Personal Registration Form

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Department

Name of Interviewer

First Last

Interviewer Email Address

Date

Personal Details

Applicant Name(Required)

First Middle Last

Applicant Maiden Name

First Middle Last

Date of Birth(Required)

Marital Status(Required)

Single

Married

Divorced

Widowed

I understand that any personal data held by Indemand Associates is liable to be inspected by the and/or any other authorised 3rd party including for any audits. Please select below if you do/do not agree for your personal data to be made available to any 3rd party without direct supervision from a member of staff from Indemand Associates or myself being present(Required)

I Agree

I agree to give Indemand Associates Recruitment permission carry out online DBS checks both annually or as required(Required)

I Agree

I have received, read and understood, and agree to abide by the contents of the Indemand Associates Recruitment Locums Handbook. I have received, read and understood the terms and conditions of engagement of Indemand Associates. I understand that my ID Badge must be visible at all times during a Indemand Associates Group Recruitment assignment and that if I leave Indemand Associates that I must Hand back my identity badge. All patient records should be kept confidential in line with the Data Protection Act 2018/GDPR. I also agree not to disclose to any confidential information to any 3rd Party without prior written consent.(Required)

I agree for Indemand Associates to complete checks on my professional registration licence where required.(Required)

I agree

I agree that I will maintain my Right to Work status and inform Indemand Associates should this change at any stage of my registration.(Required)

I agree

I agree that I will adhere to the restrictions of my Right to Work status where applicable.(Required)

I agree

I agree to inform Indemand Associates should I be subject to any investigation or Fitness to Practice whilst registered.(Required)

I agree

Grade/Band(Required)

Specialty(Required)

Next of Kin

Name(Required)

First Last

Relationship(Required)

Contact Number(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Nationality

Evidence of all passports and visas are required. Please enclose photocopies with this application form and make sure you bring the originals to your interview.

Passport Number(Required)

Share Code for online Right to Work Check:(Required)

Passport Expiry Date(Required)

Working Holiday Visa

Yes

Working Holiday Visa Expiry Date(Required)

UK Residency Visa Expiry Date(Required)

Student Visa

Yes

Student Visa Expiry Date(Required)

Working Permit

Yes

Working Permit Expiry Date(Required)

Should you hold any other Visa or residency permit, please provide the information below:

Current Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile Phone(Required)

Home Phone

Work Phone

Applicant Email Address(Required)

Availability for Work

Availability to start work(Required)

Availability over the next 12 months(Required)

Which part of the UK do you prefer to work in?

Declarations

In line with the Government legislation under the terms of the “Working Time Regulations” we recommend that your working hours should not exceed 48 hours per week (averaged over a 17 week period.)

Should you wish to waive this right, please confirm my ticking below:(Required)

I confirm that I wish to work more than 48 hours per week

I understand that information give on this form will be stored and handled by in demand associates in accordance with the Data Protection Act 1988, however, I agree that this information may be made available for audit by the relevant Government organisations.
Data Protection Act 1998 / The General Data Protection Regulations 2018
In relation to the Data Protection Act 1998 / The General Data Protection Regulations 2018, you agree to the processing of personal data for the purposes of the recruitment process as well as for future potential employment arrangements for the purposes of calculating your remuneration and maintaining records on attendance, health, discipline and grievances such as are necessary for the performance of your contract. Our full GDPR Privacy Notice can be found on our website www.indemandassociates.com. For further information, please see the Information Commissioner's website ww.dataprotection.gov.uk, from which the above guidance is reproduced.
I acknowledge that I have been given a copy of the terms and conditions of service issued by in demand associates, which is mine to keep and further more that I have read those terms and conditions and agree to abide by them. I am not aware of any condition, medical or otherwise which would affect or limit my employment or performance, other than those declared in my Pre-employment Health Questionnaire From and I am fit for work.
I authorise in demand associates to disclose any convictions to any potential employers in accordance with the DBS Code of Practice and the Rehabilitation of Offenders. I declare that the details given by me on this application form are correct to the best of my knowledge and belief. I understand that if I have given any information which is false, or I withhold any relevant information, this may lead to my application being rejected, or if already appointed, to my dismissal, as well as a claim for recovery of any payments I have received, together with a claim for loss of profit to in demand associates.
I also give in demand associates Group Permission to apply and to check my DBS certificate on the UK DBS update service annually.
I give in demand associates Group Permission if required to conduct any relevant right to work checks Via the Government websites.

Signature(Required)

Professional Details

Professional Registration Number(Required)

Are you currently undergoing any disciplinary action, complaints or investigation by an NHS Trust or your professional body?(Required)

Yes

If yes, please provide more details:(Required)

Have you previously been subject to any disciplinary action, investigation or complaints by patients, relatives, other members of staff or by an NHS Trust, previous employer or professional body?(Required)

Yes

If yes, please provide more details:(Required)

If Psychiatry Doctor, do you have a Section 12 certificate?

