Human Resources Directorate
NHS Tayside
Ninewells Hospital
Level 9
DUNDEE DD1 9SY
Telephone Number : (01382) 660111
Fax Number: (01382) 632098 or
496237
www.nhstayside.scot.nhs.uk
Date
Your Ref
Our Ref
Date as Postmark
Enquiries to
Extension
Direct Line
Email
Ilene Ferguson
33687
IF/14/13
Ilene.ferguson@nhs.net
Dear Doctor
POST OF CONSULTANT PHYSICIAN IN RESPIRATORY MEDICINE (IF/14/13)
Further to your enquiry regarding the above post, I am now pleased to enclose an information and
application pack. Your application should be submitted to this department via the following e-mail
address medicalrecruitment.tayside@nhs.net or sent by post to the above address. Please submit
the following documents when submitting your application.
-
1 copy of your CV, including the names and addresses of 3 referees, including your current
or most recent employer. It would also be helpful if you could include details of your
Registration on the Specialist Register of the General Medical Council or your expected
Date of Completion of Training.
-
Your completed Immigration Status Form and a *photocopy of your passport/current
immigration status documents – NB British and EEA Nationals must also enclose a photocopy
of their passport to verify nationality.
-
Your completed Declaration Statement in respect of Fitness to Practice and Crimminal
Convictions.
-
As an Equal Opportunities Employer, it is NHS Tayside’s policy to ensure that all applicants
are given the same consideration in relation to job selection, promotion and treatment. In
this connection, I enclose an Equal Opportunities Form which should be returned
with your application. This information is for statistical purposes only and will be kept in
strict confidence.
-
Please quote Reference Number IF/14/13 when submitting your application.
-
Please be aware that failure to enclose documentation confirming your current immigration
status will result in your application being rejected.
Headquarters
King’s Cross Hospital, Clepington Road, Dundee, DD3 8EA
Chairperson, Mr Peter Bates
Chief Executive, Professor Tony Wells
The closing date for receipt of completed applications is 17 December 2013. Owing to the number of
applications received and to make the best use of resources, we are unable to acknowledge receipt
of applications or to advise all candidates of the outcome of their application. If you have not heard
from us within 6 weeks of the closing date you may assume that, on this occasion, your application
has been unsuccessful.
Yours faithfully
Ilene Ferguson
Workforce Services Adviser
Encs
NINEWELLS HOSPITAL AND MEDICAL SCHOOL: DUNDEE
CONSULTANT PHYSICIAN IN RESPIRATORY MEDICINE (2 POSTS)
AVAILABLE FROM 24th FEBRUARY 2014
Applications are invited for two full-time Consultants to join a team of six Respiratory Physicians
based at Ninewells Hospital, the main teaching hospital for Dundee University Medical School. We
work closely with two Consultant colleagues based at Perth Royal Infirmary to provide respiratory
services to a mixed urban and rural population of 470,000 across Tayside and North Fife. Our
department has a modern integrated chest clinic with a well equipped pulmonary function laboratory,
and there is a dedicated state-of-the-art Bronchoscopy suite which provides EBUS and endobronchial
stenting. A Medical Thoracoscopy service is due to start in January 2014. We have a 30-bedded
respiratory ward supported by specialist COPD, CF, lung cancer and NIV nurses. This post will have a
1:18 on-call commitment to the Acute Medical Admissions rota (to be reviewed in 2014) and there
will be 1:6 weekend duties on the 6 bedded Medical HDU and Respiratory ward. The successful
applicant will be expected to develop a sub-specialty interest and to take an active role in
undergraduate teaching and research.
Candidates should possess MRCP and be on the Specialist Register in both Respiratory Medicine and
General Internal Medicine or be within six months of the anticipated award of CCT or CESR (CP) in
both Respiratory Medicine and General Internal Medicine at the time of interview for the post.
Further enquiries can be made to Dr Robin Smith, Clinical Lead in Respiratory Medicine on 01382
496458 and or to Dr Tom Fardon, Consultant Physician on 01382 496578
For further information on how to apply please visit www.medicaljobs.scot.nhs.uk. Applications in
the form of a CV, including names and addresses of 3 Referees should be submitted to
medicalrecruitment.tayside@nhs.net quoting Reference Number IF/14/13. You must also include
the further particular forms available via the above website.
