THE LONDON DEANERY
in association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries
Dear Applicant
Applic...
THE LONDON DEANERY
in association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries
• Please email the co...
THE LONDON DEANERY
in association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries
*****Important inform...
THE LONDON DEANERY
in association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries
*****Important inform...
THE LONDON DEANERY
in association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries
*****Important inform...
THE LONDON DEANERY
in association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries
*****Important inform...
Candidate Number : ____________________________
To applicants: you should complete your application form after carefully r...
Candidate Number : ____________________________
ORGANISATION AND
PLANNING
• Ability to prioritise
clinical need
• Ability ...
Candidate Number : ____________________________
• INTERPERSONAL
SKILLS (see patients as
people, empathise, work
co-operati...
Candidate Number : ____________________________
Please complete this application form carefully. CVs and additional pages ...
Candidate Number : ____________________________
Section C – Equal Opportunities Monitoring Form
We are committed to elimin...
Candidate Number : ____________________________
Disability Discrimination Act 1995
The Disability Discrimination Act prote...
Candidate Number : ____________________________
D: Language Skills
You are required to demonstrate skills in written and s...
Candidate Number : ____________________________
E: Right To Work in the United Kingdom
Some applicants may be considered b...
Candidate Number : ____________________________
If Other than above – Please specify the immigration category (Max 50 word...
Candidate Number : ____________________________
F: Fitness to Practise and Criminal Investigations
We aim to promote equal...
Candidate Number : ____________________________
If you would like to discuss what effect any previous convictions, police ...
Candidate Number : ____________________________
Section G – Referees
Reference reports are not used for scoring purposes d...
Candidate Number : ____________________________
Reference 2
Please give full
address
Post Details (post held by applicant)...
Candidate Number : ____________________________
Entry Criteria checklist
You should select the following checklist to indi...
Candidate Number:
___________________
APPENDIX A
Country of Origin
Afghanistan
Albania
Algeria
American Samoa
Andorra
Ango...
Please complete this application form carefully. CVs and additional pages will not be accepted.
THE LONDON DEANERY
in asso...
                 
                 
                 
                 
                 
Please give details of any
resea...
Section J – Previous Appointments
Please list posts in chronological order (most recent first) and state if locum / tempor...
Section K – Clinical Knowledge and Experience
Please list here those procedures you can perform which you feel are relevan...
Section L – Aims and career objectives
Please indicate the reasons why you wish to pursue a career in Radiology and indica...
c) Give a recent example of a clinical situation in which you feel team working could have been improved (up to
100 words)...
b) Publications (shortlisted candidates will be asked to bring copies of all publications to the interview). Please
list y...
Where the appointment involves substantial access to children and /or vulnerable adults, the
appointment is subject to a p...
To the applicant : this shows the scoring system to be used for short-listing from the application form. If the short-list...
ESSENTIAL CRITERIA Maximum Score
(Range 0 –2)
Applicant’s
score
Assessed in
this Section
of the
Application
Form
DESIRABLE...
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Paediatric Radiology Candidate Pack (080/56)

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Paediatric Radiology Candidate Pack (080/56)

  1. 1. THE LONDON DEANERY in association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries Dear Applicant Application to Specialty Training in Paediatric Radiology Thank you for applying to a training programme in the London Deanery in association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries. This letter explains the appointment process we use. This pack contains: a) A description of the training programme. b) A person specification which describes the attributes for which we are looking. This is based around the GMC's document “Good Medical Practice”. Please note that you must be able to offer all of those attributes described as essential if you are to be considered for shortlisting and . or appointment. c) An application form. d) A shortlisting score sheet (for information only) which will show you how the shortlisting committee will judge your application against the requirements of the person specification. Please read this pack carefully. As you fill out the application form you are advised to answer the questions and complete the form with reference to the person specification. Please note: • CVs and additional pages will not be accepted and therefore the application form should be fully and carefully completed. • When completing the applications form you must not make any adjustments to the spaces allowed for the responses. • The minimum type size which can be used is 10 point. • Failure to comply with the above instructions will result in your application being rejected. • Where equivalent qualifications or experience are being offered, it is essential that the candidate should provide confirmation of this from the relevant College or Faculty in the UK at interview. • The number of applicants called for interview will depend both on the number of the vacancies in the programme and on the shortlisting scores achieved by applicants during this recruitment. • The interview process will explore those areas included in the specification about which we need further information Dr Fiona Moss Director of Medical and Dental Education Commissioning
  2. 2. THE LONDON DEANERY in association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries • Please email the completed application form to : Jack Pegg, Recruit12@londondeanery.ac.uk Tel: 0207 866 3182, Fax: 0207 866 3276. • Reference number : 080/56 • Closing date and time: 21st June 2010 at 12:00 midday (UK Local Time) • Interviews will be held on : 20th July 2010 • Please let your referees know that you are applying for this post, so that if you are shortlisted, they will be prepared to respond to our reference request. • Successful applicants need to be aware that changes could occur during the progression of the training programme. The principal aim will always be to deliver the best quality training experience. • Applicants need to be aware that although trainees’ preferences are considered when making decisions on placements, final decisions take into account the service needs of all sites within our training programmes. Thank you for applying to this training programme. Good luck with your application. Yours sincerely Jack Pegg Medical Recruitment Administrator Dr Fiona Moss Director of Medical and Dental Education Commissioning