Yes

Do you currently have medical insurance/professional insurance?(Required)

Yes

Qualifications

Please complete in the table provided all professional qualifications held, including Post Graduate Diploma / Courses etc. Note that professional qualifications and training will be verified.

Child Protection / Venerable Adults level 2/3

Handling Complaints

Fire Procedures

Handling Violence & Aggression

COSHH & RIDDOR

Infection Control & Prevention

Lone Worker Training

Health & Safety

Risk Incident Reporting

Moving & Handling

The Caldicott Protocols

Basic Life Support

Advanced Life Support

Have you been appraised within the last 12 months?(Required)

Yes

Name of Appraiser

First Last

In order to work within the NHS you will need to be appraised annually by a Senior Practitioner of the same discipline, this person will become your “appraiser”. Please give the details of the Senior Practitioner you have made arrangements with to act as your appraiser.

Position and Grade of Appraiser

Professional Registration Number of Appraiser

Next appraisal due?(Required)

Date of last appraisal(Required)

Appraisal Statement - Select if you agree with the following statements

I confirm the appraisal was within an "Approved NHS Appraisal System" and includes 360 degree feedback as well as feedback from patients.

I confirm that I maintain a written portfolio of my professional experience and attendance at proffessional development courses, which also includes a written and agreed "Personal Development Plan" as agreed at the appraisal.

Employment History

Can you please provide details in the boxes below of your last 3 years employment (most recent first). If there are any gaps of 3 month or more it is important that you explain the reason why in the box below.

Employer name (1)

Position Held (Employer 1)

Location (Employer 1)

Tel Number (Employer 1)

Date From (Employer 1)

Date To (Employer 1)

Employer name (2)

Position Held (Employer 2)

Location (Employer 2)

Tel Number (Employer 2)

Date From (Employer 2)

Date To (Employer 2)

Employer name (3)

Position Held (Employer 3)

Location (Employer 3)

Tel Number (Employer 3)

Date From (Employer 3)

Date To (Employer 3)

Professional Referees

You are required to supply at least two work related professional referees. The 2 referees provided must be within the last 12 months and be concurrent. (We have allocated space for additional referees to be included, should you wish to provide more than two referees you must follow the above same principle.)

Name of First Referee

First Last

Email of First Referee

Address of First Referee

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone of First Referee

Known Capacity of First Referee

Name of Second Referee

First Last

Email of Second Referee

Address of Second Referee

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone of Second Referee

Known Capacity of Second Referee

Name of Character Reference

First Last

Email of Character Reference

Phone of Character Reference

Known Capacity of Character Reference

Signature to apply for references(Required)

Please sign to allow us to contact your referees immediately.

I give Indemand Associates Recruitment permission to forward my CV to agreed clients for the purpose of obtaining employment.(Required)

I agree

Equal Opportunities Policy

As an Equal Opportunities employer the organisation welcomes applications from suitably qualified persons from all sections of the community. The organisation is committed to achieving a working environment which provides equality of opportunity and freedom from discrimination on the grounds of race, nationality, religion, gender, class, family responsibilities, marital status, sexual orientation, age, disability or special need. The Directors believe in best practice in Equal Opportunities on the grounds of morality, good business practice and awareness that certain kinds of discrimination are unlawful. This is a key employment value to which all employees and candidates are expected to give their support. To ensure that the policy is effective it is essential that detailed monitoring is carried out, which necessitates the collection of information. The information on this form will be kept confidential and will not be used by those involved in the selection procedure and is for statistical purposes only and will not form part of any job application. *

Please Select(Required)

Please Specify

Criminal Record Declaration(Required)

Yes

Under the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975, applicants for locum medical posts are not entitled to withhold information about convictions which for other purpose are ‘spent’. Therefore you are to inform Indemand Associates in writing of any convictions for criminal offences past in the future.

Please Provide Details(Required)

Have you ever had an Enhanced Disclosure Barring Service Check (previously DBS check) ?(Required)

Yes

If you haven’t completed a DBS (previously DBS) check through Indemand Associates Recruitment Ltd, or if the last one was completed over 12 months ago, you are required to complete the attached DBS form provided so that we may undertake an Enhanced DBS check on your behalf. You will not be place in employment without having completed a current DBS check. Please ensure you enclose all original documentation (e.g. passport) as photocopies will not be accepted and your form will be returned to you.

Disclosure Number

Date of Disclosure

Applicants Name(Required)

First Middle Last

Applicant's Signature(Required)

Interviewer's Name

First Last

Interviewer's Signature

For Office Purposes Only

THE F2F OFFICER MUST COMPLETE THE BELOW BEFORE LEAVING THE MEETING.

Did the candidate have a good command of the English language?

Yes

Was the candidate pleasant and polite?

Yes

Was the candidate courteous and helpful?

Yes

Are you happy to offer this candidate work on the basis of this interview?

Yes