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THE LONDON DEANERY in association with the East of England ...

  1. 1. THE LONDON DEANERYin association with the East of England and Kent, Surrey & Sussex (KSS) DeaneriesDear ApplicantApplication to a Clinical Lecturer (CL) post in Oral & Maxillo-Facial SurgeryThank you for applying to a clinical academic specialty training programme in the London Deanery. This letterexplains the selection and appointment process we are using.This pack contains:a) A person specification which describe the attributes for which we are looking in this selection and appointment process are enclosed in this pack. Please note that you must be able to offer all of those attributes described as essential if you are to be considered for short-listing and/or appointment. Additionally, you will only been considered if you can provide evidence of potential for outstanding academic achievement. You will need to list an academic referee who has confirmed that they are willing to support your application for this programme – please see below for further detailsb) an application form;c) short-listing scoring form (for information only) which will show you how the short-listing committee will judge your application against the requirements of the person specifications.As you fill out the application form you are advised to answer the questions and complete the form with referenceto the person specifications. Please note:• CVs and additional pages will not be accepted and therefore the application form should be fully and carefully completed.• When completing the application 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 may result in your application being rejected• Where equivalent postgraduate qualifications or experience are being offered as evidence of entry criteria, it is essential that the candidate provides confirmation from the Royal College if shortlisted for an interview.• The number of applicants called for interview will depend both on the number of the vacancies in the programme and on the short-listing scores achieved by applicants.• The interview process will explore those areas included in the specification about which we need further information.• Please return the completed application form and completed equal opportunity monitoring form to: Recruit19@londondeanery.ac.ukDO NOT SEND ANY OTHER DOCUMENTATION – INCLUDING ORIGINAL DOCUMENTS/PASSPORTS ETC. –AT THIS STAGE• Closing date : Strictly 17:00 (GMT+1) on Monday 16 August• Interviews will be held in September 2010 in a location in Central London. The exact date will be posted on the London Deanery website.• 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.• If successful, you should 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.• Please also 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.Dr Fiona MossDirector of Medical & Dental Education Commissioning
  2. 2. THE LONDON DEANERYin association with the East of England and Kent, Surrey & Sussex (KSS) DeaneriesAdvice on Academic RefereesOne of your referees should be able to advise the recruitment panel of your academic strengths and weaknesses.The referee may be someone who has knowledge of your skills and attributes from some time ago, e.g. Supervisorof an intercalated degree or special study module. It is important however that the academic referee carefullyconsiders your suitability for a long-term career in academic medicine. You are expected to discuss theirapplication with the academic referee and to have established that the referee is happy to submit a reference andwill be able to respond promptly to any request to do so.Referees will be asked to comment on: i) their perception of your commitment to an academic career, ii) academic competencies that you have already developed, iii) your potential for further development as a clinical academic,Where appropriate and applicable the referee may also comment on the role played by you in any scientificoutputs. Information supplied by the academic referee may be considered by the committee conducting theinterview.Thank you for applying to this Clinical Lectureship.Yours sincerelyAcademic Recruitment TeamLondon DeaneryDr Fiona MossDirector of Medical & Dental Education Commissioning
  3. 3. THE LONDON DEANERYin association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries *****Important information***** 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
  4. 4. THE LONDON DEANERYin association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries *****Important information***** General Statement of PolicyGeneral 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 aduty on health care professionals to provide a good standard of medical care for, and behave appropriatelytowards, patients. NHS employers also have a duty to ensure that patients receive a good standard of medicalcare 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 aplacement on a Specialty training programme have a criminal record in the UK or in another country that they canlawfully be required to disclose.Applicants for Specialty training posts are exempted from the Rehabilitation of Offenders Act 1974, and cantherefore 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 trainingposts have ever been disqualified from the practice of a profession or required to practise it subject to specifiedlimitations following fitness to practise proceedings by a regulatory body in the UK or in another country, andwhether they are currently the subject of any investigation or proceedings by any body having regulatory functionsin 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 orvulnerable adults (as defined by The Police Act 1997 (Enhanced Criminal Record Certificates)(Protection ofVulnerable Adults) Regulations 2000), applicants will also be asked whether they are currently the subject of anypolice 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 bythe Criminal Justice and Court Services Act 2000), checks will be carried out in accordance with the Protection ofChildren Act 1999. Anyone whose name is on the list is legally barred from working with children. It is an offencefor such a person to knowingly apply for, offer to do, accept or to do such work. If you are appointed to aSpecialist 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 mightbe, relevant to the position for which they are applying at an early stage in the appointment process.All applicants are also expected 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 betreated 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 fromappointment. Applicants will be given an opportunity to discuss any information supplied before a final decision istaken regarding their appointment.However, an applicant may not be selected if the selection panel considers that the information declared rendersthat person unsuitable for the position for which they have applied. In reaching such a decision the LondonDeanery will consider the nature of the record/action, its relevance to the position applied for, and any otherinformation 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 seriousmatter.Where it is found that a person has intentionally or recklessly provided inaccurate information or withheldinformation relevant to his/her position, this may disqualify them from an appointment, or if appointed,dismissal and referral to the appropriate professional regulatory body.
