Candidate Pack Gastroenterology Sub Spec Hepatology Ref: 018/15
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Candidate Pack Gastroenterology Sub Spec Hepatology Ref: 018/15

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    Candidate Pack Gastroenterology Sub Spec Hepatology Ref: 018/15 Candidate Pack Gastroenterology Sub Spec Hepatology Ref: 018/15 Document Transcript

    • THE LONDON DEANERYin association with the East of England and Kent, Surrey & Sussex (KSS) DeaneriesDear ApplicantApplication to Sub-Specialty Training in HepatologyThank you for applying to a training programme in the London Deanery in association with the East of England andKent, 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 GMCs 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 andcomplete 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 informationDr Fiona MossActing Dean Director of Postgraduate Medical & Dental Education
    • THE LONDON DEANERYin association with the East of England and Kent, Surrey & Sussex (KSS) DeaneriesPlease email the completed application form to : Kasia Zawadzka Recruit1@londondeanery.ac.uk Tel: 0207 866 3122, Fax: 0207 866 3276. • Reference number : 018/15 • Closing date and time: 14th May 2010 at 12.00 (noon) GMT+1 • Interviews will be held on : to be confirmed • For further information about this training programme and visiting arrangements (shortlisted candidates only), please contact: Recruit1@londondeanery.ac.uk • 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 Kasia Zawadzka Medical Recruitment AdministratorDr Fiona MossActing Dean Director of Postgraduate Medical & Dental Education
    • THE LONDON DEANERYin association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries/home/pptfactory/temp/20101203115304/candidate-pack-gastroenterology-sub-spec-hepatology-ref-018154900.doc *****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 2010Dr Fiona MossActing Dean Director of Postgraduate Medical & Dental Education
    • THE LONDON DEANERYin association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries/home/pptfactory/temp/20101203115304/candidate-pack-gastroenterology-sub-spec-hepatology-ref-018154900.doc *****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 DentalCouncil, imposes a duty on health care professionals to provide a good standard of medicalcare for, and behave appropriately towards, patients. NHS employers also have a duty toensure that patients receive a good standard of medical care and to take all practicable steps toensure the safety of patients and staff.In order to assess job related risks, the London Deanery needs to establish if applicants whomay be offered a placement on a Specialty training programme have a criminal record in the UKor in another country that they can lawfully be required to disclose.Applicants for Specialty training posts are exempted from the Rehabilitation of Offenders Act1974, and can therefore be asked to disclose “spent” convictions that they would otherwise nothave to declare.Applicants for Specialty training posts will also be asked if they are “bound over”, have receiveda police caution, warning or reprimand and whether they have been charged with a criminaloffence that is not yet disposed of.Prior to making an appointment, the London Deanery also needs to establish if applicants forSpecialty training posts have ever been disqualified from the practice of a profession or requiredto practise it subject to specified limitations following fitness to practise proceedings by aregulatory body in the UK or in another country, and whether they are currently the subject ofany investigation or proceedings by any body having regulatory functions in relation tohealth/social care professionals, including such a regulatory body in another country.Where such a position involves regular care, training, supervision or sole charge of personsaged under 18 or vulnerable adults (as defined by The Police Act 1997 (Enhanced CriminalRecord Certificates)(Protection of Vulnerable Adults) Regulations 2000), applicants will also beasked whether they are currently the subject of any police investigation in the UK or any othercountry of which they are aware.Where the position is a “regulated position” under the terms of the Protection of Children Act1999 (as amended by the Criminal Justice and Court Services Act 2000), checks will be carriedout in accordance with the Protection of Children Act 1999. Anyone whose name is on the list islegally barred from working with children. It is an offence for such a person to knowingly applyfor, 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 thatare, or that might be, relevant to the position for which they are applying at an early stage in theappointment process.Dr Fiona MossActing Dean Director of Postgraduate Medical & Dental Education