  3. 3. THE LONDON DEANERY in association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries *****Important information***** It is essential that all applicants read this page Dear Applicant Thank you for your interest in this training programme. The application form is enclosed. It is essential that you give careful thought to your answers and complete each section accurately. Please note that you may be asked to provide evidence to support the statements you have made in any part of your form. Please pay particular attention to the following and complete the corresponding sections in the application form as appropriate. Visa status – International Medical Graduates On 7 March 2006 the Home Office announced changes to the immigration rules which have an effect on Postgraduate Doctors and Dentists and which we must take into account during our recruitment activity. From 7 March 2006 we have to recruit doctors and dentists from the UK and the EEA (including those doctors and dentists who have been accepted onto the Highly skilled Migrant Programme / Tier 1 who are not prohibited from taking employment as a Doctor in Training) before we recruit migrant doctors from outside EEA countries. However, if there are posts available on any of the London Deanery training programmes and no doctor or dentists with permanent residence or HSMP / Tier 1 (as described above) status in this country is able to take up the post, fully trained international medical graduates with the appropriate qualifications may also be considered for appointment. (Please see A Points-based System : Making Migration Work for Britain, pages 1 & 8). The above statements represent our current understanding of the effects of the changes. For further information regarding the new immigration strategy please contact the Home Office’s Border Agency Enquiry Bureau on telephone 0870 606 7766 or by email: UKBApublicenquiries@ukba.gsi.gov.uk Fitness to Practise When completing that part of the application form headed “Fitness to Practise and Criminal Investigations”, you should note that all doctors are exempt from the Rehabilitation of Offenders Act and you are therefore required to complete the section of the application form which related to your Fitness to Practise status. If you have any queries about any of the statements in this section please do not hesitate to contact the Medical Workforce Department at the London Deanery as stated in the Fitness to Practise section. Any query you may have will be treated confidentially. Criminal Records Bureau checks (CRB) CRB checks are carried out by the employing Trust in accordance with the guidelines set out by NHS Employers (http://www.nhsemployers.org). All offers of appointment are subject to CRB checks. The London Deanery will inform you first employing Trust of your offer of appointment, however on receiving your offer you should make contact with the Medical Staffing Department at your Trust to arrange for a CRB check The London Deanery would like to wish you good luck with your application and your future career. Updated 10th January 2010 Dr Fiona Moss Director of Medical and Dental Education Commissioning
  4. 4. THE LONDON DEANERY in association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries *****Important information***** THE LONDON DEANERY General Statement of Policy General Statement of Policy regarding fitness to practise proceedings by a licensing/regulatory body and relating to criminal records. Registration with a professional body, such as the General Medical Council or General Dental Council, imposes a duty on health care professionals to provide a good standard of medical care for, and behave appropriately towards, patients. NHS employers also have a duty to ensure that patients receive a good standard of medical care and to take all practicable steps to ensure the safety of patients and staff. In order to assess job related risks, the London Deanery needs to establish if applicants who may be offered a placement on a Specialty training programme have a criminal record in the UK or in another country that they can lawfully be required to disclose. Applicants for Specialty training posts are exempted from the Rehabilitation of Offenders Act 1974, and can therefore be asked to disclose “spent” convictions that they would otherwise not have to declare. Applicants for Specialty training posts will also be asked if they are “bound over”, have received a police caution, warning or reprimand and whether they have been charged with a criminal offence that is not yet disposed of. Prior to making an appointment, the London Deanery also needs to establish if applicants for Specialty training posts have ever been disqualified from the practice of a profession or required to practise it subject to specified limitations following fitness to practise proceedings by a regulatory body in the UK or in another country, and whether they are currently the subject of any investigation or proceedings by any body having regulatory functions in relation to health/social care professionals, including such a regulatory body in another country. Where such a position involves regular care, training, supervision or sole charge of persons aged under 18 or vulnerable adults (as defined by The Police Act 1997 (Enhanced Criminal Record Certificates)(Protection of Vulnerable Adults) Regulations 2000), applicants will also be asked whether they are currently the subject of any police investigation in the UK or any other country of which they are aware. Where the position is a “regulated position” under the terms of the Protection of Children Act 1999 (as amended by the Criminal Justice and Court Services Act 2000), checks will be carried out in accordance with the Protection of Children Act 1999. Anyone whose name is on the list is legally barred from working with children. It is an offence for such a person to knowingly apply for, offer to do, accept or to do such work. If you are appointed to a Specialist Registrar post, you will be subject to a Criminal Records Bureau (CRB) check. Applicants are encouraged to declare criminal conviction information and any other matters that are, or that might be, relevant to the position for which they are applying at an early stage in the appointment process. Dr Fiona Moss Director of Medical and Dental Education Commissioning
  5. 5. THE LONDON DEANERY in association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries *****Important information***** All applicants are also expect to inform the London Deanery if, before taking up any position offered to them, they are charged with a criminal offence in the UK or another country. The London Deanery is an equal opportunities recruiter, and all applications will be decided fairly and on merit. Information declared will be used to consider the applicant’s suitability for the position. Information supplied will be treated in confidence and will not be used as the sole criterion to decide an applicant’s fitness for the position. Unless an appointment is prohibited by law, a criminal conviction will not automatically debar the applicant from appointment. Applicants will be given an opportunity to discuss any information supplied before a final decision is taken regarding their appointment. However, an applicant may not be selected if the selection panel considers that the information declared renders that person unsuitable for the position for which they have applied. In reaching such a decision the London Deanery will consider the nature of the record/action, its relevance to the position applied for, and any other information the applicant wishes to provide. The information declared will be treated in compliance with the Data Protection Act 1998. NOTE: Failure by an applicant to provide accurate and truthful information is considered to be a serious matter. Where it is found that a person has intentionally or recklessly provided inaccurate information or withheld information relevant to his/her position, this may disqualify them from an appointment, or if appointed, dismissal and referral to the appropriate