NHS Tayside is an equal opportunities employer and positive about disabled people.
Closing Date for applications is 17 December 2013.
Interviews will be held on 24 January 2014
NHS TAYSIDE
SHORTLISTING CRITERIA FOR APPOINTMENT OF CONSULTANT PHYSICIAN IN
RESPIRATORY MEDICINE
NHS Tayside is committed to the principle of equality of opportunity in employment and accordingly
its advertising and recruitment literature will not imply that there is a preference for any one group of
applicants, e.g. by the use of discriminatory job titles or material depicting or describing certain sexual
or racial groups.
In general, the shortlisting process will be conducted so as to give all candidates equal consideration
against defined selection criteria. The following criteria will, therefore, be applied equally to all
candidates irrespective of age, sex, religion, ethnic origin or disability and avoiding judgements on the
basis of assumptions or stereotypes.
POST: CONSULTANT PHYSICIAN IN RESPIRATORY MEDICINE - IF/14/13
CRITERION
ESSENTIAL
1.
Length of Service
Appropriate time served to
achieve consultant status.
2.
Qualifications
MRCP
Accredited by relevant
Committee
Candidates should be on the
Specialist Register in both
Respiratory Medicine &
General Internal Medicine,
or be within 6 months of
achieving CCT or CESR
(CP) in Respiratory
Medicine & General
Internal Medicine at the
time of interview for the
post.
Completed, or within 6
months of completing,
accredited training in
Respiratory and General
Medicine
3.
Advanced clinical training
and experience
4.
Teaching experience
5.
Particular requirements
and/or areas of special
interest
6.
Research and publications
Previous experience of
teaching undergraduate
students and evidence of
commitment to medical
education
Desire to undertake and
develop a sub-specialty
interest
Evidence of understanding
of and participation in
DESIRABLE
MD or PhD thesis
Experience in EBUS and
medical thoracoscopy
Level 2 competency in Thoracic
Ultrasound
Expertise in Level 2 critical care
(Medical HDU)
Formal qualification in medical
education and/or evidence of
attendance at courses, meetings
etc for undertaking educational
activity
Evidence of training and
experience in a sub-specialty
field of Respiratory Medicine
which will enhance the Tayside
Respiratory Service
Evidence of presentations at
National Meetings, publications
clinical research
in peer reviewed journals.
7.
Management training
Completed management
course at appropriate level
Evidence of participation in
management activity
8.
Audit/Quality & Safety
activity
Evidence of role in local
audit activity/Quality
improvement works
Evidence of lead role in
completed and presented /
published audit projects
JOB DESCRIPTION FOR CONSULTANT PHYSICIAN IN
RESPIRATORY MEDICINE (TWO NEW POSTS)
Applicants are invited for two Consultant Physicians with an interest in Respiratory Medicine based at
Ninewells Hospital.
1. Background information
This post offers the opportunity to live and work in the Tayside region of central Scotland, widely
regarded as one of the most scenic areas in the UK with a high quality of living standards. There is
outstanding housing available in both rural and suburban settings with excellent schooling in both the
state and private sectors. The region’s countryside, mountains, beaches and numerous golf courses
provide diverse leisure opportunities with sailing, fishing, hill walking and skiing only a short drive
from the hospital. The University of Dundee is among the top universities in the United Kingdom for
biomedical research and teaching.
.
Tayside covers a wide area; the approximate population is given in the table beneath.
Area
Population
Tayside
Of which:
392,000
113,000
144,000
147,000
74,000
Angus
Dundee City
Perth and Kinross
North East Fife
NHS Tayside is widely regarded as one of the most forward looking and well run boards in Scotland.
There are two hospitals in the Delivery Unit which admit acute general medical patients and provide
in-patient services; Ninewells Hospital, Dundee and Perth Royal Infirmary. The hospitals are 20 miles
apart and there is a direct bus service to facilitate travel. There are a number of intermediate care
hospitals in Angus and Perthshire which also provide out patient services.
