDS Do you have reason to believe that you may have been exposed to HIV infection? 3.3. Hepatitis C Do you have reason to believe you may have been exposed to Hepatitis C infection? YES/NO (delete as appropriate) YES/NO (delete as appropriate)

4. Health vaccination records Please tick all relevant vaccination/immunisations received and show dates. Vaccination/Immunisation Diptheria Tetanus Polio Meningitus MMR or Measles Mumps Rubella Haemophilus Influenza B Hep B initial Hep B second Hep B third Tuberculosis 5. Disclaimer and Signature I certify that to the best of my knowledge, the information I have given is correct. I understand that any false statement may affect my inclusion on the National Performers List. Signature: Date: Date received

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