professional regulatory body. If you would like to discuss what effect any criminal record or fitness to practise proceedings might have on your application, you may telephone Jane Appleyard, telephone 0207 866 3105, in the Medical Workforce department, in confidence or email fitnesstopractise@londondeanery.ac.uk . Any information you provide regarding criminal investigations, convictions or fitness to practise proceedings will be kept confidential. If the Deanery considers that the information provided may have a bearing on your appointment and that the information needs to be considered by the selection panel, we will discuss this with you in advance. If we do not raise this information with you, this is because we do not believe that it should be taken into account. In that event, you still remain free, should you wish, to discuss the matter with the interviewing panel. Prior to making a final decision concerning your application, we shall discuss with you any information declared by you that we believe has a bearing on your suitability for the position. The London Deanery aims to promote equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of race, gender, marital status, religion, disability, sexual orientation or age. We undertake not to discriminate unfairly against applicants on the basis of criminal conviction or other information declared. Dr Fiona Moss Director of Medical and Dental Education Commissioning
  6. 6. THE LONDON DEANERY in association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries *****Important information***** The Data Protection Act 1998 requires us to provide you with certain information and to obtain your consent before processing sensitive data about you. Processing includes: obtaining, recording, holding, disclosing, destruction and retaining information. Sensitive personal data includes any of the following information: criminal offences, criminal convictions, criminal proceedings, disposal or sentence. The information that you provide on the Declaration Form in the application form will be processed in accordance with the Data Protection Act 1998, and will only be used for the purpose of determining your application for this position. Once a decision has been made concerning your appointment, we will not retain this Declaration Form longer than is necessary (i.e. until you leave your post/programme or the recruitment episode is closed). The Declaration Form will be kept in securely and in confidence, and access to it will be restricted to designated persons within the Medical Workforce Department of the London Deanery and other persons who need to see it as part of the selection process and who are authorised to do so. The information may be passed to your employing trusts. Dr Fiona Moss Director of Medical and Dental Education Commissioning
  7. 7. Candidate Number : ____________________________ To applicants: you should complete your application form after carefully reading this person specification which is based on the GMC’s “Good Medical Practice” THE LONDON DEANERY in association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries SPECIALTY TRAINING IN PAEDIATRIC RADIOLOGY PERSON SPECIFICATION ESSENTIAL WHEN EVALUATED DESIRABLE WHEN EVALUATED QUALIFICIATIONS • Eligible for registration with the GMC • MBBS (or equivalent) • FRCR by date of shortlisting panel OR • Eligible to be registered as a Specialist with the GMC AF AF AF AF • BSc (or other intercalated degree), other degrees / qualifications • MRCP, MRCS or equivalent • Research MD, PhD AF AF AF CLINICAL EXPERIENCE • At least 4 years Radiology experience • Resuscitation training in last 3 years of clinical experience eg ALS etc AF AF • Broad clinical experience AF CLINICAL SKILLS • Experience of and competent at practical procedures • experience of clinical risk management • Competent to work without direct supervision where appropriate • Clear, logical thinking showing an analytical / scientific approach AF, I/V, Ref AF, I/V I/V, Ref AF, I/V KNOWLEDGE • Appropriate level of clinical knowledge • Shows knowledge of evidence informed practice • Shows awareness of own limitations Ref I/V I/V, Ref • Demonstrates breadth of experience and awareness in and outside specialty / medicine • Demonstrates use of evidence informed practice AF, I/V I/V
  8. 8. Candidate Number : ____________________________ ORGANISATION AND PLANNING • Ability to prioritise clinical need • Ability to organise oneself and own work • Completed audit project in last 2 clinical years • Experience and ability to work in multi- professional teams I/V, Ref I/V, Ref AF AF, I/V, Ref • Understanding of NHS, clinical governance & resource constraints; management / financial awareness; experience of committee work • Active involvement in audit • Information technology skills • Leadership / administrative responsibilities AF, I/V AF, I/V AF AF TEACHING SKILLS • Evidence of teaching experience; enthusiasm for teaching; exposure to different groups / teaching methods AF, I/V ACADEMIC / RESEARCH • Research experience • Presentations, publications, prizes and honours I/V AF, I/V CAREER PROGRESSION • Progression of career consistent with personal circumstances • Demonstrates a commitment to and knowledge of the specialty AF AF, I/V START DATE • • Available to start on post on 1st May 2010 AF, I/V PERSONAL SKILLS • COMMUNICATION & LANGUAGE SKILLS (the ability to communicate with clarity and intelligibility in written and spoken English; ability to build rapport, listen, persuade, negotiate) AF, I/V, Ref • DECISIVENESS/ ACCOUNTABILITY (ability to take responsibility, show leadership, make decisions, exert appropriate authority) I/V, Ref
  9. 9. Candidate Number : ____________________________ • INTERPERSONAL SKILLS (see patients as people, empathise, work co-operatively with others, open and non- defensive, sense of humour) AF, I/V, Ref • USES A NON- JUDGMENTAL APPROACH TO PATIENTS AND COLLEAGUES regardless of their sexuality, ethnicity, disability, religious beliefs or financial status Ref • FLEXIBILITY (able to change and adapt, respond to rapidly changing circumstances) I/V, Ref • RESILIENCE (able to operate under pressure, cope with setbacks, self- aware) I/V, Ref • THOROUGHNESS (is well prepared, shows self- discipline/commitment, is punctual and meets deadlines) I/V, Ref • SHOWS INITIATIVE/ DRIVE/ENTHUSIASM (self-starter, motivated, shows curiosity, initiative) AF, I/V, Ref • PROBITY (displays honesty, integrity, aware of ethical dilemmas, respects confidentiality) I/V, Ref PHYSICAL REQUIREMENTS • Meets professional health requirements pre- employment health screening
  10. 10. Candidate Number : ____________________________ Please complete this application form carefully. CVs and additional pages will not be accepted. THE LONDON DEANERY in association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries APPLICATION FORM SPECIALTY TRAINING PROGRAMME IN PAEDIATRIC RADIOLOGY (080/56) PART ONE Section A – Personal Details Surname :      Forenames :      Title :      If previously known by another name, please specify :      Home Address :      Address for correspondence :      Home telephone number :      Home Fax number :      Email address :      Mobile phone number :      Work telephone number :      Work fax number :      Date available to start if offered the post       Section B – General Medical Council Registration Do you have, or are you eligible for, FULL GMC registration? GMC Number Renewal date Name in which you are registered                         If not registered with the GMC at time of application, will you be eligible for FULL registration by the time of appointment? Please give details below.      