    • THE LONDON DEANERYin association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries/home/pptfactory/temp/20101203115304/candidate-pack-gastroenterology-sub-spec-hepatology-ref-018154900.doc *****Important information*****All applicants are also expect to inform the London Deanery if, before taking up any positionoffered 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 decidedfairly and on merit. Information declared will be used to consider the applicant’s suitability forthe position. Information supplied will be treated in confidence and will not be used as the solecriterion to decide an applicant’s fitness for the position.Unless an appointment is prohibited by law, a criminal conviction will not automatically debarthe applicant from appointment. Applicants will be given an opportunity to discuss anyinformation supplied before a final decision is taken regarding their appointment.However, an applicant may not be selected if the selection panel considers that the informationdeclared renders that person unsuitable for the position for which they have applied. Inreaching such a decision the London Deanery will consider the nature of the record/action, itsrelevance 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 consideredto be a serious matter.Where it is found that a person has intentionally or recklessly provided inaccurateinformation or withheld information relevant to his/her position, this may disqualify themfrom an appointment, or if appointed, dismissal and referral to the appropriateprofessional regulatory body.If you would like to discuss what effect any criminal record or fitness to practise proceedingsmight have on your application, you may telephone Jane Appleyard, telephone 0207 866 3105,in the Medical Workforce department, in confidence or emailfitnesstopractise@londondeanery.ac.uk .Any information you provide regarding criminal investigations, convictions or fitness to practiseproceedings will be kept confidential. If the Deanery considers that the information providedmay have a bearing on your appointment and that the information needs to be considered bythe selection panel, we will discuss this with you in advance. If we do not raise this informationwith 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 anyinformation 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 allapplicants for positions fairly and on merit regardless of race, gender, marital status, religion,disability, sexual orientation or age. We undertake not to discriminate unfairly againstapplicants on the basis of criminal conviction or other information declared.Dr Fiona MossActing Dean Director of Postgraduate Medical & Dental Education
    • THE LONDON DEANERYin association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries/home/pptfactory/temp/20101203115304/candidate-pack-gastroenterology-sub-spec-hepatology-ref-018154900.doc *****Important information*****The Data Protection Act 1998 requires us to provide you with certain information and to obtainyour consent before processing sensitive data about you. Processing includes: obtaining,recording, holding, disclosing, destruction and retaining information. Sensitive personal dataincludes any of the following information: criminal offences, criminal convictions, criminalproceedings, disposal or sentence.The information that you provide on the Declaration Form in the application form will beprocessed in accordance with the Data Protection Act 1998, and will only be used for thepurpose of determining your application for this position. Once a decision has been madeconcerning 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 berestricted to designated persons within the Medical Workforce Department of the LondonDeanery and other persons who need to see it as part of the selection process and who areauthorised to do so. The information may be passed to your employing trusts.Dr Fiona MossActing Dean Director of Postgraduate Medical & Dental Education
    • Template 2009 – last amended 8th January 2009To applicants: you should complete your application form after carefully reading this person specificationwhich 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 SUB SPECIALTY TRAINING IN HEPATOLOGY PERSON SPECIFICATION ESSENTIAL WHEN DESIRABLE WHEN EVALUATED EVALUATEDQUALIFICIATIONS • Eligible for registration AF • ALS AF with the GMC • MBBS (or equivalent) AF • MRCP or equivalent by AF date of shortlisting panelCLINICAL EXPERIENCE • Will have completed 3 AF • MD / PhD with an AF years specialty training interest in Hepatology in Gastroenterology by time of commencement of post • Will have completed 1 AF year’s specialty training including substantial Hepatology experience or research by time of commencement of post • Experience of managing AF patients in ITU / HDU and A & ECLINICAL SKILLS • Ability to manage and AF, I/V, Ref • Additional clinical skills AF, I/V cope with unselected in Gastroenterology and medical emergency nutritional medicine takes • ERCP skills to AF • Understanding of clinical I/V intermediate level of risk management training • Competent to work without direct supervision where I/V, Ref appropriate • Clear, logical thinking showing an analytical / AF, I/V, Ref scientific approach • Advanced endoscopy skills AF, I/VKNOWLEDGE • Appropriate level of Ref • Demonstrates breadth AF, I/V clinical knowledge of experience and awareness in andAF = Application FormI/V = InterviewRef = ReferenceAny attributes which are evaluated on the basis of the application form alone may be further explored at the interview stage
    • Template 2009 – last amended 8th January 2009 • Shows knowledge of I/V outside specialty / evidence informed medicine I/V practice I/V, Ref • Demonstrates use of • Shows awareness of evidence informed own limitations practiceAF = Application FormI/V = InterviewRef = ReferenceAny attributes which are evaluated on the basis of the application form alone may be further explored at the interview stage