  5. 5. THE LONDON DEANERYin association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries *****Important information*****If you would like to discuss what effect any criminal record or fitness to practise proceedings might have on yourapplication, 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 bekept confidential. If the Deanery considers that the information provided may have a bearing on your appointmentand that the information needs to be considered by the selection panel, we will discuss this with you in advance. Ifwe do not raise this information with you, this is because we do not believe that it should be taken into account. Inthat 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 byyou 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 forpositions 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 informationdeclared.The Data Protection Act 1998 requires us to provide you with certain information and to obtain your consent beforeprocessing sensitive data about you. Processing includes: obtaining, recording, holding, disclosing, destructionand 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 accordancewith the Data Protection Act 1998, and will only be used for the purpose of determining your application for thisposition. Once a decision has been made concerning your appointment, we will not retain this Declaration Formlonger 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 designatedpersons within the Medical Workforce Department of the London Deanery and other persons who need to see it aspart of the selection process and who are authorised to do so. The information may be passed to your employingtrusts.
  6. 6. 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 CLINICAL LECTURER IN ORAL & MAXILLO-FACIAL SURGERY PERSON SPECIFICATION ESSENTIAL WHEN DESIRABLE WHEN EVALUATED EVALUATEDQUALIFICATIONS • Current NTN Holder AF • Intercalated BSc, BA, AF MSc • Eligible for registration with the GMC AF • Other degrees / AF AF qualificationsResearch • Eligible for registrationexperience with the GDC • PhD/MD thesis AF submitted by date of • MB BS (or equivalent) AF application close • BDS (or equivalent) AF • MRCS AFCLINICAL • Demonstrates AF, I/VEXPERIENCE competence in all core skills • Demonstrates I/V educational progression supported by a satisfactory RITA Cs as appropriate • Evidence of good progress in clinical I/V training and that completion of specialty training may be accommodated either during or after the 4 year period of the CL awardCLINICAL SKILLS • Demonstration of I/V, Ref • ATLS / APLS / ALS AF acquisition of the level of within 2 years knowledge and skills necessary for the achievement of Foundation and clinical (matched to the entry level) competencies or equivalent • Understanding of clinical I/V risk management • Competent to work I/V, Ref without direct supervision where appropriate AF, I/V
  7. 7. ESSENTIAL WHEN DESIRABLE WHEN EVALUATED EVALUATED • Clear, logical thinking showing an I/V, Ref analytical/scientific approach • Good manual dexterity and hand / eye co- ordinationKNOWLEDGE • Appropriate level of Ref • Demonstrates breadth of AF, I/V clinical knowledge experience and awareness in and • Shows knowledge of I/V outside specialty / evidence-informed medicine practice I/V • Demonstrates use of • Shows awareness of I/V, Ref evidence-informed own limitations practiceORGANISATION & • Ability to prioritise clinical I/V, Ref • Understanding of NHS, AF, I/VPLANNING need clinical governance & resource constraints; • Ability to organise I/V, Ref management / financial oneself & own work awareness; experience • Evidence of participation AF, I/V of committee work and active involvement • Information technology AF in an audit project skills • Experience and ability to AF, I/V, Ref, work in multi- professional teamsTEACHING SKILLS • Evidence of teaching AF, I/V • Enthusiasm for teaching; AF, I/V experience; involvement exposure to different in organized teaching groups / teaching methods AF, I/V • Teaching the teachers course