NINEWELLS HOSPITAL
Ninewells Hospital is a busy regional hospital serving the populations of Dundee, Angus and North
Fife. It houses most of the specialties and sub-specialties expected in a large teaching hospital with the
exception of cardiothoracic surgery.
Ninewells Hospital is the major teaching hospital for the Dundee University Medical school and most
clinical departments have a regular undergraduate teaching commitment.
Within Respiratory Medicine we have the following staff and facilities:
Respiratory Department Staffing
We currently have four full time consultants working in Respiratory medicine at Ninewells hospital.
These two new posts will increase the complement to six consultants in:
Dr R.P.Smith. Clinical Leader, Training Program Director and Regional Specialty Advisor. Sleep
disordered breathing, NIV, Interstitial Lung Disease.
Dr T.C.Fardon. Phase 1 & 2 convenor for Medical School. CF, Bronchiectasis, difficult asthma,
Oxygen, interventional bronchoscopy.
Dr S.Schembri. Sleep disordered breathing. NIV. CPET, Pleural diseases, NRS fellow with an
interest in COPD and lung cancer screening.
Dr W Anderson CPET, NRS Fellow with a research interest in Asthma, Undergraduate teaching
Dr A. Al Dabbagh. Associate Specialist. Chronic cough, tuberculosis
Prof B. Lipworth. Asthma, allergy and rhinology. Clinical pharmacology research.
Six specialist registrars in respiratory medicine - working between Ninewells and Perth Royal
Infirmary
Other staffing in Respiratory Medicine
Fully staffed Pulmonary function laboratory with 5 wte scientists/technicians
Six respiratory specialist nurse specialists serving COPD, asthma, sleep apnoea, NIV and domiciliary
oxygen services
Three Lung cancer specialist nurses, a Lung cancer coordinator and a part-time lung cancer audit
officer
Multi-disciplinary Cystic Fibrosis team
Secretarial Support and Out-patient administration staff
Respiratory Department Services
In-patient Service
We have a dedicated 30-bedded respiratory ward on the medical floor and we have access to beds in
the Clinical Investigation Unit (eg CT-guided lung biopsies, complex bronchoscopy, planned inpatient therapy (eg immunoglobulins, cyclophospamide etc).
There is a six-bedded fully equipped Medical High Dependency Unit adjacent to the AMU. It is
anticipated that one of the new consultant appointments will take on administrative duties and clinical
leadership of the MHDU.
There is also a short-stay medical unit where acute respiratory patients, with an anticipated length of
stay less than 48 hours, can be housed. Management and discharge planning of short stay respiratory
patients is generally delivered by the Acute Medicine team and the respiratory liaison nurses.
We have a close working relationship with the Intensive Care anaesthetists and with the clinical and
medical oncologists for the care of mutual patients.
Consultants participate in a rolling rota for in-patient care for two weeks at a time. During this two
week block all other duties are cancelled to allow exclusive delivery of in-patient care (daily ward
round on ward 3, review of respiratory referrals from the AMU and other specialties, thoracic
ultrasound, ward procedures and supervision of the junior medical staff). In addition, there will be a
rolling rota of morning duties on the MHDU for one week at a time. Once the new appointments are in
post it is anticipated that each consultant will commit to both of these rotas on a 1 in 6 basis with
outpatient clinics, bronchoscopy and SPA duties being undertaken during the remaining nine-out-oftwelve weeks. We have successfully run a consultant delivered in-patient model for 12 years and it has
resulted in better standards of care, better patient safety outcomes, shorter length of stay and better
opportunities for junior doctor training and supervision.
Out-patient Service
The Ninewells Hospital East Block was specifically designed and built to accommodate the chest
clinic. Five clinic rooms and a treatment area are located adjacent to consultant and secretarial offices
and the pulmonary function lab. The clinic has its own chest X-ray facility. Daily general and subspecialty chest clinics are undertaken. Clinics are supported by registrars and specialist nurses.
There is a weekly peripheral clinic undertaken in Angus which alternates between Montrose and
Arbroath.
A major review of chest out-patient services is currently underway with a view to improving
efficiency and quality of care for patients.