    • Template 2009 – last amended 8th January 2009ORGANISATION AND • Ability to prioritise I/V, Ref • Understanding of NHS, AF, I/VPLANNING clinical need clinical governance & resource constraints; • Ability to organise I/V, Ref management / financial oneself and own work awareness; experience • Active involvement in AF of committee work audit • Experience and ability to AF, I/V, Ref work in multi- professional teams • Information technology AF skillsTEACHING SKILLS • Evidence of teaching AF • Enthusiasm for AF, I/V experience teaching; exposure to different groups / teaching methodsACADEMIC / RESEARCH • Familiar with I/V • Research experience AF, I/V publications and (beyond BSc) potential developments • Presentations & / or , AF, I/V in the specialty publicationsCAREER PROGRESSION • • Progression of career AF consistent with personal circumstancesSTART DATE • • Available to start on the AF, I/V post start datePERSONAL 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) • DECISIVENESS/ I/V, Ref 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)AF = Application FormI/V = InterviewRef = ReferenceAny attributes which are evaluated on the basis of the application form alone may be further explored at the interview stage
    • Template 2009 – last amended 8th January 2009 • 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- 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 screeningAF = Application FormI/V = InterviewRef = ReferenceAny attributes which are evaluated on the basis of the application form alone may be further explored at the interview stage
    • Template 2009 – last amended 10th February 2010 Candidate Number : ____________________________Please complete this application form carefully. CVs and additional pages will not beaccepted. THE LONDON DEANERY in association with the East of England and Kent, Surrey & Sussex (KSS) Deaneries APPLICATION FORM SUB-SPECIALTY TRAINING PROGRAMME IN HEPATOLOGY 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?If not registered with the GMC at time of application, will you be eligible for FULL registration by the time ofappointment? Please give details below.
    • Template 2009 – last amended 10th February 2010 Candidate Number : ____________________________ Section C – Equal Opportunities Monitoring FormWe are committed to eliminating unlawful discrimination from employment and selection practices. We will take stepsto ensure that employees are recruited, trained and promoted on the basis of ability, the requirements of the job and theneed to maintain an efficient and effective service. To monitor this policy, we require the following information whichwill only be used for this purpose. It will form no part of the interviewing process, and will be treated in strictconfidence. This sheet will be detached from your application form on receipt. If you are appointed, it will be kept onyour 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 backgroundBlack 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
    • Template 2009 – last amended 10th February 2010 Candidate Number : ____________________________Disability Discrimination Act 1995The Disability Discrimination Act protects disabled people. This includes people with long-term health conditions. If youtell us that you have a disability we can make reasonable adjustments to where you work and your work arrangements orat interview.Do you consider yourself to have a disability? Yes I do not wish to disclose this information NoPlease state the type of impairment which applies to you. People may experience more than one type of impairment, inwhich 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 attend Yes Nofor 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 the envelope“CONFIDENTIAL”. Alternatively, you may send an email to Confidentialenquiries@londondeanery.ac.uk , Pleasealso 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 thePerson Specification, do you wish to be considered under the Guaranteed InterviewScheme? Pleas see the Disability Discrimination Act for more detailsIf you tick Yes you must email ConfidentialEnquiries@londondeanery.ac.uk to ensure Yes Noyour eligible for the guaranteed interview scheme. Failure to do so may result inyou not being granted a guaranteed interview. Emails to this address are managed instrict confidence and will not be shared with the interview panel. Please see theDisability 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)? Yes NoDate available to start post – please give reasonsDo 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 Yes No
    • Template 2009 – last amended 10th February 2010 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, Speaking7, Listening 7, Reading 7, Writing 7
    • Template 2009 – last amended 10th February 2010 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 a placeon this training programme and you are subject to the Resident Labour Market Test, your application will notbe considered in this round of recruitment. Applicants in this category should consider re-applying to anyfurther 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 StatusSelect 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
    • Template 2009 – last amended 10th February 2010 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 3 Partner / civil partner or spouse of UK / EEA 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
    • Template 2009 – last amended 10th February 2010 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 that date.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.
