APPLICATION FOR A CLINICAL ACADEMIC POST
Application for the post of:
Ref:
(see advertisement)
DECLARATION
I confirm that the information provided is true and correct, and understand that providing false or misleading
information, or canvassing University employees or those of partner organisations involved in the Brighton and
Sussex Medical School, will disqualify me from appointment or, if appointed, could lead to termination of
employment.
Additionally I understand that as I am applying for a post within the Brighton and Sussex Medical School (a joint
venture between the Universities of Brighton and Sussex with the involvement of local NHS trusts) it may be
necessary for the information I have supplied to be shared with these other organisations. Under the terms of
the Data Protection Act I give my consent, by signing below that the information I have supplied be shared with
the University of Brighton and/or local NHS trust as necessary as part of the selection process. If you have any
queries about this matter, you should contact the HR Division, University of Sussex, Tel 01273 877769.
I understand that the information provided on this form may be entered onto a computerised database.
Signed_______________________________________________
Date ________________
If you are offered and formally accept a post, you must not then withdraw unless there is sufficient time to make
other arrangements to cover the duties of the post. Failure to comply with this requirement may result in a
complaint to the GMC.
YOUR DETAILS
Surname:
Forename(s):
Previous surname:
(1) Home Address:
Preferred Name:
Title:
Post Code:
(2) Preferred correspondence address:
………………………………………………………………………… Post Code:
Home telephone no:
Work telephone no:
Mobile telephone no:
Can we contact you at work?
Email:
When is the best time to contact you?
Where did you see this post advertised?
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YES/NO
General Medical Council registration and Medical Defence Insurance
Type of registration:
Award date (or expected
date) of CCST/JCP/TGP:
Name in which you are registered:
GMS Number:
Name of Medical Defence Organisation:
Renewal date:
Date of expiry of cover:
Higher Medical Training
Training Received:
Dates:
Speciality/Specialities:
CURRENT OR MOST RECENT EMPLOYMENT
Name and address of employer:
Postcode:
Employer’s telephone number:
Job Title:
Locum: YES/NO
Current Salary:
Consultant seniority level:
Current Threshold point:
Date of transfer to current
Threshold point:
£
Transfer date to new consultant contract:
Length of contract
(if fixed term):
Period of notice required:
Details of any discretionary points, distinction awards or Clinical Excellence Awards
currently held:
Date Award effective from:
Level of Award received:
Expiry Date:
Name of NHS Trust Award held with:
Speciality:
Reason for leaving current/ most recent employment:
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Duties and Responsibilities of current/most recent employment:
Please list the main duties and responsibility of your current/most recent employment, making sure that you
have included details with regard to both the academic and clinical elements of your role. Continuing on a
separate sheet if required.
PREVIOUS EMPLOYMENT
Employer:
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Position held:
Dates:
HIGHER EDUCATION and QUALIFICATIONS
Academic Qualifications
Dates
From
(M/Y)
To
(M/Y)
Academic
Qualification
Subject(s)
Level/
Grade
Institution/provider
Professional Qualifications
List both completed professional qualifications and those currently being undertaken.
Dates
From
(M/Y)
To
(M/Y)
Professional
Qualification
Subject(s)
Level/
Grade
Institution/provider
Post Graduate student supervision
Number of postgraduate students supervised and
fields of research:
Degrees obtained/in progress:
Research Funding obtained (within the last five years)
From
(M/Y)
4
To
(M/Y)
Title of Project/Funding (£) secured:
Funding Body
REFERENCES
Please give details of three referees, one of whom must be your current / most recent employer. For
applicants currently holding a consultant contract, one referee must be the Medical Director of the
relevant NHS trust. Please ensure your referees are in a position to respond promptly as no appointment will
be made without receipt of satisfactory references. Please indicate if we can take up references immediately.
(1) Title and name of referee:
Position held:
Contact address:
Post code:
Working relationship:
May we contact this referee prior to interview?
At which company/organisation?
YES/NO
Dates:
Email:
Tel no (day):
Fax no:
(2) Title and name of referee:
Position held:
Contact address:
Post code:
Working relationship:
May we contact this referee prior to interview?
At which company/organisation?
YES/NO
Dates:
Email:
Tel no (day):
Fax no:
(3) Title and name of referee:
Position held:
Contact address:
Post code:
Working relationship:
May we contact this referee prior to interview?
At which company/organisation?
YES/NO
Dates:
Email:
Tel no (day):
Fax no:
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Please complete the following information. This information will be kept separately from your job application
form. If you are short-listed the information provided below may be discussed at interview.
Candidate No. ___________
(office use only)
CRIMINAL INVESTIGATIONS and FITNESS to PRACTISE
All those appointed to the Brighton and Sussex Medical School who will be engaged in clinical practice will be
subject to a Disclosure & Barring Service (DBS) check. We treat this information in accordance with our
obligations outlined in the DBS Code of Practice and undertake to treat all applicants for positions fairly.
Information concerning applicants who are not selected will be destroyed. We undertake to treat all applicants
fairly and operate a policy on the recruitment of ex-offenders. Registration with the General Medical Council
imposes on doctors the duty to provide a good standard of medical care for, and behave appropriately towards,
patients. Our NHS partners 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 know 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. Those working in the NHS are exempt from the Rehabilitation of
Offenders Act, 1974 (Exceptions) Order 1975 (as amended in 2013) by SI 2013 1198. You are required to
declare prosecutions or convictions, including those that are ‘protected° under this Act. This information will be
treated in confidence and will not debar you from 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.