Bronchoscopy Service
Bronchoscopy is undertaken in a dedicated bronchoscopy suite close to the out-patient department.
The suite has a preparation and recovery room and has state-of-the-art Olympus equipment. There are
three scheduled lists per week. In addition to standard flexible bronchoscopy we provide
transbronchial biopsy, endobronchial stenting, EBUS, diathermy and photodynamic therapy. It is
anticipated that a new thoracoscopy service will also be delivered in the bronchoscopy suite.
Pulmonary Function
The pulmonary function laboratory is located in spacious accommodation within the respiratory
department in East Block and is staffed with five wte scientists/technicians. It provides a wide range of
physiologically testing that would be expected in a regional centre. In addition to standard Spirometry,
lung volume (plethysmography and nitrogen washout) and gas transfer measurements, the lab provides
forced oscillometry, bronchial challenge tests, exhaled nitric oxide fitness to fly testing, and exercise
testing. There are two weekly consultant supervised cardiopulmonary exercise test lists which are
organized in conjunction with the anaesthetic department.
In addition the pulmonary lab is responsible for undertaking sleep studies for the regional sleep apnoea
service based at Ninewells and performs approximately 900 domiciliary limited PSG (Embletta) tests
per year.
Lung Cancer
There are approximately 350 new cases of lung cancer per year. We run a pan-Tayside service with
Dr Peter Brown as the clinical lead. Specialized lung cancer clinics are held at Ninewells and are
supported by three dynamic Macmillan specialist nurses. A weekly lung cancer MDT is held in the
radiology department on a Thursday afternoon with monthly attendance by Mr Bill Walker, consultant
Thoracic Surgeon from Edinburgh Royal Infirmary.
Cystic Fibrosis
There are approximately 50 adult CF patients in Tayside and these patients are looked after by a
multidisciplinary team based at Ninewells. The service is supported by two NSD funded consultant sessions and
Dr Helen Rogers from Edinburgh Western General undertakes a weekly clinic on a Thursday morning. The
local clinical lead is provided by Dr Tom Fardon. There is a close liaison with the paediatric CF team and a
regular transition clinic is held several times per year.
Sleep Apnoea Service and NIV
The sleep apnoea service was repatriated from Edinburgh to Tayside in 2005 and is based in Ninewells
Hospital. The service receives approximately 900 new referrals per year and there are currently 2700 patients
established on CPAP. We run a streamlined service with all patients undertaking a domiciliary sleep study prior
to their clinic appointment. There are two consultant sleep clinics per week The CPAP service is supported by
an administrator, three part-time specialist nurses and a medical physics technician. There is close liaison with
the ENT surgeons who run snoring clinics, and also the orthodontic clinic in Fife who provide a nationally
funded Mandibular Advancement Device service.
In-patient NIV is an established therapy on the AMU, the MHDU and on ward three. There are 70 patients
established on home NIV under the supervision of Dr Smith and the sleep apnoea specialist nurses.
Asthma Service
Professor Brian Lipworth runs a weekly difficult asthma outpatient clinic. He also has a very active asthma and
allergy research programme and has an impressive track record of producing high quality MD theses for his
research fellows.
Dr Tom Fardon undertakes the transition asthma clinics and shares the burden of difficult asthma.
The respiratory liaison nurses also run asthma clinics and there are close ties with the extensive network of
specialist nurses who supervise asthma in primary care via the Tayside Respiratory MCN
Bronchiectasis Service
Dr Fardon has a specialist interest in bronchiectasis and non-HIV immunodeficiency and has developed a
clinical database. This service has close academic ties with Dr James Chalmers, Wellcome Trust Post-doctoral
lecturer in the College of Life Sciences. There are proposals to run a joint clinic with Professor Sara Marshall,
Consultant Immunologist.
Undergraduate Teaching
The respiratory department has a big commitment to teaching Dundee University medical students at all stages
of their training. This involves both formal and informal teaching, and examining within the respiratory
curriculum. Professor Brian Lipworth is the Respiratory system Convenor, and Dr Tom Fardon is the Phase 1
and 2 convenor for the Medical School. Dr Anderson holds one ACT session within his job plan and there will
be a further ACT resource given to the department. There may be the opportunity to take on an extended
teaching role with protected time funded by ACT monies.