  11. 11. Candidate Number : ____________________________ Section C – Equal Opportunities Monitoring Form We are committed to eliminating unlawful discrimination from employment and selection practices. We will take steps to ensure that employees are recruited, trained and promoted on the basis of ability, the requirements of the job and the need to maintain an efficient and effective service. To monitor this policy, we require the following information which will only be used for this purpose. It will form no part of the interviewing process, and will be treated in strict confidence. This sheet will be detached from your application form on receipt. If you are appointed, it will be kept on your training record, otherwise it will be destroyed 6 months after the appointments committee. IF YOU DO NOT COMPLETE THIS SECTION OF THE APPLICATION FORM, YOUR APPLICATION WILL NOT BE CONSIDERED COMPLETE AND WILL NOT BE PUT FORWARD FOR SHORTLISTING DATE OF BIRTH:       AGE:       GENDER: please select Male Female Transgender Male Transgender Female I do not wish to disclose my gender Race Relations (Amendment) Act 2000 I would describe my ethnic origin as: (please select) Asian or Asian British Mixed Other Ethnic Group Bangladeshi White & Asian Chinese Indian White & Black African Any other ethnic group Pakistani White & Black Caribbean Please specify below: Any other Asian background Any other mixed background       Black or Black British White Undisclosed African British I do not want to disclose my Caribbean Irish Ethnic origin Any other Black background Any other white background Employment Equality Regulations 2003 Please select the option which best describes your sexuality Lesbian / Gay woman Heterosexual Gay Man I do not wish to disclose my sexual orientation Bisexual Please indicate your religious belief Atheism Jainism Judaism Buddhism Sikhism Hinduism Christianity Other Islam I do not wish to disclose by religion / belief
  12. 12. Candidate Number : ____________________________ Disability Discrimination Act 1995 The Disability Discrimination Act protects disabled people. This includes people with long-term health conditions. If you tell us that you have a disability we can make reasonable adjustments to where you work and your work arrangements or at interview. Do you consider yourself to have a disability? Yes I do not wish to disclose this information No Please state the type of impairment which applies to you. People may experience more than one type of impairment, in which case you may indicate more than one. If none of the categories apply, please mark “other”. Physical impairment Learning Disability / Difficulty Mental Health Condition Sensory impairment Long-standing illness Other If you have a disability, do you require any specific arrangements to enable you to attend for interview? ---Please Select--- If YES, (I have a disability which I consider relevant to my application) please describe any adaptation or adjustment you consider an employer should make to accommodate you if you are shortlisted for interview / appointed on a separate piece of paper and place in a sealed envelope addressed to Jane Appleyard, Medical Workforce, London Deanery, Stewart House, 32 Russell Square, London WC1B 5DN. Please mark the envelope “CONFIDENTIAL”. Alternatively, you may send an email to Confidentialenquiries@londondeanery.ac.uk , Please also let us know if you need any special arrangements to enable you to attend for interview. If you have a disability, provided you meet the minimum criteria as specified in the Person Specification, do you wish to be considered under the Guaranteed Interview Scheme? Pleas see the Disability Discrimination Act for more details If you tick Yes you must email ConfidentialEnquiries@londondeanery.ac.uk to ensure your eligible for the guaranteed interview scheme. Failure to do so may result in you not being granted a guaranteed interview. Emails to this address are managed in strict confidence and will not be shared with the interview panel. Please see the Disability Discrimination Act for more details. ---Please Select--- Do you wish to apply for a deferred start date because you are registered for a higher degree (eg PhD, MD)? ---Please Select--- Date available to start post – please give reasons       Do you wish to be considered for less than full-time training? If you select “Yes” as you wish to be considered for less than full-time training, this information will not be made known to the selection panel but you will need to formally apply for less than full-time training via the deanery Flexible Training Team. Further guidance and details on how to apply can be found on the deanery website ---Please Select---
  13. 13. Candidate Number : ____________________________ D: Language Skills You are required to demonstrate skills in written and spoken English that are adequate to enable effective communication about medical and/or health topics with patients, colleagues and the public. Evidence of English language proficiency – If you select ‘No’ to both boxes then you must complete the ‘Other’ Section. Country of Primary Medical Qualification (See list within Appendix A)       Was your undergraduate training taught in English? ---Please Select--- Have your language skills been tested through the IELTS (International English Language Testing System) to the minimum overall score required as per the person specification1 ? ---Please Select--- Overall Score     Speaking Score     Listening Score     Reading Score     Writing Score     Date IELTS taken (dd/mm/yyyy)       Have all components of the IELTS been completed in one sitting? ---Please Select--- Other – Please provide details below – provide evidence of your English Language proficiency (max 50 words)       Where did you see this post advertised? BMJ London Deanery website NHS Jobs 1 The Applicant must have achieved as a minimum the following scores in the academic International English Language Testing System (IELTS) in a single sitting within 24 months at time of application – Overall 7, Speaking 7, Listening 7, Reading 7, Writing 7
  14. 14. Candidate Number : ____________________________ E: Right To Work in the United Kingdom Some applicants may be considered before others on the basis of immigration status, in accordance with guidance from the UK Border Agency. If you require Tier 2 sponsorship in order to take up the offer of a place on this training programme and you are subject to the Resident Labour Market Test, your application will not be considered in this round of recruitment. Applicants in this category should consider re-applying to any further rounds of recruitment in this speciality. 1a Are you a United Kingdom (UK) national ---Please Select--- 1b Are you a European Community (EC) or European Economic Area (EEA) national?2 ---Please Select--- 1c Are you a Bulgarian or Romanian national *Please complete the immigration status applicable ---Please Select--- 2 If not, do you have evidence of entitlement to enter and work permanently in the United Kingdom without restriction i.e Indefinite Leave to remain – free from immigration control? ---Please Select--- If you have selected no to both of the above please mark with a cross the boxes below in the Personal Status section which define your immigration status and complete start and expiry date of your permit, unless you also tick yes to the question below, in which case you need to go to the Partner/Civil Partner/Spouse Status section. 