    • Template 2009 – last amended 10th February 2010 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 YES NO 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? YES NO3 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 YES NO 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 YES NO country following allegations made against you?5 Are you aware of any current NHS Counter Fraud and Security Management Service YES NO 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, YES NO 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 YES NO 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 YES NO 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 YES NO 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 YES NO 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 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 contactJane Appleyard at the Deanery (see above).
    • Template 2009 – last amended 10th February 2010 Candidate Number : ____________________________Section G – RefereesReference 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 DateConsultant / Level End DateEducationalSupervisor) Consultant / Educational Supervisor Name Job title AddressPlease give fulladdress Town County Post code Country Telephone number Fax Number Email address
    • Template 2009 – last amended 10th February 2010 Candidate Number : ____________________________Reference 2 Post Details (post held by applicant) Specialty Start Date Level End Date Consultant / Educational Supervisor Name Job title AddressPlease give fulladdress Town County Post code Country Telephone number Fax Number Email addressReference 3 Post Details (post held by applicant) Specialty Start Date Level End Date Consultant / Educational Supervisor NamePlease give full Job titleaddress Address Town County Post code Country Telephone number Fax Number Email address
    • Template 2009 – last amended 8th January 2009 Candidate Number : ____________________________Entry Criteria checklistYou should select the following checklist to indicate that you have completed this application form in conjunctionwith the entry criteria set out in the relevant Specialty / entry level Person Specification for the post applied for.Entry CriteriaI meet the entry qualifications Yes NoI have the right to work in the UK Yes NoI have no fitness to practice restrictions, or any other prohibition, limitation or Yes Norestriction which would prevent me from applying for this postI am proficient in English Language Skills at the required level Yes NoThe Deanery is currently seeking advice on whether it is classified as an Employment Agency for thepurposes 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 theDeanery 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.
    • Template 2009 – last amended 10th January 2010 Candidate Number: ___________________ APPENDIX A Country of Origin Afghanistan Ecuador Macedonia San Torne and Principe Albania Egypt Madagascar Saudi Arabia Algeria El Salvador Malawi Senegal American Samoa Equatorial Guinea Malaysia Seychelles Andorra Eritrea Maldives Sierra Leone Angola Estonia Mali Singapore Anguila Ethiopia Malta Slovakia(Slovak Republic) Antarctica Falkland Islands (Malvinas) Marshall Islands Slovenia Antigua and Barbuda Faroe Islands Martinique Solomon Islands Argentina Fiji Mauritania Somalia Armenia Finland Mauritius South Africa Aruba France Mayotte South Georgia and South Australia French Guiana Mexico Sandwich Islands Austria French Southern Territories Micronesia(Federated South Korea Azerbaijan Gabon States of) Spain Bahamas Gambia Moldova Sri Lanka Bahran Georgia Monaco St Helena Bangladesh Germany Mongolia St Pierre and Miquelon Barbados Ghana Montserrat Sudan Belarus Gibraltar Morocco Suriname Belgium Greece Mozambique Svalbard and Jan Mayen Belize Greenland Myanmar Islands Berin Grenada Namibia Swaziland Bermuda Guadeloupe Nauru Sweden Bhutan Guam Nepal Switzerland Bolivia Guatemala Netherland Antilles Syrian Arab Republic Bosnia&Herzegovina Guinea Netherlands Taiwan Botswana Guinea Bissau New Caledonia Tajikistan Bouvet Island Guyana New Zealand Tanzania Brazil Haiti Nicaragua Thailand British Indian Ocean Heard and McDonald Niger Togo Territory Islands Nigeria Tokelau Brunei Darussalam