Post-graduate Teaching
The respiratory department is responsible for the training Foundation doctors, Core Medical Trainees and GP
trainees attached to the unit. It is expected that all consultants will undertake Clinical and Educational
Supervisor roles within the eastern Deanery Post-Graduate office. Appropriate training for, and appraisal of,
these roles will be offered.
There are six specialist registrars in Respiratory Medicine in Tayside (Dr Robin Smith is TPD). This post will
also involve clinical and educational supervisor duties for these trainees.
Educational Meetings
There is a weekly X-ray meeting held each Tuesday morning at 8.30am
There is a weekly lunchtime Medical Grand Round held on Thursday lunchtimes during the academic term.
There is a weekly respiratory Academic Meeting held every Friday lunchtime. This meeting hosts a variety of
audit presentations, case presentations, journal club and external speakers.
There is a three-monthly regional Clinical Respiratory Meeting held in Perth or Dundee.
Research
There are number of on-going research programmes within the department. Two of current consultants (Drs
Schembri and Anderson) hold 4 sessions each of research sessions. Furthermore, the respiratory department has
close ties with Dr James Chalmers, . There is an active audit programme and the department contributes to a
number of national audit initiatives.
Participation in research and audit is actively encouraged.
Part of the funding (two sessions) for these two new consultant posts comes from the Clinical Research Centre
(CRC) based on the Ninewells site. The CRC hosts a number of clinical trials involving biologic therapies in
development and the respiratory department is committed to delivering two clinical sessions (one full day) of
senior medical cover per week. This commitment will be shared by the two new post-holders.
PERTH ROYAL INFIRMARY
The Respiratory department in Ninewells Hospital works closely with the Chest Physicians at Perth Royal
Infirmary to provide a Pan-Tayside service
Respiratory medicine
Respiratory medicine services in Perth and Kinross are centred on Perth Royal Infirmary where there
are two physicians (Dr Peter Brown and Dr Peter Williamson) with an interest in respiratory medicine.
There is an ST3 trainee in respiratory medicine and specialist nurses in COPD/asthma (Maureen Blair)
and lung cancer (Gillian Sandeman). There is dedicated secretarial support. The pulmonary function
laboratory provides a service for measurement of dynamic and static lung volumes (plethysmography
and nitrogen washout) and gas transfer, bronchial challenge and exhaled nitric oxide, six minute walk,
cardiorespiratory exercise testing and fitness to fly and is co-located with non-invasive cardiology
investigation with integrated clinical physiologists. There is a weekly bronchoscopy list with
anaesthetist support for interventional bronchoscopy work. The service has expanded to include
autofluorescence and endobronchial ultrasound.
Cross-sectional imaging with CT and MR is on site, together with a new nuclear medicine facility. CT
guided lung biopsies are undertaken on site and PET-CT in Dundee. There are excellent links to the
Thoracic Surgery service in Edinburgh Royal Infirmary.
Indicative Contracted Sessions total 10 (8 DCC/1 ACT/1 SPA)
AMU duties and weekend cover (including OOH and on call commitments)
1
Supporting professional activities
1
Bronchoscopy
0.5
Outpatients
1.5
Administration (clinic letters & results etc)
0.5
Multidisciplinary meeting
0.5
In-patient duties
3
Teaching (ACT) and / or research (CRC)
2
Specimen Timetable for 42 weeks /year (each post will combine A,B & C job plans)
Job Plan A – 8 weeks out of 12 – “off-ward” (24 weeks per year)
A.M.
P.M.
CRC
CRC
Monday
Admin
Outpatient clinic
Tuesday
Teaching
Bronchoscopy
Wednesday
Outpatient Clinic
Lung cancer MDT
Thursday
SPA time
off
Friday
Job Plan B – 2 weeks out of 12 – “ward 3 duties” (9 weeks per year)
A.M.
P.M.