3 Are you on a dependents visa* *If you have answered YES please complete the Partner/Civil Partner/Spouse status section ---Please Select--- Nationality (Choose country pertaining to your nationality - see country list – Appendix A)       Personal Status Select Status Start Date Expiry Date Bulgarian or Romanian National with Blue registration certificate             Highly Skilled Migrant Programme (dates of endorsement stamp in passport)             Points based system – with endorsement “no employment as a doctor in training”             Points based system – no endorsement regarding “employment as a doctor in training”             Permit Free Training / Postgraduate doctor or dentist             Refugee in the UK             Work Permit / Tier 2             Tier 4 – UK Graduate             Tier 4 – Not a UK Graduate             Tier 4 – Studying for a Masters/PHD             UK ancestry             Student visa holder             Other immigration categories i.e. Overseas government employees, Innovators etc.             2 For the purposes of this form Switzerland has been included within the EEA national category
  15. 15. Candidate Number : ____________________________ If Other than above – Please specify the immigration category (Max 50 words – 455 Characters)       Partner / civil partner / spouse status Please complete this section if you have answered YES to question 3 above. Select Status Start Date Expiry Date Partner / civil partner or spouse of UK / EEA3 citizen             Non EEA national partner / civil partner or spouse of EEA4 citizen exercising a treaty right             Partner / civil partner or spouse of HSMP holder             Partner / civil partner or spouse under the Points based system – with endorsement “no employment as a doctor in training”             Partner / civil partner or spouse under the Points based system – no endorsement regarding “employment as a doctor in training”             Partner / civil partner or spouse of student visa holder – student visa holder must have 12 months or more leave to remain             Partner / civil partner or spouse of other immigration categories i.e. refugees, work permit holders, Overseas government employees, Innovators etc.             If Other than above – Please specify the immigration category (Max 50 words – 455 Characters)       If you are shortlisted, you will be required to produce the original documents (passports, page with the stamp and letter from the Home Office) on the interview day. 3 For the purposes of this form Switzerland has been included within the EEA national category
  16. 16. Candidate Number : ____________________________ F: Fitness to Practise and Criminal Investigations We aim to promote equality of opportunity and are committed to treating all applicants for positions fairly and on merit regardless of race, gender, marital status, religion, disability, sexual orientation or age. We undertake not to discriminate unfairly against applicants on the basis of criminal conviction or other information declared. Prior to making a final decision concerning your application, we shall discuss with you any information declared by you that we believe may have a bearing on your suitability for the position. If we do not raise this information with you, this is because we do not believe that it should be taken into account. In that event, you still remain free, should you wish to discuss the matter with the interviewing panel. As part of assessing your application, we will only take into account relevant criminal record and other information declared. However, please be advised that any failure to declare relevant information relating to your fitness to practice may well lead to your application being withdrawn, and/or any employment or training programme placement terminated. The Data Protection Act 1998 requires us to provide you with certain information and to obtain your consent before processing sensitive data about you. Processing includes: obtaining, recording, holding, disclosing, destruction and retaining information. Sensitive personal data includes but is not limited to any of the following information: criminal offences, criminal convictions, criminal proceedings, disposal or sentence. The information that you provide in this Declaration Form will be processed in accordance with the Data Protection Act 1998. It will be used for the purpose of determining your application for this position. It will also be used for purposes of enquiries in relation to the prevention and detection of fraud. Once a decision has been made concerning your appointment, we will not retain this Declaration Form longer than is necessary (ie until you leave the post you are applying for / programme or the recruitment episode is closed). This Declaration Form and any information provided relating to a positive declaration will be kept securely and in confidence, and access to it will be restricted to designated persons within the Recruitment Department and other persons who need to see it as part of the selection process and who are authorized to do so. If successfully appointed to a training post, this information may be passed to your employing trusts. Rehabilitation of Offenders Act 1974 Before you can be considered for appointment in a position of trust as a Specialty Trainee on a Deanery programme, we need to be satisfied about your character and suitability. This post is considered a “regulated activity” within the terms of the Safeguarding Vulnerable Groups Act 2006, and appointments made after 26 July 2010 will be subject to registration with the Independent Safeguarding Authority (ISA). This will become a mandated requirement from 1st November 2010. Only successfully registered employees will be permitted to continue their training and employment after that date. It is vitally important that you read, understand and answer the questions asked in this section by selecting each box – please read the accompanying notes carefully before completing this part of the form. Please answer all of the following questions. If you answer “YES” to any of the questions, please ensure you provide full details via email to fitnesstopractise@londondeanery.ac.uk by the closing date if application. Failure to do so may result in your application being withdrawn. In this email please indicate clearly the programme for which you are applying, the question(s) to which you have provided a positive response. The position for which you have applied is exempted from the Rehabilitation of Offenders Act 1974. This means that you must declare all criminal convictions, including those that would otherwise be considered “spent”. Answering “YES” to any of the questions below will not necessarily bar you from appointment. This will depend on the nature of the position for which you are applying and the particular circumstances.
