performer list documents

8/12/2019 Performer List Documents

http://slidepdf.com/reader/full/performer-list-documents 1/19

Documents Required to Support Your Applicat ion

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 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 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.

2

1.

r

Page 2 of 20



SECTION 1: Personal details

1. Surname (This should be the name in which

r 7 / A N Uou are known by your registration body) - - - - 2. Forenames <O/?-J6 /l l 1 /; '0 k1} r l

3. Any other surname previously used

(including Maiden Name)

4. Gender Male 1 1 Female 1V

5. Title M 1.

6. Date of Birth 1 s -I 1 1 / 1 / 1 5 1 1 6 1 97. National Insurance Number 2{;91/0J'-33tt222

8. UK Contact Address I~ S/rO/l/b coute /(This should your home address which should be in

£ i LL /VJ4 S fI ; 'L -Local NHSCS's locality. If you are relocating and

currently live in another part of the country, ort r f J - / 7 7 1 V 6S UI<broad, please include details of your intentions,

using Section 6 Additional information.)Postcode TN 3Zos,p

9. Private Telephone Number

10. Mobile Telephone Number 00401-26 -» 4/ 11

11. Preferred Contact NumberoV009-2£79~dJ7

12. Email AddressJ z O h f > / lM L J)a .lA~£ L//i hnt7 ( /)///

13. GMC/GDC/GOC Registered Address (If Sm. VJ/~8:;1JCE t ~/)77<ftIV 6different to UK Contact Address)

j 8I e I .Jc-/9 -/ If;J 9

R I+fVllV/W VA-Lull / ~OI1///l--/1//A

Postcode 2~01JO

Page 3 of 20



SECTION 1: Personal details (cont)

14. Please indicate in what capacity you wish to join the performer list

Medical List Medical List Dental List

D GP Performer D GP Returner Scheme D Dental Locum

[2J Salaried GP by practice D GP Retainer Scheme Ophthalmic List

D Salaried GP by CCG D Armed Services D Optometric Performer

D GP Trainee Dental List D Ophthalmic Medical

Practitioner

D GP Locum D Dental Performer D Optometric Locum

D Flexible Career Scheme D Dental Trainee D Optometric Trainee

Yes ( v ) No (X)

15. Nationality

15.1. Are you a full British Citizen or an EC National? If No go to next Vuestion

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 nextquestion.

15.3. Were you admitted to the United Kingdom as a doctor before 15t 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

15.9. Please state your country of birth

Page 4 of 20



SECTION 2: Practice Details

16 If you are linked to a practice, please t-/TILD R'IJ6b 5.U~GfR1provide the full name and address.

L iTTLG j(/AGE A-vN.B. Trainees and Students should provide

their training practice details SaJu.i ..el7 UC lJLcUJ -{JU JeO.

'IN 3f i-LS fl fJ-J77it ;G s

CWJt JM/j~

17 Practice Telephone Number O I C , . / ; 1 . r j-Fr3 JJ

18 Practice Fax No OJ'r2~ -t-1J -c,o

19

Practiceernall

address ~ z-pdtiltle/(/dqeJIJ)lQ(-7JWrl/nhl1l ULf

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

This section is for Trainees and Students only

21 Date of Commencement

22 Expected end Date

23 Name of Approved Trainer

Page 5 of 20



SECTION 3: Professional details

24. Professional Council Registration - 9 D 6 2 9/7Number (e.g. GMC/GDC/GOC)

25. Date of First Registration / { a 3 2 a 26. Date of Full Registration I 1 0 ~ 2 0 / /

27. GPs only

Date of Inclusion in GP Register (non

Registrars)

28. Do you have a license to practise? Yes

[X]No

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

29. Please give details of your Professional

indemnityllnsurance at a level

commensurate with the performer list

application

30. Ophthalmic Medical Practitioners only

OQC Number

31. Date of Qualification

32. Please list all your primary, vocational and postgraduate qualifications

MIMJ m o

Institution (give name place) Date of Qualification

MiN/J1 I f . of E UcnTlON

JeO/VlFJ '/'

Page 6 of 20



SECTION 3: Professional details (cont)

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 Start and finish date WT PT

OJ·200:;'-O.J. ZO 3

Location and Specialty

t5vJEA06J1/ 0/ J-T{)/P//)9-L O J : :

L - ,02. 201?.

S O AIl-NU;]l; O£U/JbJ.

j OM 4/11//l

01.0 ;. 2oo f. -I /Z f £jJicl/- L CgJI/7( G kl;q

2 Jf £0, v?/J

M~\U1L CElVlXEi fLEA-)S Ot:200-?--08.2Cf)if-

~f)M :;/l

O/.200?- 12200(

6, JUtI .6ERy Af2-·/bIEJ ca ao · / r c n ~/2. ZO o e

r/; ; E/)J4 RO/P J/W/4

Page 7 of 20



SECTION 3: Professional detai ls cont)

he provide the fol lowing inform t ion rel ting to ssessments or ppr is ls

38. Please provide details of your current revalidation cycle

e.g. 2012 - 2017

Appraisal Appraisal Year Date of appraisal or Organisation that Name of your appraiser

No grounds of undertook the

exemption appraisal

1 2oJ'L 1 :f . o : J GIII1C ROMfM/J R

2 20 /3 l s .o : GM C /(OMftJlil}

3 ~JJ 110r 6/V1C

4 to r z . 2 ,?,Q 1 011J7r: o «5

to 11'. /0 )J 6MC UKIf you have not undertaken appraisal, please provide the reasons for this:

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

Ev'~ Iv: ~ e~ we,aJu, C UJ/{e d +0 1Wlle ltlol ~e eM lUcl200ta/~

J

f b -cJ..p c£ug ,liJ ~U.LU) g bWclJd ~oo C8U 46J.

