Human Resources Directorate
NHS Tayside
Ninewells Hospital
Level 9
DUNDEE DD1 9SY
Telephone Number : (01382) 660111
Fax Number: (01382)
www.nhstayside.scot.nhs.uk
Date
Your Ref
Our Ref
28 November 2014
Enquiries to
Extension
Direct Line
Email
Ilene Ferguson
33687
01382 660 111 Ext 33687
Ilene.ferguson@nhs.net
IF/11/14
Dear Doctor
POST OF PART-TIME SPECIALTY DOCTOR IN PALLIATIVE MEDICINE (IF/11/14)
Further to your enquiry regarding the above post, I am now pleased to attach an information and application
pack.
Your application should be submitted to this department, by emailing the documents below to
medicalrecruitment.tayside@nhs.net quoting Job Reference Number IF/11/14 in the subject box.

A copy of your current CV including the names, addresses and contact details of 3 referees

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. Failure to enclose documentation confirming your current immigration status will
result in your application being rejected.

Your completed Declaration Statement in respect of Fitness to Practice and Criminal Convictions

Your completed Equal Opportunities Form. This information is for statistical purposes only and will
be kept in strict confidence.
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.
The closing date for receipt of completed applications is 6 December 2014. 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
Employment Services Adviser
Headquarters
Ninewells Hospital, Dundee DD1 9SY
Chairman, Mr Sandy Watson, OBE DL
Chief Executive, Ms Lesley McLay
SPECIALTY DOCTOR IN PALLIATIVE MEDICINE
PART-TIME, PERMANENT POST (4 SESSIONS)
ANGUS COMMUNITY BASED POST
An exciting opportunity has arisen for a suitable applicant to join the NHS Tayside Palliative Medicine
Team working within the Angus Community. The post is available from 1 February 2015.
Angus is a rural area encompassing the towns of Carnoustie and Arbroath in the South, Forfar and
Kirriemuir centrally and Brechin, Edzell and Montrose in the North. The Angus Palliative Care Service
is Consultant led and comprises 3 full time Macmillan Nurses, experienced Day Care Nurses, a
dedicated Occupational Therapist as well as input from Community Physiotherapists, Complimentary
Therapists and Volunteers.
The Angus Palliative Care Service delivers care to the largely rural population (around 110, 000
people) through a unique peripatetic service. This integrated model involves provision of 4 outpatient
clinics per week in Arbroath, Forfar and Stracathro which run in parallel with Day Services
programmes. The service provides support to the Angus primary care teams including 5 community
hospitals, one of which is a purpose built 4 bedded in patient palliative care unit run by General
Practitioners and experienced nurses.
The NHS Tayside Palliative Care Service provides a range of Inpatient, Outpatient and Day Therapy
Services for patients with palliative care needs across Tayside. Within the wider service, new
initiatives include an Acute Palliative Care Unit in Ninewells Hospital, extension of Palliative Care
undergraduate education in Dundee University Medical School, a new Master of Public Health
(Palliative Care Research) course, a newly built education unit at Roxburghe House and a range of
service developments including renal supportive care service, a cognitive behavioural therapy skills
network and developing research links with the University of Dundee.
Applicants must have experience in palliative care.
Informal enquiries to: Dr Katharine Thompson, Medical Lead for Angus Palliative Care (01382 423
132, katharine.thompson@nhs.net) or Dr Deans Buchanan, Clinical Lead, Ninewells Hospital (01382
423 055, deansbuchanan@nhs.net)
For information on how to apply please visit medicaljobs.scot.nhs.uk. Applications in the form of a
current CV, including name and addresses of 3 referees should be submitted to
medicalrecruitment.tayside@nhs.net quoting Reference Number IF/11/14. You must also include
the further particular forms available from www.medicaljobs.scot.nhs.uk website.
NHS Tayside is an equal opportunities employer and positive about disable people.
Closing Date: 6 December 2014
Continued
Specialty Doctor in Palliative Medicine
Permanent, part time post (4 sessions per week)
Based in the Angus Community
DESCRIPTION OF THE POST
1. Introduction
NHS Tayside has a Tayside Wide Specialist Palliative Medicine Service which supports patients and staff in all
health care settings including: home, nursing homes, community hospitals, two specialist palliative care units
and two University teaching hospitals.
This post is a permanent post for 4 session per week based in the Angus community. This represents