  17. 17. Candidate Number : ____________________________ If you would like to discuss what effect any previous convictions, police investigations or fitness to practice 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: Jane Appleyard at the Deanery on 020 7 866 3105 in confidence. 1 Are you currently bound over or have you ever been convicted of any offence by a Court or Court-Martial in the United Kingdom or in any other country? NB You do not need to tell us about parking offences. ---Please Select--- 2 Have you ever received a police caution, reprimand or final warning? ---Please Select--- 3 Have you been charged with any offence in the United Kingdom or in any other country that has not yet been disposed of? Please note: you must inform us immediately if you are charged with any offence in the United Kingdom or in any other country after you complete this form and before taking up any position offered to you. You do not need to tell us if you are charged with a parking offence. ---Please Select--- 4 Are you aware of any current police investigation in the United Kingdom or in any other country following allegations made against you? ---Please Select--- 5 Are you aware of any current NHS Counter Fraud and Security Management Service investigation following allegations made against you? ---Please Select--- 6 Have you ever been investigated by the Police, CFSMS or any other Investigatory Body resulting in a caution, conviction or dismissal from your employment? (Investigatory bodies include Local Authorities, Customs & Excise, Immigration, Passport Agency, Inland Revenue, Department of Trade & Industry, Banks and Building Societies, General Life Insurance Companies – this list is not exhaustive, and you must declare any investigation conducted by an Investigatory Body). ---Please Select--- 7 Have you ever been dismissed by reason of misconduct from any employment, office or other position previously held by you? ---Please Select--- 8 Have you ever been disqualified from the practice of a profession or required to practice subject to specified limitations / conditions / warnings following fitness to practice proceedings by a regulatory or licensing body in the United Kingdom or in any other country? ---Please Select--- 9 Are you currently the subject of any investigation or fitness to practice proceeding by any employer, any licensing or regulatory body in the United Kingdom or any other country? ---Please Select--- 10 Are you subject to any other prohibition, limitation, or restriction that means we are unable to consider you for the position for which you are applying? ---Please Select--- If you have answered “YES” to any of the questions, please provide full details on a separate sheet and place in a sealed envelope addressed to Jane Appleyard, Medical Workforce, London Deanery, Stewart House, 32 Russell Square, London, WC1B 5DN. Alternatively, you can email the details to fitnesstopractise@londondeanery.ac.uk . Please indicate clearly the number(s) of the question (s) that you are answering. Please mark the envelope “CONFIDENTIAL” You are reminded that if you are appointed to a training post or programme, you will have a continuing responsibility to inform your employer(s) and the Postgraduate Dean of any new criminal convictions, police investigations or fitness to practice proceedings that arise in the future. Note: if you wish to withdraw your consent at any time after completing this Declaration Form, please contact Jane Appleyard at the Deanery (see above).
  18. 18. Candidate Number : ____________________________ Section G – Referees Reference reports are not used for scoring purposes during shortlisting or interview, but will be reviewed during the selection process and again prior to confirmation of appointment for successful applicants. The reference process is designed to check the accuracy of your previous employment and training history and to provide assurance of your qualifications, integrity and track record. You must provide contact details, including email addresses of three referees who have supervised your clinical training during the last three years of your employment or undergraduate training. One referee must be your current or most recent Consultant / Educational supervisor familiar with your clinical development. Please provide NHS email addresses where possible. Your clinical and academic referees should be contacted by you in advance to confirm that they are willing to provide a reference and are available to do so in the time period required for selection and appointment. Please ensure these details are correct as you will be unable to begin in post until references are supplied and checked. Reference 1 (Present or most recent Consultant / Educational Supervisor) Please give full address Post Details (post held by applicant) Specialty       Start Date       Level       End Date       Consultant / Educational Supervisor Name       Job title       Address                   Town       County       Post code       Country       Telephone number       Fax Number       Email address      
  19. 19. Candidate Number : ____________________________ Reference 2 Please give full address Post Details (post held by applicant) Specialty       Start Date       Level       End Date       Consultant / Educational Supervisor Name       Job title       Address                   Town       County       Post code       Country       Telephone number       Fax Number       Email address       Reference 3 Please give full address Post Details (post held by applicant) Specialty       Start Date       Level       End Date       Consultant / Educational Supervisor Name       Job title       Address                   Town       County       Post code       Country       Telephone number       Fax Number       Email address      
  20. 20. Candidate Number : ____________________________ Entry Criteria checklist You should select the following checklist to indicate that you have completed this application form in conjunction with the entry criteria set out in the relevant Specialty / entry level Person Specification for the post applied for. Entry Criteria I meet the entry qualifications ---Please Select--- I have the right to work in the UK ---Please Select--- I have no fitness to practice restrictions, or any other prohibition, limitation or restriction which would prevent me from applying for this post ---Please Select--- I am proficient in English Language Skills at the required level ---Please Select--- The Deanery is currently seeking advice on whether it is classified as an Employment Agency for the purposes of the Employment Agencies Act 1973 (“the Act”) and associated regulations. In the meantime, you are notified of the following terms and conditions that will apply to the provision of services by the Deanery in connection with the recruitment of junior doctors to training programmes. 1. The services provided include a work-finding service for which the Act prohibits the Deanery from charging a fee. 2. The services provided by the Deanery will be provided without any charge to either junior doctors or the NHS employers that engage them. 3. If it is determined that the Act applies to the Deanery, the Deanery will operate as an employment agency in providing the services. 4. The Deanery is authorised to act for NHS employers that are offering training posts as part of the junior doctor training programme and is not authorised to enter into contracts with junior doctors on behalf of those employers. By proceeding with the application process you are deemed to accept these terms and conditions. Please note, PART ONE of this form is for office use only and will not be seen by the shortlisting panel and will not form any part of the interviewing process.