Honduras Niue Tonga Bulgaria Hong Kong Norfolk Islands Trinidad and Tobago Burkina Faso Hungary North Korea Tunisia Burundi Iceland NorthernMariana Islands Turkey Cambodia India Norway Turkmenistan Cameroon Indonesia Oman Turks and Caicos Islands Canada Iran (Islamic Republic) Pakistan Tuvalu Cape Verde Iraq Palau Uganda Cayman Islands Ireland PalestinianTerritory Ukraine Central African Republic Israel (Occupied) United Arab Emirates Chad Italy Panama United Kingdom Chile Jamaica Papua New Guinea United States of America China Japan Paraguay United States Minor Christmas Island Jordan Peru Outlying Islands Cocos (Keeling) Islands Kazakhstan Philippines Uruguay Colombia Kenya Pitcairn Uzbekistan Comoros Kiribati Poland Vanuatu Congo (Republic of) Kuwait Portugal Vatican City State (Holy Cook Islands Kyrgyzstan Puerto Rico See) Costa Rica LaoPeoplesDemocratic Qatar Venezuela Côte dIvoire Republic Reunion Vietnam Croatia Latvia Romania Virgin Islands (British) Cuba Lebanon Russian Federation Virgin Islands (U.S.) Cyprus Lesotho Rwanda Wallis and Futuna Islands Czech Republic Liberia Saint Kitts and Nevis Western Sahara Denmark Libyan Arab Jamahiriya Saint Lucia Yemen Djibouti Liechtenstein SaintVincent and the Yugoslavia Dominica Lithuania Grenadines Zambia Dominican Republic Luxembourg Samoa Zimbabwe East Timor Macau San MarinoPlease complete this application form carefully. CVs and additional pages will not beaccepted. Printed : 03 December 2010
    • Template 2009 – last amended 10th January 2010 Candidate Number: ___________________ SUB SPECIALTY TRAINING IN HEPATOLOGY PART TWO Ref: 018/15 Section H – Professional QualificationsMedical / Dental 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,MRCP, MRCS etc) – state class ofdegree awardedPlease give details of anyresearch degree (MD,PhD) currently beingundertakenSection I – Present EmploymentEmployer’s / NHS Trust name :Address :Telephone number :Current position – please state Length of Nationalif locum position Date Length of notice TrainingSpecialty Grade appointed contract required Number Printed : 03 December 2010
    • Template 2009 – last amended 10th January 2010 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 postPlease explain any gaps in your employment history Printed : 03 December 2010
    • Template 2009 – last amended 10th January 2010 Candidate Number: ___________________Section K – Clinical Knowledge and ExperienceExperience of managing patients in ITU / HDU and A & EExperience of the management of acute unselected medical takeBasic skills in GastroenterologyExperience with nutritional supportExperience with Endoscopy and ERCP Printed : 03 December 2010
    • Template 2009 – last amended 10th January 2010 Candidate Number: ___________________ALS Course (please give date andplace)Section L – Audit and Managementa) Please describe your experience of clinical audit. Indicate clearly your own level of involvement.b) Please describe any experience of managing people and / or resources / or of working in teams. You may give examples from both inside and outside medicine.c) Briefly describe what you understand by the term “clinical governance”d) Please indicate your level of familiarity with Information Technology Printed : 03 December 2010
    • Template 2009 – last amended 10th January 2010 Candidate Number: ___________________Printed : 03 December 2010
    • Template 2009 – last amended 10th January 2010 Candidate Number: ___________________Section M – Other AchievementsA range of personal skill have been identified as being particularly important in successful medical specialists. Foreach 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 the space below, give a recent example that demonstrates that you possess these skills.b) Initiative. In the space below, give a recent example that demonstrates this. Printed : 03 December 2010
    • Template 2009 – last amended 10th January 2010 Candidate Number: ___________________Section N – Academic Achievementsa) Prizes or other academic distinctionsb) Research, whether past or in progress. If you have undertaken or are undertaking a research project, please give details and indicate your involvement.c) 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 authord) Presentations / posters at conferencese) Experience of teaching (including outside medicine) Printed : 03 December 2010