an opportunity to join a dynamic palliative medicine team and to contribute to a well developed,
modern palliative care service. It would allow successful applicants to experience community based
palliative care practice.
2. Background
Tayside is a region in Eastern Scotland, and is conveniently situated for travel to the three other large
cities in Scotland, Aberdeen, Edinburgh, and Glasgow. London is accessible by rail within six hours
and by air in just over one hour. The area is strikingly beautiful, with good and relatively inexpensive
housing in either a rural or a city environment. The two major conurbations in Tayside are Dundee
(150,000) and Perth (42,000). The area provides excellent access to hill walking, water sports, and
golfing, as well as providing for cultural interests via several local professional repertory theatres and
regular concerts are provided by visiting national orchestras.
Tayside Palliative Care Service
NHS Tayside serves a population of approximately 400,000 people. The Angus population is around
110,000. It is a large geographical area with its population scattered over an area of approximately
100 miles by 80 miles. This in itself presents an exciting challenge in offering access to specialist
palliative care to those at home, in hospitals, in community hospitals in urban or rural areas in
Tayside. There are approximately 1,200 deaths from cancer per year. Tayside Palliative Care Service
aims to provide quality care appropriate to location [home, hospice, nursing home or hospital] and
level of complexity. Education and telephone advice for all health professionals are core activities of
the service. The Tayside Palliative Care Service operates across four main clinical hubs: Angus
Palliative Care Service, Roxburghe House & Dundee Palliative Care Service, Ninewells Palliative Care
Service and Cornhill Macmillan Centre & Perth and Kinross Palliative Care Service. The Tayside
Palliative Medicine Team work across each of these clinical hubs as a unified team and provides
specialist palliative care support across Tayside out of hours.
Specialist Palliative Care in Angus
The Angus Palliative Care Service provides a community based service through an integrated model
of four outpatient clinics per week (Stracathro, Forfar and Arbroath); day services which include
delivering goal-related programmes, complimentary therapies and AHP input (Stracathro, Forfar and
Arbroath) and Specialist Palliative Care Nurse services provided by 3 full time Macmillan Nurses. The
service provides specialist support to 5 community hospitals including a 4 bed purpose built palliative
care unit run by experienced nursing staff and local General Practitioners. The Angus service links
Continued
into GP run palliative care beds on the Forfar site as required and link to Roxburghe House for
admissions to specialist palliative in-patient care.
Specialist Palliative Care in Dundee
Roxburghe House, Dundee
Roxburghe House is a 24-bed purpose built NHS palliative care unit in the Royal Victoria Hospital,
Jedburgh Road, Dundee. It has day care and clinic facilities and a newly developed education centre.
It is situated in the west of the city less than one mile from Ninewells Hospital and Medical School.
Roxburghe House has an experienced Multidisciplinary Team consisting of a clinical co-coordinator,
medical staff (described in detail later), nursing staff, one advanced nurse practitioner, occupational
therapist, physiotherapist, pharmacist, counselor, volunteer manager, complementary therapies
coordinator, chaplain and service manager. The Community Macmillan Nursing Team is based in
Roxburghe House and is aligned to Primary Healthcare Teams in the Dundee area. The Out of Hours
District Nursing Service is also based at Roxburghe House to ensure continuity of patient-centred
care for people with palliative care needs.
Ninewells Palliative Care Service
The Ninewells Palliative Care Service consists of an advisory service (1.9 WTE Consultants, 0.6 WTE
Specialty Doctor and 2.6 WTE Clinical Nurse Specialists) and a unique 3 bed Acute Palliative Care Inpatient Unit. Ninewells is a large University teaching hospital, which includes all main specialties. It
also hosts the Regional Cancer Centre, the Medical School and the Postgraduate Centre. It also
contains new Cancer Research Facilities of the University of Dundee. Tayside also benefits from the
presence of the Maggies Centre in the grounds of Ninewells Hospital which provides a wide range of
support for patients with cancer.
Specialist Palliative Care in Perth & Kinross
Cornhill Macmillan Centre
Cornhill Macmillan Centre is a 10 bed purpose built NHS palliative care unit in the grounds of Perth