Ward 3 round
Referrals and ward duties
Monday
Ward 3 Round
Referrals and ward duties
Tuesday
Ward 3 round
Referrals and ward duties
Wednesday
Ward 3 Round
Referrals and ward duties
Thursday
Ward 3 Round
Referrals and ward duties
Friday
Job Plan C – 2 weeks out of 12 – “HDU duties” (9 weeks per year)
A.M.
P.M.
HDU
+
Referrals
Admin
Monday
HDU + Referrals
Outpatient Clinic
Tuesday
HDU + Referrals
Bronchoscopy
Wednesday
HDU + Referrals
Lung cancer MDT
Thursday
HDU + Referrals
off
Friday
On-call commitments and weekend work
1:18 oncall for AMU and medical floor (the on-call consultant rota is being reviewed in 2014 and it is
anticipated that the Respiratory physicians may leave this rota)
1:6 weekend duties (HDU/ward 3/ward 42 ward round on Saturday + Sunday)
Further Information
Dr Robin Smith
01382 496458
Clinical Lead for Respiratory Service
robinsmith@nhs.net
Dr Tom Fardon
01382 496578
Consultant Respiratory Physician
Medical Unit, PRI
tom.fardon@nhs.net
RESPONSIBILITY FOR RECORDS MANAGEMENT
All records created in the course of the business of NHS Tayside are corporate records and are public
records under the terms of the Public Records (Scotland) Act 1937. This includes email messages and
other electronic records. It is your responsibility to ensure that you keep appropriate records of your
work in NHS Tayside and manage those records in keeping with the NHS Tayside Records
Management Policy and with any guidance produced by NHS Tayside specific to your employment.
IMPORTANT NOTICE
IMMIGRATION STATUS
Please be aware that all job applicants, including British and EEA nationals must enclose photocopies of their
passport (outside front cover, page containing personal details and resident permit/visa stamps). If you have
been issued with a Biometric Residence Permit, a photocopy (front and back of card) must also be enclosed.
Shortlisted applicants will be required to bring their original documents with them, for inspection, when attending
for interview.
1
Are you a national from Austria, Belgium, Cyprus,
Denmark, Finland, France, Germany, Greece,
Iceland, Ireland, Italy, Liechtenstein, Luxembourg,
Malta, Netherlands, Norway, Portugal, Spain,
Sweden, United Kingdom or Switzerland?
YES
NO
2
Are you a national from the Accession States (A8
Countries) – Czech Republic, Estonia, Hungary,
Latvia, Lithuania, Poland, Slovakia or Slovenia?
YES
NO
3
Are you a national from the Accession States
(A2 Countries) – Bulgaria and Romania?
YES
NO
If you have circled ‘NO’ to the above sections please tick the box which relates to your current
immigration status, and provide expiry dates:
Tick
Status
Expiry
Date
I hold a Tier 1 (General) Visa as a highly skilled
worker
I require a Certificate of Sponsorship
I hold refugee status
I have indefinite leave to remain in the United
Kingdom
I have right of abode
Any other immigration status – please specify:
Print Name: ………………………………….........................
Signature:…………………………………………………….
Date: ………………………………………………………….
APPOINTMENT AND REVIEW PROCEDURES
Declaration Statements and Statements of Policy
Statement of Policy regarding fitness to practise proceedings by a licensing/regulatory body and
relating to criminal investigations in the UK or overseas.
Registration with the General Medical Council or General Dental Council imposes on doctors and
dentists the duty to provide a good standard of medical care for, and to behave appropriately,
towards patients. NHS Employers also 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 establish 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.
Applicants for posts in the NHS are exempt from the Rehabilitation of Offenders Act 1974. Application
forms will include a declaration for applicants to complete declaring any previous or pending
prosecutions or convictions, including those considered ‘spent’ under this Act. Forms will also include
a declaration of any cautions or bind overs.
We also need to establish if you have been the subject of any fitness to practise proceedings in the
past, or any fitness to practise proceedings are being contemplated, by a licensing or regulatory body
in the UK or another country and this is also reflected in the declaration.
This information will be treated in confidence and will not debar 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 others factors
that 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, an order binding you over or 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 [General Dental Council] for
consideration if such a discrepancy came to light.