and certificateACADEMIC/ • Research experience, AF, I/V • Academic prizes and AF, I/VRESEARCH presentations, honours publications • Formal research training AF, I/V • Research plans AF, I/V (seminars, courses etc) • Major potential for • Indication of medium I AF, I/V, Ref development as a and long-term career /V clinical academic in goals ie what sort of research or education position trainee proposes to be in next and • Demonstration of I/V eventually potential for scientific independence and • Understands the I/V ability to lead a research principles of research team governance • Familiarity with research I/V • Demonstrates a high I/V level of interest in the ethics requirements academic aspects of the I/V • Knowledge of hosting specialty the research and • Familiarity with whether this is the best publications and I/V place to support the research, education and
  8. 8. ESSENTIAL WHEN DESIRABLE WHEN EVALUATED EVALUATED potential developments AF, I/V training needs in the specialty • • Potential to become a leader in chosen field •CAREER • Clarity of career AF, I/V • Progression of career AFPROGRESSION aspirations consistent with personal circumstances • Understanding of how AF, I/V I/V academic training will • Evidence of provide opportunities for commitment to specialty career developmentPERSONAL SKILLS • COMMUNICATION & AF, I/V, Ref LANGUAGE SKILLS (the ability to communicate with clarity and intelligibility in written and spoken English; ability to build rapport, listen, persuade, negotiate) I/V, Ref • DECISIVENESS/ ACCOUNTABILITY (ability to take responsibility, show leadership, make decisions, exert appropriate authority) • INTERPERSONAL AF, I/V, Ref SKILLS (see patients as people, empathise, work co-operatively with others, open and non- defensive, sense of humour) • USES A NON- Ref JUDGMENTAL APPROACH TO PATIENTS AND COLLEAGUES regardless of their sexuality, ethnicity, disability, religious beliefs or financial status • FLEXIBILITY (able to I/V, Ref change and adapt, respond to rapidly changing circumstances) • RESILIENCE (able to I/V, Ref operate under pressure, cope with setbacks, self- aware) • THOROUGHNESS (is I/V, Ref well prepared, shows self-
  9. 9. ESSENTIAL WHEN DESIRABLE WHEN EVALUATED EVALUATED discipline/commitment, is punctual and meets deadlines) • SHOWS INITIATIVE/ AF, I/V, Ref DRIVE/ENTHUSIASM (self-starter, motivated, shows curiosity, initiative) • PROBITY (displays I/V, Ref honesty, integrity, aware of ethical dilemmas, respects confidentiality)PHYSICAL • Meets professional pre-REQUIREMENTS health requirements employment health screening AF = Application Form I/V = Interview Ref = Reference Any attributes which are evaluated on the basis of the application form alone may be further explored at the interview stage. • • •
  10. 10. • • • • •This person specification should be used in conjunction with a person specification for assessment of clinicalcompetences.
  11. 11. Candidate Number:_________________Please complete this application form carefully. CVs and additional pages will not be accepted. LONDON DEANERY APPLICATION FORM FOR CL in ORAL & MAXILLO-FACIAL SURGERY Ref: 061/45 PART ONE Section A – Personal DetailsSurname :       Forenames :     Title :      If previously known by another name, please specify :      Home Address : Address for correspondence :           Home telephone number :      Work telephone number :     Home Fax number :       Work fax number :      Email address :      Mobile phone number :      Date available to start if offered the post       Section B – General Medical Council RegistrationDo you have, or are you GMC Number Renewal date Name in which you areeligible for, FULL GMC registeredregistration?                       Do you have, or are you GDC Number Renewal date Name in which you areeligible for, FULL GDC registeredregistration?                       If not registered with the GMC/GDC at time of application, will you be eligible for FULL registration by the timeof appointment? Please give details below.     