Royal Infirmary, Taymount Terrace, Perth. It has day care and clinic facilities. It has an experienced
Multidisciplinary Team consisting of a service manager, medical staff (described in detail later),
nursing staff, two advanced nurse practitioners, occupational therapy, physiotherapist, pharmacist,
social worker, counselor, complementary therapies and chaplain. The team is closely linked with the
Macmillan Nursing Service for both Perth and Kinross communities and Cornhill houses the out of
hours district nursing service.
Perth Royal Infirmary Palliative Care Service
Perth Royal Infirmary is a University teaching hospital located approximately one mile from the city
centre. It provides a range of out-patient and in-patient services including acute admissions, general
surgery and medicine, medicine for the elderly and on-site chemotherapy and dialysis. The palliative
care team based in Cornhill provide specialist palliative care to patients in Perth Royal Infirmary.
Continued
3. Current Issues and Developments
The service aim is to continue to provide access to specialist palliative care for anyone with needs whether at
home or in hospital, in an urban or rural location. We are currently evaluating a restructure of our regional
working into a managed clinical network framework. We wish to build on the existent collaborative and
integrated working across Tayside and embed a regional approach to standards whilst retaining local
flexibilities for modes of delivery. In addition to this there are several ongoing developments:
a. Acute Palliative Care Unit and the Palliative Care Service in Ninewells University Teaching Hospital
b. Undergraduate Teaching in palliative medicine.
The service has the allocation of 4 Consultant ACT sessions (Addition Cost of Teaching).
Undergraduate teaching is being developed in line with the proposed national curriculum for
palliative care. The teaching programme will involve lectures, small group work, clinical placements
and web based teaching.
c. Master in Public Health (Palliative Care Research)
An Master in Public Health (Palliative Care Research) has been developed in conjunction with the
Department of Public Health, The University of Dundee.
http://www.dundee.ac.uk/postgraduate/courses/palliative_care_research.htm
d. Research
Projects are on going in the patient dignity question, supportive renal care, acute hospital care,
nursing home care and care of those with illness other than cancer. There are strong collaborative
links with the University of Dundee and further research projects with Dr Bridget Johnston, Reader in
Palliative Care, University of Dundee relating to the dignity care pathway, dignity conserving
therapies and patient centred care.
e. Renal Supportive Care Service
This recently developed service provides supportive care for patients with renal failure through a
collaborative service model with the NHS Tayside renal team. Dr Claire Douglas provides palliative
medicine leadership and service delivery for this service and works alongside a clinical nurse
specialist in renal supportive care.
f. Macmillan Cognitive Behavioural Skills Network
Focused CBT approaches in palliative care have been evidenced to enhance care without the
requirement for in-depth training in these skills. This 3 year project is aimed at establishing a network
of professionals across our service who have additional skills in CBT (but not trained to practioner
level) that can be used within the remit of their current roles. In particular this focuses on nonpharmacological approaches to dyspnoea, anxiety, fatigue and uncertainty. The network is lead by Dr
Betty Ellis and supported by a clinical psychologist based in the Maggies Centre (Dr Lesley Howells).
g. Other developments
In addition to the vibrant service provision of core palliative care there are developments relating to
cardiac failure supportive care, lung cancer supportive care and spinal analgesia.
Continued
4. Current Substantive Medical Staff in Palliative Medicine and Advanced Nurse Practioners
Consultants
Dr Katharine Thompson
Dr Rosie Conway
Dr Deans Buchanan
Dr Fiona McFatter
Dr Claire Douglas
Dr Abi Walton
Dr Elinor Brabin
8.5 PA
6.5 PA
Fulltime
9.5 PA
7.5 PA
6.5 PA
6.5 PA
Roxburghe House, Dundee and Angus
Roxburghe House, Dundee
Ninewells Palliative Care Service
Ninewells Palliative Care Service
Cornhill and Perth & Kinross
Cornhill and Perth & Kinross
Roxburghe House and Dundee
Associate
Specialists
Dr Betty Ellis
5 PA
Roxburghe House and Dundee
Dr Barbara Sinclair
8 PA
Roxburghe House and Dundee
Dr Anne Watson
1 PA
Roxburghe House and Dundee
Dr Anne-Marie Todd
Dr Anne Kelly