    • Template 2009 – last amended 10th January 2010 Candidate Number: ___________________Printed : 03 December 2010
    • Template 2009 – last amended 10th January 2010 Candidate Number: ___________________Section O – Aims & Career Objectives / Commitment to theSpecialtySection P – Interests, Skills & Achievements Outside Medicine Printed : 03 December 2010
    • Template 2009 – last amended 10th January 2010 Candidate Number: ___________________Section Q – Any Further Information Relevant to this Application Printed : 03 December 2010
    • Template 2009 – last amended 10th January 2010 Candidate Number: ___________________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 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 S - Equal OpportunitiesThe London Deanery aims to promote equality of opportunity and is committed to treating all applicantsfor 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 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.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 Occupational Healthclearance 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 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. Printed : 03 December 2010
    • Template 2009 – last amended 10th January 2010 Candidate Number: ___________________Signature Date Printed : 03 December 2010
    • To the applicant : this shows the scoring system to be used for short-listing from the application form. If the short-listingpanel agrees that you have scored “0” in any of the essential criteria this means that you have not provided sufficientevidence to demonstrate the attribute. You therefore cannot be shortlisted. You are advised to self-assess yourself priorto application and to seek advice from your educational supervisor if necessary. This should not be returned with yourapplication. 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 – SPECIALTY TRAINING IN HEPATOLOGYNB All entry criteria must be met by date of shortlisting committeeENTRY 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 YES / NO by Deanery of the essential criteria?MBBS (or equivalent) H If an applicant scores 0 in any of the essential criteria, the application must be discussed at the shortlisting committeeMRCP (or equivalent) HCompletion of 3 years specialty clinical training in Gastroenterology I&Jby time of commencement of postCompletion of 1 year’s specialty training including substantial I&JHepatology experience or research by time of commencement ofpostESSENTIAL CRITERIA Maximum Score Applicant’s Assessed in DESIRABLE CRITERIA Maximum Score Applicant’s (Range 0 –2) score this Section (Range 0 – 2) score of the Application Form H MD / PhD with an interest in Hepatology 2 I&J Appropriate progression of career 2Experience of managing patients in ITU / 2 KHDU and A&EExperience in the management of acute 2 K Additional experience in Gastroenterology and 2unselected take nutritional medicine
    • ESSENTIAL CRITERIA Maximum Score Applicant’s Assessed in DESIRABLE CRITERIA Maximum Score Applicant’s (Range 0 –2) score this Section (Range 0 – 2) score of the Application FormEndoscopy skills 2 K ERCP skills 2 K ALS 2Active involvement in Audit 2 L (a)Experience of working in multi-professional 2 L (b)teams L (c) Management / financial awareness, experience of 2 committee work, understanding of the NHS, clinical governance and resource constraintsAppropriate Information Technology skills 2 L (d)Communication and interpersonal skills 2 M (a)Demonstrates drive and initiative 2 M (b) N (b) Experience of research (beyond BSc) 2 N (c & d) Presentations & / or publications 2Experience of teaching 2 N (e) Enthusiasm for teaching, exposure to different groups / 2 teaching methodsDemonstrates analytical / scientific 2 AF Demonstrates breadth of awareness 2approachTotal number of points (Maximum - 40) points scored ______________________Minimum number of points required to be considered for short-listing is 18Please note that if an applicant achieves this score he/she will not automatically be short-listed. This is the minimum standardwhich 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