  12. 12. Candidate Number:_________________ Section C – Equal Opportunities Monitoring FormWe are committed to eliminating unlawful discrimination from employment and selection practices. We will takesteps to ensure that employees are recruited, trained and promoted on the basis of ability, the requirements of thejob and the need to maintain an efficient and effective service. To monitor this policy, we require the followinginformation which will only be used for this purpose. It will form no part of the interviewing process, and will betreated 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:       Male Female GENDER: Transgender Male Transgender Female please select I do not wish to disclose my genderRace Relations (Amendment) Act 2000I 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 backgroundEmployment Equality Regulations 2003Please select the option which best describes your sexuality Lesbian / Gay woman Heterosexual Gay Man I do not wish to disclose my sexual orientation BisexualPlease indicate your religious belief Atheism Jainism Judaism Buddhism Sikhism Hinduism Christianity Other Islam I do not wish to disclose by religion / belief
  13. 13. Candidate Number:_________________Disability Discrimination Act 1995The Disability Discrimination Act protects disabled people. This includes people with long-term health conditions. Ifyou tell us that you have a disability we can make reasonable adjustments to where you work and your workarrangements or at interview.Do you consider yourself to have a Yes I do not wish to disclose this informationdisability? NoPlease 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 OtherIf you have a disability, do you require any specific arrangements to enable you to ---Please Select---attend for interview?If YES, (I have a disability which I consider relevant to my application) please describe any adaptation oradjustment 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, MedicalWorkforce, London Deanery, Stewart House, 32 Russell Square, London WC1B 5DN. Please mark theenvelope “CONFIDENTIAL”. Alternatively, you may send an email toConfidentialenquiries@londondeanery.ac.uk , Please also let us know if you need any special arrangements toenable you to attend for interview.If you have a disability, provided you meet the minimum criteria as specified in thePerson Specification, do you wish to be considered under the GuaranteedInterview Scheme? Pleas see the Disability Discrimination Act for moredetailsIf you tick Yes you must email ConfidentialEnquiries@londondeanery.ac.uk to ---Please Select---ensure your eligible for the guaranteed interview scheme. Failure to do so mayresult in you not being granted a guaranteed interview. Emails to this address aremanaged in strict confidence and will not be shared with the interview panel.Please see the Disability Discrimination Act for more details.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 madeknown to the selection panel but you will need to formally apply for less than full-time training via the deaneryFlexible Training Team. Further guidance and details on how to apply can be found on the deanery website---Please Select---
  14. 14. Candidate Number:_________________D: Language SkillsYou are required to demonstrate skills in written and spoken English that are adequate to enable effectivecommunication 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 ---Please Select---English Language Testing System) to the minimum overall score required asper the person specification1? 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 NHS Jobs website1 The Applicant must have achieved as a minimum the following scores in the academic International EnglishLanguage Testing System (IELTS) in a single sitting within 24 months at time of application – Overall 7,Speaking 7, Listening 7, Reading 7, Writing 7
  15. 15. Candidate Number:_________________E: Right To Work in the United KingdomSome applicants may be considered before others on the basis of immigration status, in accordance withguidance from the UK Border Agency. If you require Tier 2 sponsorship in order to take up the offer of aplace on this training programme and you are subject to the Resident Labour Market Test, your applicationwill not be considered in this round of recruitment. Applicants in this category should consider re-applyingto 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 Select--- *Please complete the immigration status applicable2 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 ---Please Select--- control?If you have selected no to both of the above please mark with a cross the boxes below in the Personal Statussection which define your immigration status and complete start and expiry date of your permit, unless youalso tick yes to the question below, in which case you need to go to the Partner/Civil Partner/Spouse Statussection.3 Are you on a dependents visa* *If you have answered YES please complete the Partner/Civil Partner/Spouse status ---Please Select--- sectionNationality (Choose country pertaining to your nationality - see country list –      Appendix A)Personal StatusSelec Status Start Date Expiry Date t 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
  16. 16. Candidate Number:_________________If Other than above – Please specify the immigration category (Max 50 words – 455 Characters)     Partner / civil partner / spouse statusPlease 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