Dr Jane Boyden
Dr Fiona Paterson
6.5 PA
4.5 PA
4.5 PA
6 PA
Cornhill and Perth & Kinross
Cornhill and Perth & Kinross
Cornhill and Perth & Kinross
Ninewells
Dr Karen Harvie
Fulltime
Tayside
Dr Claire Holmes
Fulltime
Tayside
Specialty
Doctors
Specialty
Trainees
Foundation
Year 1
Doctors
4 month rotation
Fulltime
2 FY doctors based in
Roxburghe House
Roxburghe House
ANPs
Faye Hamilton
Gill Tomison
Alison Liddell
Fiona Barnett
Cornhill and Perth & Kinross
Cornhill and Perth & Kinross
Roxburghe House
Roxburghe House
5. The Posts
i) Position:
ii) Responsible to:
Fulltime
Fulltime
Fulltime
Fulltime
Part time (4 sessions) Specialty Doctor in Palliative Medicine
Dr Deans Buchanan
Dr David Dorward
Dr Bill Nicoll
Dr Andrew Russell
(Clinical Lead for Palliative Medicine)
(Clinical Director, Dundee, CHP)
(General Manager, Perth CHP)
(Medical Director, NHS Tayside)
iii) Duties of the Posts:
Clinical duties include:
Working with the Angus palliative care team to provide advice to the primary care teams of
community based patients. This will include delivering 3 outpatient clinics per week (Tuesdays,
Wednesdays and Thursdays), providing domiciliary visits where required, attending a weekly
Multidisciplinary Team Meeting as well as providing clinical support for Macmillan Nurses and GPs.
Cross cover for other units in NHS Tayside may be required during periods of leave; and such other
Continued
clinical duties as may be reasonably be requested. Clinical work is supported by the medical lead for
Angus and the Roxburghe House team.
On call
There are currently no on-call duties for this post. An indicative job plans for the post is shown below
iv) Continuing Professional Development
The post holder will be expected to participate in continuing medical education as advised by the
medical Royal Colleges. There is a video-linked cross Tayside CPD education programme in place.
There is weekly education available in both Ninewells and in Roxburghe House.
v) Research
The person appointed may participate in research projects within the service or undertake research
on his/her own account. There would be opportunities to participate in the Master of Public Health
(Palliative Care Research) course and supervision of clinical research projects. There are strong links
to the University of Dundee and this is an area we wish to develop further.
vii) Quality Issues. The post holders will be expected to contribute to the setting and monitoring of
quality standards within the services.
viii) Audit and Clinical Effectiveness
The post holders will be expected to contribute to the audit programme within the services.
ix) Staff Training and Teaching
The post holders will be expected to support junior doctors in training who may be attached to the
services and contribute to the teaching of undergraduates and postgraduates. The post holder will be
expected to work in partnership with the Macmillan Practice Educators and contribute to the multiprofessional modules in Symptom Control and Communication and other relevant courses delivered
from the Palliative Care Education Unit, Cornhill Macmillan Centre and onsite in both hospitals
x) Management
The post holders will be expected to work with the service managers and professional colleagues to
ensure the efficient and effective running of the Palliative Care Service.
xi) Personal Development
The Board has a policy in operation helping personnel develop their full potential. There is a Tayside
scheme for annual appraisal of medical staff, which contributes to revalidation.
xii) Cover for holidays
So far as is consistent with the proper discharge of the above duties the post holder undertakes to
deputise from time to time for absent colleagues. The post holder undertakes, exceptionally, to
perform additional duties in occasional circumstances. The post holder undertakes, exceptionally to
be available for such irregular commitments outside normally rostered duties as are essential for
continuity of patient care.
Indicative Job Plan: Example of the weekly timetable for Specialty Doctor in Angus
This may change with the many new developments and teaching planned in the palliative care
services.
Continued
Angus Palliative Care Service – 4 PA
0900-1300
1300-1400
Mon
Tue
Wed
Thu
Stracathro - Meeting with Day Services and
Macmillan Nurse for North Angus,Out
patient Clinic, Domiciliary visit if needed
Forfar - Meeting with Day Services and
Macmillan Nurse for Forfar and
Kirriemuir,,Out patient Clinic, In patient
reviews in Strathmore Hospice if required
(4 bedded GP run unit)
Stracathro - Angus Multidisciplinary Team
Meeting with Consultant, Day services and
Macmillan Nurses ,Out patient Clinic,