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 a conviction, and order binding you over, of 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 for consideration if such a discrepancy came to light.
If you would like to discuss what effect any previous convictions, police investigation or fitness to practice
proceedings may have on your application, you should contact the Human Resources Division.
Do you have any convictions, cautions, reprimands or final warnings that are not “protected”?
YES/NO
Have you ever been bound over or cautioned: YES/NO
Are you currently the subject of criminal proceedings or fitness to practise proceedings? YES/NO
If YES please give details on a separate sheet.
RIGHT TO WORK IN THE UK
Do you need a visa in order to work in the UK? YES/NO
If YES please give details if you already have a visa.
We may be able to issue a Certificate of Sponsorship subject to the necessary criteria being met.
TERMINATION OF PREVIOUS EMPLOYMENT
Have you ever left a job for any reason other than resignation, termination due to ill health or the end of a fixed
term contract?
YES/NO
If YES please state reason:
PREVIOUS ASSOCIATION WITH UNIVERSITY OF SUSSEX
Have you ever worked at, studied at or had any other association with the University of Sussex? YES/NO
If YES please tick box below
a)
b)
c)
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have been previously employed by the University of Sussex,
have studied at the University of Sussex
other (please give details)
FURTHERING DISABILITY EQUALITY AT THE UNIVERSITY
As part of the University’s commitment to supporting disabled people in the recruitment process, we offer an
interview to anyone with a disability who meets the minimum essential criteria as set out in the Person
Specification for the job.
The Equality Act defines a disabled person as someone who has a physical or mental impairment which has
a substantial and adverse long-term effect on his or her ability to carry out normal day to day activities.
Please answer the questions below:
(a)
Using the definition above do you consider yourself to have a disability?
Yes
No
(b)
Would you like to be considered under the University’s policy to offer an
interview to anyone with a disability who meets the essential criteria for
the job?
Yes
No
The information you provide at this stage will be treated with the utmost confidence by appropriate staff in
Human Resources. If you have indicated ‘yes’ in (b) above this information will be shared with members of
the selection panel in the event that you meet the essential criteria for the job but have not been shortlisted
for interview.
If you are successful in being invited for an interview you will be given the opportunity to discuss any specific
requirements you might have in relation to your disability.
If you are have any queries on the above, please contact Human Resources on 01273 877769 or at
human.resources@sussex.ac.uk.
HR use only - Please complete if candidate has asked to be considered under the University’s policy
to offer an interview to anyone with a disability who meets the essential criteria for the job.
Job Ref:
Met the essential criteria
YES / NO
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Equal opportunities monitoring form
The University of Sussex is committed to equality of opportunity and will consider applications solely on the
basis of merit and the ability to do the job. The data collected here is used for equal opportunities
monitoring and will be kept separately from your application form. It will assist the University to support
and encourage under-represented groups and promote diversity. Anonymised data will also be provided to
the Higher Education Statistics Agency (HESA) which is the central source for the collection and
dissemination of statistics about publicly funded UK higher education.
Any personal data collected here will be held securely and confidentially and only used in accordance with
the provisions set out in the Data Protection Act 1998.
Please complete the sections below by circling the categories or ticking the boxes where appropriate.
Date of Birth
Country of Birth
Nationality
Gender
Male
Female
Female
Postcode where you live now
Disability
Yes
Have you a disability that is covered by the Equality Act 2010?
No
When answering this question please note that under the Equality Act 2010 you are considered to be
disabled if you have a mental or physical impairment which has a substantial and long term adverse effect
upon your ability to carry out normal day to day activities.
If Yes what is your impairment? Please tick any of the following that apply:
Specific learning disability, eg dyslexia,
dyspraxia
General learning disability eg Downs syndrome
Cognitive impairment eg autistic spectrum
disorder
Long-standing illness or health condition eg cancer,
HIV, diabetes, chronic heart disease, epilepsy
Mental health condition eg depression,
schizophrenia
Physical impairment or mobility issues
Deaf / serious hearing impairment
Blind / serious visual impairment
Other type of disability not mentioned above
Please specify
Ethnic Background
Please note that ethnic background is not about nationality, place of birth or citizenship. It is about colour
and broad ethnic grouping. People may belong to any of the groups listed below. Please tick any of these
that apply.
White
White British
White Irish
Other White background
Black or Black British
Caribbean
African
Other Black background
Asian or Asian British
Indian
Pakistani
Bangladeshi
Chinese
Other Asian background
Mixed
White and Black Caribbean
White and Black African
White and Asian
Other Mixed background
Other ethnic group
Arab
Other ethnic background
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Candidate Number _______
RETURNING YOUR APPLICATION
Thank you for your interest in employment at the Brighton and Sussex Medical School, a School of the
University of Sussex.
Completed application forms must be returned by the closing date shown on the job advertisement to:
Human Resources Division
The University of Sussex
Falmer
Brighton
East Sussex
BN1 9RH
Fax: 01273 877401
Email: bsmsrecruitment@sussex.ac.uk
We will only acknowledge receipt of completed applications where a stamped addressed envelope is sent to
us for this purpose.
If you have not been contacted within 6 weeks of the closing date, please assume that your
application has been unsuccessful.
If you are a disabled person and require adjustments to be made to the selection process please contact us
on 01273 877324 to discuss your requirements. Please let us know if you require the documentation in an
alternative format or by email.
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