  17. 17. Candidate Number:_________________F: Fitness to Practise and Criminal InvestigationsWe aim to promote equality of opportunity and are committed to treating all applicants for positions fairly and on meritregardless of race, gender, marital status, religion, disability, sexual orientation or age. We undertake not todiscriminate 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 youthat we believe may have a bearing on your suitability for the position. If we do not raise this information with you, thisis because we do not believe that it should be taken into account. In that event, you still remain free, should you wishto discuss the matter with the interviewing panel. As part of assessing your application, we will only take into accountrelevant criminal record and other information declared. However, please be advised that any failure to declarerelevant information relating to your fitness to practice may well lead to your application being withdrawn, and/or anyemployment or training programme placement terminated.The Data Protection Act 1998 requires us to provide you with certain information and to obtain your consent beforeprocessing sensitive data about you. Processing includes: obtaining, recording, holding, disclosing, destruction andretaining information. Sensitive personal data includes but is not limited to any of the following information: criminaloffences, 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 Act1998. It will be used for the purpose of determining your application for this position. It will also be used for purposes ofenquiries in relation to the prevention and detection of fraud. Once a decision has been made concerning yourappointment, we will not retain this Declaration Form longer than is necessary (ie until you leave the post you areapplying 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 inconfidence, and access to it will be restricted to designated persons within the Recruitment Department and otherpersons who need to see it as part of the selection process and who are authorized to do so. If successfully appointedto a training post, this information may be passed to your employing trusts.Rehabilitation of Offenders Act 1974Before you can be considered for appointment in a position of trust as a Specialty Trainee on a Deaneryprogramme, 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 Act2006, and appointments made after 26 July 2010 will be subject to registration with the IndependentSafeguarding Authority (ISA). This will become a mandated requirement from 1st November 2010. Onlysuccessfully registered employees will be permitted to continue their training and employment after thatdate.It is vitally important that you read, understand and answer the questions asked in this section by selectingeach 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 providefull details via email to fitnesstopractise@londondeanery.ac.uk by the closing date if application. Failure to do so mayresult in your application being withdrawn. In this email please indicate clearly the programme for which you areapplying, 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. Thismeans 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. Thiswill depend on the nature of the position for which you are applying and the particular circumstances.
  18. 18. Candidate Number:_________________If you would like to discuss what effect any previous convictions, police investigations or fitness to practice proceedingstaken 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 ---Please Select--- or Court-Martial in the United Kingdom or in any other country? NB You do not need to tell us about parking offences.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 Select--- 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.4 Are you aware of any current police investigation in the United Kingdom or in any other ---Please Select--- country following allegations made against you?5 Are you aware of any current NHS Counter Fraud and Security Management Service ---Please Select--- investigation following allegations made against you?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, ---Please Select--- 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).7 Have you ever been dismissed by reason of misconduct from any employment, office or ---Please Select--- other position previously held by you?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 ---Please Select--- proceedings by a regulatory or licensing body in the United Kingdom or in any other country?9 Are you currently the subject of any investigation or fitness to practice proceeding by any ---Please Select--- employer, any licensing or regulatory body in the United Kingdom or any other country?10 Are you subject to any other prohibition, limitation, or restriction that means we are ---Please Select--- unable to consider you for the position for which you are applying?If you have answered “YES” to any of the questions, please provide full details on a separate sheet and place in asealed envelope addressed to Jane Appleyard, Medical Workforce, London Deanery, Stewart House, 32 RussellSquare, 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 continuingresponsibility 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 contactJane Appleyard at the Deanery (see above).