Domiciliary visit if needed
Liaison and clinical admin work
Post clinic SPA (until 1500)
Liaison and clinical admin work
Fri
7. Educational Opportunities
An extensive postgraduate programme takes place weekly in Ninewells, Perth Royal Infirmary and
the Royal Victoria Hospital. Video linking is available in Angus sites. The post-holder can contribute to
teaching and GPST training in palliative care.
Ninewells Hospital and Medical School has an extensive medical and nursing library
8. Responsibility for Record Management
All records created in the course of business of NHS Tayside are corporate records and are public
records under the terms of 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.
9. Further Information and Applications
Should you wish to arrange a visit or to have further information please contact either:
Dr Katharine Thompson, Consultant in Palliative Medicine, Medical Lead for Angus Palliative Care.
Roxburghe House, Dundee
Telephone
Email
(01382) 423 132
Katharine.thompson@nhs.net
Dr Deans Buchanan, Consultant in Palliative Medicine, Clinical Lead for Palliative Care, South Block,
Level 7, Ninewells Hospital, NHS Tayside, Dundee DD1 9SY
Telephone
Email
(01382) 632 055
deansbuchanan@nhs.net
Applications in the form of one copy of your up to date CV containing the names, addresses and
email addresses of three referees and your completed Immigration, Equal Opportunities and Fitness
to Practice forms should be emailed to medicalrecruitment.tayside@nhs.net quoting the job
reference number in the subject box.
Continued
NHS TAYSIDE
SHORTLISTING CRITERIA FOR APPOINTMENT OF SPECIALTY DOCTOR - MEDICAL AND DENTAL STAFF
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.
The short listing process will be conducted so as to give all candidates equal consideration against defined selection
criteria. The following criteria will, therefore, be applied to all candidates irrespective of age, gender, religion, ethnic
origin or disability and avoiding judgements on the basis of assumptions or stereotypes.
The following framework is suggested as a basis for preparing the short listing criteria for use by the Clinical/ Group
Director in conjunction with the Chairperson of the Appointments Committee. An alternative format may be used if this is
felt to be desirable provided that the basic principles of objectivity and equality are observed.
POST : PART-TIME SPECIALTY DOCTOR IN PALLIATIVE MEDICINE (IF/11/14)
CRITERION
1.
Length of Service
2.
Qualifications
EXPECTED MINIMUM
Applicants must be post registration and
have experience of palliative care E
Full GMC registration & licence to practice.
E
Accredited by relevant Committee
3.
Specific training in advanced symptom
control. D
Advanced clinical training and experience
Experience in palliative care, general
medicine, general practice or pain service E
Training and experience in clinical teaching
and learning in small and large groups. D
4.
Teaching experience
5.
General experience
6.
Particular requirements and/or areas of special interest
Palliative care unit, clinic, home visit and
consultations in teaching hospital experience.
D
Must be willing to travel across Tayside and
perform on call duties. E
Satisfactory enhanced disclosure from
Disclosure Scotland and clearance by the
Occupational Health Service E
Evidence of audit and research
D
7.
Research and publications
8.
Management training
Not required
9.
Interpersonal Skills
Evidence of effective team working and
leadership
E
NOTE: Criteria marked with an “E” on the enclosed documents have
been identified as essential for the post concerned.
Continued
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: ………………………………………………………….
Continued
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.
Continued
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:__________________________________________________
Continued
NHS TAYSIDE
EQUAL OPPORTUNITY MONITORING FORM
Job reference number: IF/11/14
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:


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?

Yes

No

Prefer not to say

If you answered ‘yes’ please tick if it is either of the following:
Learning Disability
Long standing illness
Mental health condition



Physical impairment
Sensory impairment


Other (please describe):

Again, if yes, please describe any particular arrangements you would need for your
work location:
(Continued on next page)
Continued
-
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
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
Medical Jobs Website (medicaljobs.scot.nhs.uk)
Doctors.net
Other (please specify)
Thank you.
 Gay Man
 Lesbian/Gay Woman
 Prefer not to answer