  21. 21. Candidate Number: ___________________ APPENDIX A Country of Origin Afghanistan Albania Algeria American Samoa Andorra Angola Anguila Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahran Bangladesh Barbados Belarus Belgium Belize Berin Bermuda Bhutan Bolivia Bosnia&Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo (Republic of) Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan LaoPeoplesDemocratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia(Federated States of) Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherland Antilles Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Islands North Korea NorthernMariana Islands Norway Oman Pakistan Palau PalestinianTerritory (Occupied) Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia SaintVincent and the Grenadines Samoa San Marino San Torne and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia(Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia and South Sandwich Islands South Korea Spain Sri Lanka St Helena St Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Vietnam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe
  22. 22. Please complete this application form carefully. CVs and additional pages will not be accepted. THE LONDON DEANERY in association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries APPLICATION FORM SPECIALTY TRAINING PROGRAMME IN PAEDIATRIC RADIOLOGY (080/56) PART TWO Section H (1) Entry Criteria Medical school / university Dates             Basic Medical Qualification       Registration with the General Medical Council Type of registration GMC number Renewal date Name in which you are registered                         Experience Do you have a minimum of 1 year post registration clinical experience ---Please Select--- Essential Criteria Please give answers to the following (more detailed information is requested later) Do you have : FRCR or eligible to be registered as a Specialist with the GMC ---Please Select--- 4 years specialist training (or equivalent) in Radiology by time of taking up post ---Please Select--- A completed Audit in the last 24 months of your clinical experience ---Please Select--- A certificate of completion of resuscitation training in the last 3 years of your clinical experience ---Please Select--- Section H (2) – Professional Qualifications Shortlisted candidates will be required to bring original certificates to the interviews Degree / Diploma / Postgraduate qualifications (include BSc, MBBS, MRCP, MRCS etc) – state class of degree awarded Awarding body Date of qualification                                                                         Radiology qualifications (include only those parts which have been passed)
  23. 23.                                                                                           Please give details of any research degree (MD, PhD) currently being undertaken       Section I – Present Employment Employer’s / NHS Trust name :      Address :      Telephone number :       Current position – please state if locum position Specialty Grade Date appointed Length of contract Length of notice required National Training Number                                    
  24. 24. Section J – Previous Appointments Please list posts in chronological order (most recent first) and state if locum / temporary / substantive posts. Please asterisk those posts in the specialty for which you are currently applying. Specialty, Hospital, Consultant Grade Date from Date to Months in post                               Please explain any gaps in your employment history      
  25. 25. Section K – Clinical Knowledge and Experience Please list here those procedures you can perform which you feel are relevant to your career in Radiology. Please also state the level of competence achieved, ie unsupervised / indirect supervision / direct supervision. Name of procedure Details             Resuscitation Training Indicate date and place of training experience      
  26. 26. Section L – Aims and career objectives Please indicate the reasons why you wish to pursue a career in Radiology and indicate your specific educational objectives for the post. Why should you be selected for progress to CCT? (maximum 100 words)       Section M – Audit and Management a) Please describe your experience of clinical audit within the last 2 years of your clinical practice. Indicate clearly your own level of involvement and the clinical relevance of the audit.       b) What methods do you personally and your Trust management use to ensure the quality of your professional performance?      