MJ UVXf 1LL'II/eNV ta RO/JAaJJ. \ .D. w/IIbe co UJIt

F/JrJJT /lllnp)/J/ -In uk vu/j/ h~ iLl 2-014

Page 9 of 20



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 berefused:

1. Do you have a certificate of graduation from

D 0UK or Irish Republic Medical or Dental Yes No

School or University Optometry Department

If you answer YES, proceed to Section 5

2. Do you have a certificate of graduation from

D [Z Jrecognised Medical or Dental School or Yes No

University Optometry Department abroad

which was taught in English


3. Do you have proof of having worked in an

[2J Dnglish speaking environment in which Yes No

communications were in English for at least

6 months within the last 2 years


4 Do you have proof of having lived in a multi-

D [Z Jingual household in which a relative or carer Yes No

used English as their primary form of

communication

5. If you answer YES, proceed to Section 5

6. Do you have certification of a recent pass of

one at the appropriate level from a

recognised institution (see following list of

D Wpproved courses). Yes No

(see note above)

Page 10 of 20

=



SECTION 4: English Language Knowledge (cont)

Table of Recognised Institutions and Pass/Score Required

Awarding Body Title of Qualification Pass/Minimum

Average Score

Cambridge UniversityBusiness English Certificate (BEC BEC VantageCertificate in English (ESOL)

www.cambridgeesol.org

London Chamber of Commerce

Institute Examination (LCCIEB) English for Business (EFB) EFB Level 2

www.lccieb.com

National Open College Network NOCL Entry Level Certificate in

Entry 2NOCN ESOLwww.nocn.org.uk Skills for Life

Pitmans

www.pitmangualifications.com Certificate in English Achiever B2 *CEF Leve

Trinity Certificate in IntegratedB2 *CEF Levelwww.trinitycollege.co.uk Skills in English (ISE I)

Avalon/University of Bath English Language2.5www.bath.ac.uklubeltl Assessment

Linguarama Linguarama English Test2.0www.linguarama.com

International English Language General International English7Testing System Language Testing System

www.ielts.org

International English Language International English Language TE6esting System System Academic

www.ielts.org

Educational Testing Service Test of English as a Foreign Lang80ww.ets.org (TOEFL) Internet Based Test

Educational Testing Service Test of English as a Foreign Lang200ww.ets.org (TOEFL) Computer Based Test

Educational Testing Service Test of English as a Foreign Lang450ww.ets.org (TOEFL) Paper Based Test

Educational Testing Service Test of English for International660ww.ets.org Communication (TOEIC)

Eutopia Medical Solutions Eutopia Certificate in Dental Engli

www.eutooiamedical.com Language 60

* CEF: Common European Framework

Page 11 of 20



SECTION 5: Clinical References

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.

Referee 1

~R=e=la=ti~o~n=s~h~iP~/~c=a~p~a=C~i~~K=n~o~w~n~__ ~~~~~~~~~~~~~~~~~

Length of Time Known

Name

Address

Telephone Number

Email Address

Referee 2

Name

Address

Telephone Number

Email Address

Relationshipl Capaci~ Known

Length of Time Known

Page 12 of 20



SECTION 6: Addit ional Information

I V z tJ/II/U fJll-L OJ/)E l2 G l7 J 1 c y

liolp'17JJ-£m V,4Lc£ f

Please provide any other information that the Commissioning Board may reasonably require

to determine your application

leas e c on tin u e an y o f th e ab o ve n fo nn at lo n o n a s ep arate s heet f n e c es s ar y

Page 13 of 20



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;

Page 14 of 20



SECTION7: 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

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.

Page 15 of 20



SECTION 8: Undertakings

I Undertake:

• 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

Page 16 of 20



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 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.

Name: (please print)

Signature:

Professional Registration Number:

Date:

Page 17 of 20



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. 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.

Page 18of 20



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: ;[ iftN U First Name: ROr~E~77+V /o l(/CIl- Date of birth: OS/IJ/i161

Profession: Doctor/OentistlOptometl ist (delete as appropriate)

Street Address: J ~ J+ONE COut<.T G/L.LIVIIfNJ If;'LL..

Town/City: ftffJTiI/lG.C County: HJrJri jV t 3 s . . Postcode: T N 3 zoJP

Phone No: Oo~Oi2b fg 't 2rf. E-mail Address:twhelffQJiCu.Lu. @ y a i J oo .r.

1. Have you lived or worked in a country other than the UK. European < =ountries, New Zealand, USA and Canada? appropriate)

If YES, which countries?

Dates:

2. Do you have any health issues that may affect your ability to undertake

the duties of your role?

If YES, please give details.

)::eS/NO

(delete as

appropriate)

Infectious diseases:

3.1. Tuberculosis

Have you lived continuously in the UK for the last 5

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:

K O M f t N , A - rRfttJcc G,;P-MINI/If / } . ( J J 1 X ? / 1 fIU IV 6 ,4RY ffO{u4ltrJ~

Do you have reason / 0 believe thaI you may have ~~en Y~NO (d I t I . t )exposed to tuberculosis? },rVI e e e as appropna e

Have you had TB? ¢NO (delete as appropriate)

~/NO (delete as appropriate)

Page 19 of 20



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?

Y~/NO (delete as appropriate)

YjZ$'/NO

(delete as appropriate)

4. Health vaccination records

Please tick all relevant vaccination/immunisations received and show dates.

Vaccination/lmmunisation Date received

Diptheria

Tetanus

Polio

Meningitus

MMR or

Measles

Mumps

Rubella

Haemophilus

Influenza 8

Hep 8 initial

Hep 8 second

Hep 8 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:

Page 20 of 20