8/12/2019 Performer List Documents http://slidepdf.com/reader/full/performer-list-documents 1/19 Documents Required to Support Your Application The following documents should be brought along with you at the t i me 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 10driving 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 - OMP 's only Recent Occupational Health Report - if available A detailed Curr i culum 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. 2 1. r Page 2 of 20
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16 If you are linked to a practice, please t-/TILD R'IJ6b 5.U~GfR1provide the full name and address.
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20 Level of CommitmentJ J I
Please indicate the basis you will be working in 'FULL -TiMEthe practice. If not full time, state the number of
sessions -
For guidance:-
1 Session = 4 hours and 10 minutesFull-time = 37 hours and 30 minutes per weekThree-quarter time = up to 6 sessions, but notmore than 25 hours per week
You must provide details of two referees who have consented, if requested, to provide aclinical 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.
SECTION7: 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. Is convicted of a criminal offence in the United Kingdom;b. is bound over following a criminal conviction in the United Kingdom;
c. accepts a police caution in the United Kingdom;
d. 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);
e. 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;
f. is convicted elsewhere of an offence which would constitute a criminal offence if
committed in England and Wales;
g. 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;
h. 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;i. is informed by any regulatory or other body of the outcome of any investigation which
includes a finding adverse to the Performer;
j. becomes the subject of any investigation by any regulatory or other body;
k. 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;
I. becomes the subject of any investigation by the NHS Business Services Authority inrelation to fraud, or is informed of the outcome of such an investigation which
includes a finding adverse to the Performer;
m. becomes the subject of any investigation by the holder of any list which could lead to
the Performer's removal from the list;
n. is removed or suspended from, refused inclusion in, or included subject to conditions
in, any list; or
o. becomes subject to a national disqualification.
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;
• to provide the declarations and documents ,if applicable, required by Regulation 9 of theNHS 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 inrespect 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 fromthe 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 GP's);
• 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 andUndertake:
• not to perform any primary care services, except when acting for and under the directionof 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 havecompleted my training
• 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 privatetelephone number and any change in my employment arrangements or name (e.g. as a
result of change in marital status).
I Consent:
• 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 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.
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. Monitoringof 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 i s your ethn ic group ?
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
D
D
Welsh D Scottish D Northern Irish D
Gypsy or Irish Traveller D Other White background Kl
Mixed/mult iple ethnic groups
White and Black Caribbean
White and Asian
D
D
White and Black African D
Any other mixed background D
Asian/Asian Brit ish
Indian
Bangladeshi
Any other Asian background
Pakistani
Chinese
D
D
D
D
D
Black African/ Caribbean/ Black Brit ish
African D
Any other Black/African/Caribbean background
Caribbean D
D
Other ethnic group
Arab Any other ethnic group D
Do you consider yourself to be a disabled person? ~No
If 'Yes', please describe the nature of your disability.