  19. 19. Candidate Number:_________________Section G – Referees (NB: Reference 3 needs to be Academic)Reference reports are not used for scoring purposes during shortlisting or interview, but will be reviewed duringthe selection process and again prior to confirmation of appointment for successful applicants. The referenceprocess is designed to check the accuracy of your previous employment and training history and to provideassurance of your qualifications, integrity and track record.You must provide contact details, including email addresses of three referees who have supervised yourclinical training during the last three years of your employment or undergraduate training. One referee mustbe your current or most recent Consultant / Educational supervisor familiar with your clinicaldevelopment. 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 toprovide 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 andchecked.Reference 1 Post Details (post held by applicant)(Present ormost recent Specialty       Start Date      Consultant / Level       End Date      EducationalSupervisor) Referee Details Name       Job title       Address      Please give full      address       Town       County       Post code       Country       Telephone number       Fax Number       Email address      
  20. 20. Candidate Number:_________________Reference 2 Post Details (post held by applicant) Specialty       Start Date       Level       End Date       Referee Details Name       Job title       Address            Please give full      address Town       County       Post code       Country       Telephone number       Fax Number       Email address      Reference 3 Post Details (post held by applicant)( Academic Specialty       Start Date      Reference) Level       End Date       Referee Details Name       Job title       Address            Please give fulladdress       Town       County       Post code       Country       Telephone number       Fax Number       Email address      
  21. 21. Candidate Number:_________________Entry Criteria checklistYou should select the following checklist to indicate that you have completed this application form inconjunction with the entry criteria set out in the relevant Specialty / entry level Person Specification for the postapplied for.Entry CriteriaI 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 ---Please Select---restriction which would prevent me from applying for this postI 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 forthe purposes of the Employment Agencies Act 1973 (“the Act”) and associated regulations. In themeantime, you are notified of the following terms and conditions that will apply to the provision ofservices 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.
  22. 22. Candidate Number:_________________APPENDIX ACountry of OriginAfghanistan Estonia Mauritius SudanAlbania Ethiopia Mayotte SurinameAlgeria Falkland Islands (Malvinas) Mexico Svalbard and Jan MayenAmerican Samoa Faroe Islands Micronesia (Federated IslandsAndorra Fiji States) )of) Moldova SwazilandAngola Finland Monaco SwedenAnguila France Montserrat SwitzerlandAntarctica French Guiana Morocco Syrian Arab RepublicAntigua and Barbuda FrenchSouthern Territories Mozambique TaiwanArgentina Gabon Myanmar TajikistanArmenia Gambia Namibia TanzaniaAruba Georgia Nauru ThailandAustralia Germany Nepal TogoAustria Ghana Netherland Antilles TokelauAzerbaijan Gibraltar Netherlands TongaBahamas Greece New Caledonia Trinidad and TobagoBahran Greenland New Zealand TunisiaBangladesh Grenada Nicaragua TurkeyBarbados Guadeloupe Niger TurkmenistanBelarus Guam Nigeria Turks and Caicos IslandsBelgium Guatemala Niue TuvaluBelize Guinea Norfolk Islands UgandaBerin Guinea Bissau North Korea UkraineBermuda Guyana Northern Mariana Islands United Arab EmiratesBhutan Haiti Norway United KingdomBolivia Heard and McDonald Oman United States of AmericaBosnia & Herzegovina Islands Pakistan United States MinorBotswana Honduras Palau Outlying IslandsBouvet Island Hong Kong Palestinian Territory (Occupied) UruguayBrazil Hungary Panama UzbekistanBritish Indian Ocean Iceland Papua New Guinea VanuatuTerritory India Paraguay Vatican City State (HolyBrunei Darussalam Indonesia Peru See)Bulgaria Iran (Islamic Republic) Philippines VenezuelaBurkina Faso Iraq Pitcairn VietnamBurundi Ireland Poland Virgin Islands (British)Cambodia Israel Portugal Virgin Islands (U.S.)Cameroon Italy Puerto Rico Wallis and Futuna IslandsCanada Jamaica Qatar Western SaharaCape Verde Japan Reunion YemenCayman Islands Jordan Romania YugoslaviaCentral African Republic Kazakhstan Russian Federation ZambiaChad Kenya Rwanda ZimbabweChile Kiribati Saint