If you would like to discuss what effect any previous convictions, police investigations or fitness to
practise proceedings taken or being taken either in the UK or by an overseas licensing or regulatory
body might have on your application, you may telephone the Employment Services Adviser, Medical
Staffing, on 01738 473302, in confidence, for advice.
Model Declaration Statement regarding
(a) any criminal offence, being bound over or cautioned, or current proceedings which might
lead to a conviction, an order binding you over or a caution and
(b) fitness to practice proceedings taken or being currently contemplated by a
licensing/regulatory body
1. Have you been convicted of a criminal offence, been bound over or cautioned or are currently the
subject of any police investigations, which might lead to a conviction, an order binding you over or a
caution in the UK or any other country?
YES/NO
Note: Applicants for posts in the NHS are exempt from the Rehabilitation of Offenders Act 1974.
You are required to declare prosecutions or convictions, including those considered ‘spent’ under this
Act.
If yes, please provide details of the criminal offence, order binding you over or caution or details of
any current proceedings which might lead to a conviction, an order binding you over or a caution,
including approximate date, the offence, and the authority and country which dealt with the offence.
2. To the best of your knowledge have you been or are you currently subject to any fitness to practise
proceedings by an appropriate licensing or regulatory body in the UK or any other country?
YES/NO
If yes, please provide details of the nature of proceedings undertaken, or contemplated, including
approximate date of proceedings, country where proceedings were undertaken and the name and
address of the licensing or regulatory body concerned.
I hereby declare that the information given here is true.
Signature:______________________________________________
Date:__________________________________________________
NHS TAYSIDE
EQUAL OPPORTUNITY MONITORING FORM
Job reference number: IF/14/13
Equal opportunities monitoring
We want to ensure that our job opportunities are open to all. The only way we can ensure
there is equal opportunity is to monitor applications we receive, and compare the profile of
people who apply with those appointed. Therefore this form asks you for your ethnic
origin, gender, disability, religion, sexuality and age. The information you provide is
confidential and is not used in the selection process. It will be separated from the
rest of your application when we receive it.
1) If you are currently an employee of this NHS Board, will getting this job be a
promotion?
Yes

No

2) You are:
Female 
Male 
3) Have you undergone, are you undergoing or do you intend to undergo gender
reassignment? For example, this includes having changed your sex (gender).?
Yes

No 
Prefer not to say 
4) What is your age?
I am ___ years old, and my date of birth is: _ _ / _ _ / _________
5) Do you have a physical or mental health condition or disability that:


Yes

has a substantial effect on your ability to carry out day to day activities?
has lasted or is expected to last 12 months or more?

No 
If you answered ‘yes’ please tick if it is either of the following:
Learning Disability
Long standing illness
Mental health condition
Other (please describe):

Prefer not to say 



Physical impairment
Sensory impairment


Again, if yes, please describe any particular arrangements you would need for your
work location:
(Continued on next page)
1.
2-
6) What is your ethnic group?
Choose one section from A to F, then tick the appropriate box to indicate your cultural
background
A: White
 Scottish  Irish
 Gypsy Traveller
B: Mixed
 Any mixed background
 Other British
 Polish
 Any other White background
C: Asian; Asian Scottish; Asian British
 Pakistani
 Indian
 Chinese
 Bangladeshi  Any other Asian background
D: Black; Black Scottish; Black British
 Caribbean
 African
 Any other Black background
E: Other ethnic background
 Any other background
F: Prefer not to answer 
7) To which religion, religious denomination or body do you actively belong?
 (Christianity)- Church of Scotland
 (Christianity) - Roman Catholic
 Hinduism
 Sikhism




 Judaism
 Islam
 No religion (none)
Christianity (Other)
Other faith / belief
Buddhism
Prefer not to answer
8) Which of the following best describes your sexual orientation?
 Bisexual
 Heterosexual
 Other
 Gay Man
 Lesbian/Gay Woman
 Prefer not to answer
9) Where did you see the Advertisement for this Post?
Newspaper (which one?)
Professional Journal (which one?)
Vacancy Bulletin
SHOW (NHS Scotland Website)
Job Centre Plus
Other (please specify)
Thank you.
equaloppsmonform