  27. 27. c) Give a recent example of a clinical situation in which you feel team working could have been improved (up to 100 words)       d) Please list positions of administrative responsibility / leadership inside and outside of medicine.       e) Indicate how your activities outside medicine will contribute to your career in Radiology.       Section N – Academic Achievements a) Undergraduate and postgraduate prizes or other academic distinctions      
  28. 28. b) Publications (shortlisted candidates will be asked to bring copies of all publications to the interview). Please list your best 5 publications with full citation and PubMed number. Please asterisk those for which you are first author       c) Presentations / posters at national or international meetings. Please indicate whether N – national or I – international       d) Experience of teaching (including outside medicine). What do you offer as a teacher?       Section O – Any Further Information Relevant to this Application       Section P - Notes 1 Children and Vulnerable Adults
  29. 29. Where the appointment involves substantial access to children and /or vulnerable adults, the appointment is subject to a police check. The Criminal Records Bureau will be asked to verify that you have no convictions and cautions or pending prosecutions, convictions, cautions and bind-over orders. This will include local police force records in addition to checks with the Police National Computer and the government department lists held by the Department of Health and Department for Education and Employment, where appropriate. 2 Declaration If you are related to a member or Senior Officer/Manager of the Trusts involved in the training programme, you must disclose such a relationship. You are also required to declare any involvement, either directly or indirectly, with any firm, company or organisation which has a contract with Trusts involved in the training programme. Failure to declare any information on these matters may result in your application being rejected or, if it is discovered after appointment that such information has been withheld, then this may lead to dismissal. Please note canvassing of a Senior Officer/Manager shall disqualify an applicant. Please state any disclosure/declaration related to the above on a separate sheet. Section Q - Equal Opportunities The London Deanery aims to promote equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of race, national origin, gender, gender reassignment, marital status, civil partner status, religion, disability, sexual orientation or age. Section R – Accepting an Appointment You must take up any post, including a locum post, you have formally accepted unless the employer has adequate time to make other arrangements. (Good Medical Practice published by the General Medical Council – 3rd edition, May 2001). Failure to comply with this requirement may result in a complaint to the GMC. Section S - Signature I confirm that I have fairly and honestly completed this application by myself, without significant help or input from other sources. I understand that my application form will be checked, and if it is subsequently discovered that any statement is false, misleading or copied from another source, or that I have withheld relevant information, particularly on criminal convictions and fitness to practice, my application may be disqualified and / or my employment terminated. This may result in a referral to the General Medical Council / General Dental Council or other relevant professional body. I understand that employment offered in this training programme is subject to satisfactory Occupational Health clearance and subject to the information provided on the application form or any other document being correct The Data Protection Act 1998 requires us to provide you with certain information and, in certain circumstances, to obtain your consent before processing data about you. Processing includes: obtaining, recording, holding, disclosing, destruction and retaining information. The information that you provide on this application form will be processed in accordance with the Data Protection Act 1998, and will be used for recruitment and if you are successful, will form part of your training record at the Deanery. If you are appointed, the information will be passed to your employing trust. Information relating to your name, contact address, email address, date of birth, GMC/GDC registration, specialty, grade and your photograph will be passed to the Department of Health & NHS Employers for the production of an Occupational Health Smartcard. I understand and agree that the information provided on this form being entered onto the Deanery’s computer information system and used for the Deanery’s legitimate business. Please do not complete this signature electronically. If you are invited to interview you will be asked to sign a paper copy at that stage. Signature Date
  30. 30. To the applicant : this shows the scoring system to be used for short-listing from the application form. If the short-listing panel agrees that you have scored “0” in any of the essential criteria this means that you have not provided sufficient evidence to demonstrate the attribute. You therefore cannot be shortlisted. You are advised to self-assess yourself prior to application and to seek advice from your educational supervisor if necessary. This should not be returned with your application. It is for your information only. THE LONDON DEANERY in association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries APPLICATION FORM SPECIALTY TRAINING PROGRAMME IN PAEDIATRIC RADIOLOGY – SHORTLISTING SCORESHEET NB All entry criteria must be met by date of shortlisting committee ENTRY CRITERIA Assessed In Section YES/NO ESSENTIAL CRITERIA Eligible for registration with the GMC B To be confirmed by Deanery Has this applicant scored a 0 in any of the essential criteria? YES / NO MBBS (or equivalent) H (1) If an applicant scores 0 in any of the essential criteria, the application must be discussed at the shortlisting committee FRCR or eligible to register as a Specialist with the GMC H (1) 4 years satisfactory completion of specialist training by time of taking up post H (1) ESSENTIAL CRITERIA Maximum Score (Range 0 –2) Applicant’s score Assessed in this Section of the Application Form DESIRABLE CRITERIA Maximum Score (Range 0 – 2) Applicant’s score Completed audit in last 2 clinical years 1 H (1), M (a) Resuscitation training (in last 3 clinical years) 1 H (1) Radiology experience 2 H (1), I & J H (2) BSc (I or II:I, MSc, Research MD / PhD 2 H (2) MRCP, MRCS or equivalent 2 I & J Broad appropriate clinical experience 2 I ,J & L Appropriate progression of career 2
  31. 31. ESSENTIAL CRITERIA Maximum Score (Range 0 –2) Applicant’s score Assessed in this Section of the Application Form DESIRABLE CRITERIA Maximum Score (Range 0 – 2) Applicant’s score Experience of procedures 2 K L, M (e) Commitment to a career in Radiology 2 M (a) Active involvement in Audit 2 Knowledge of clinical risk management 2 M (b) Understanding of clinical governance 2 Experience of working in multi-professional teams 2 M (c-d) Demonstrates leadership / administrative responsibility 2 N (a) Prizes and honours 2 N (b) Publications 2 N (c) Presentations 2 N (e) Experience of teaching. Enthusiasm for teaching, exposure to different groups / teaching methods 2 Communication skills 2 AF Appropriate Information Technology skills 2 Demonstrates analytical / scientific approach 2 AF Demonstrates breadth of awareness 2 Total number of points (Maximum - 42) points scored ______________________ Minimum number of points required to be considered for short-listing is 18 Please note that if an applicant achieves this score he/she will not automatically be short-listed. This is the minimum standard which must be achieved, but the final shortlist for interview will also reflect the ranking of applicants applying on this occasion. Any attributes which are evaluated on the basis of the application form alone may be further explored at the interview stage

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