Kitts and NevisChina Kuwait Saint LuciaChristmas Island Kyrgyzstan Saint Vincent and theCocos (Keeling) Islands Lao Peoples Democratic GrenadinesColombia Republic SamoaComoros Latvia San MarinoCongo (Republic of) Lebanon San Torne and PrincipeCook Islands Lesotho Saudi ArabiaCosta Rica Liberia SenegalCôte dIvoire Libyan Arab Jamahiriya SeychellesCroatia Liechtenstein Sierra LeoneCuba Lithuania SingaporeCyprus Luxembourg Slovakia (Slovak Republic)Czech Republic Macau SloveniaDenmark Macedonia Solomon IslandsDjibouti Madagascar SomaliaDominica Malawi South AfricaDominican Republic Malaysia South Georgia and SouthEast Timor Maldives Sandwich IslandsEcuador Mali South KoreaEgypt Malta SpainEl Salvador Marshall Islands Sri LankaEquatorial Guinea Martinique St HelenaEritrea Mauritania St Pierre and Miquelon
  23. 23. Candidate Number:_________________ LONDON DEANERY APPLICATION FORM FOR CL in ORAL & MAXILLO-FACIAL SURGERY Ref: 061/45 PART TWO Section H – Professional QualificationsMedical School / University Dates            Shortlisted candidates will be required to bring original certificates to the interviewsDegree / Diploma / Postgraduate Awarding body Date of qualificationqualifications (include BSc, MBBS,BDS, MRCP, MRCS, PhD etc) –state class of degree awarded                                                                                                                       Prizes or awards at academic level     Section I – Present EmploymentEmployer’s / NHS Trust name :     Address :     Telephone number :      Current position – please Length of Nationalstate if locum position Date Length of notice TrainingSpecialty Grade appointed contract required Number
  24. 24. Candidate Number:_________________                                   Section J – Previous AppointmentsPlease 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 Date to Months from in post                             
  25. 25. Candidate Number:_________________Section K – Clinical Knowledge and ExperiencePlease give details of your clinical experience which would be of particular use in this post.     Summarise your clinical experience and skills in Oral & Maxillo-Facial Surgery (max 200 words)     Additional experiencePlease indicate any additional skills which you would bring to this appointment, including ATLS, APLS, ALS     
  26. 26. Candidate Number:_________________Section L – Audit, Management and Information Technologya) Please describe your experience of clinical audit. Indicate clearly your own level of involvement.     (b) Please describe the strengths and weaknesses of working in a multi-disciplinary team.     (c) What contribution can a Specialty Trainee make to Clinical Governance in their trust?     (d) Please indicate your level of familiarity with Information Technology     
  27. 27. Candidate Number:_________________Section M – Other AchievementsA range of personal skills have been identified as being particularly important in successful medical specialists.For each of the skills indicated below, please give an example, preferably recent, from your own experience, toillustrate how you dealt with particular situations. You may draw from work or from other outside activities.(a) COMMUNICATION AND INTERPERSONAL SKILLS . In approximately 150 words discuss what you think is currentlythe most important issue in Oral & Maxillo-Facial Surgery.     (b) In approximately 150 words please describe the most challenging situation you have ever been in and howyou dealt with this.     
  28. 28. Candidate Number:_________________(c) INITIATIVE . In approximately 150 words please give an example that best illustrates your drive and initiative.     (d) DEMONSTRATES POTENTIAL . Explain how you have developed your interest in becoming an academicmedical specialist and how this illustrates your potential for the development of a career in research.     
  29. 29. Candidate Number:_________________ You may adjust the size of the boxes in this section – Section NSection N – Academic Achievements(a) Research, whether past or in progress. If you have undertaken or are undertaking a research project, please give details and indicate your involvement (Up to 750 words)     Please outline your plans for research in this post.     
  30. 30. Candidate Number:_________________(b) Publications in peer review journals. Shortlisted candidates will be asked to bring copies of all publications to the interview.     (c) Other publications     
  31. 31. Candidate Number:_________________(d) Presentations / posters at conferences     (e) Experience of teaching (including outside medicine)     (f) Teaching the teachers course – please give details.     
  32. 32. Candidate Number:_________________(g) Formal research training – please give details.     Section O – Aims and Career Objectives     Section P – Interests, other skills and achievements outside medicine     
  33. 33. Candidate Number:_________________Section Q – Any further information relevant to this application     Section R – Notes 1 Children and Vulnerable Adults 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 organization 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 S – Equal OpportunitiesNHS employers are committed to equal opportunities. No applicants will be discriminated against onthe grounds of colour, race, ethnic origin, nationality, age, disability, gender, sexual orientation,marital status, religion, or politicsSection T – 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.
  34. 34. Candidate Number:_________________Section U – SignatureI confirm that I have fairly and honestly completed this application by myself, without significant help or inputfrom other sources. I understand that my application form will be checked, and if it is subsequently discoveredthat any statement is false, misleading or copied from another source, or that I have withheld relevantinformation, 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 DentalCouncil or other relevant professional body.I understand that employment offered in this training programme is subject to satisfactory medical clearanceand 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 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 computerinformation 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
  35. 35. Candidate Number: ___________________________________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 theessential criteria this means that you have not provided sufficient evidence to demonstrate the attribute. You therefore cannot be shortlisted. You are advised to self-assessyourself 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 SHORT-LISTING SCORE SHEET –CLINICAL LECTURER IN ORAL & MAXILLO-FACIAL SURGERYENTRY CRITERIA Assessed In Section YES/NO ESSENTIAL CRITERIAEligible for registration with the GMC B To be confirmed Has this applicant scored a 0 in any of YES / NO by Deanery the essential criteria?Eligible for registration with the GDC B To be confirmed If an applicant scores 0 in any of the essential criteria, the by Deanery application must be discussed at the shortlisting committeeMBBS (or equivalent) HBDS (or equivalent) HMRCS HNTN holder IESSENTIAL CRITERIA Maximum Score Applicant’ Assessed in DESIRABLE CRITERIA Maximum Score Applicant’s (Range 0 –2) s score this Section (Range 0 – 2) score of the Application Form H Intercalated BSc, BA, MSc 2 H Other degrees, qualifications 2 H PhD/ MD (original research) thesis submitted or 2 awarded by date of application close H Academic prizes and honours 2 I, J &O Appropriate progression of career 2Demonstrates competence in all core skills 2 K ATLS / APLS / ALS within two years 2Evidence of participation and active 2 L (a)involvement in AuditExperience of and ability to work in multi- 2 L (b)professional teams
  36. 36. Candidate Number: ___________________________________ESSENTIAL CRITERIA Maximum Score Applicant’ Assessed in DESIRABLE CRITERIA Maximum Score Applicant’s (Range 0 –2) s score this Section (Range 0 – 2) score of the Application Form L (c) Management / financial awareness, experience of 2 committee work, understanding of the NHS, clinical governance and resource constraints L (d) Appropriate Information Technology skills 2Communication and interpersonal skills 2 M (a & b)Demonstrates drive and initiative 2 M (c)Clarity of career aspirations 2 M (d) & OUnderstanding of how academic training 2 M (d) & Owill provide opportunities for careerdevelopmentPotential for development as a clinical 2 M (d) & Nacademic in researchResearch experience 2 N (a)Research plans 2 N (a)Publications in peer review journals 2 N (b)Publications in other journals 2 N (c)Presentations 2 N (d)Experience of teaching 2 N (e) Enthusiasm for teaching, exposure to different groups / 2 teaching methods N (f) Teaching the teachers course 2 N (g) Formal research training 2Demonstrates analytical / scientific 2 AF Breadth of experience and awareness in and outside 2approach specialty/medicineTotal number of points (Maximum – 54) points scored ________ Date:____________________ Shortlister:__________________________
  37. 37. Candidate Number: ___________________________________Minimum number of points required to be considered for short-listing is 20 Signature: _______________________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 ofthe application form alone may be further explored at the interview stage.

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