We recommend you have personal professional indemnity insurance. If you already have this, please provide details of your membership and include a copy.

The nature of the work you are applying for is exempt from the provision of section 4(2) of the Rehabilitation of offenders Act 1974 Exception Order 1975. Applicants are therefore, not entitled to withhold any information about convictions, even if they are regarded as “spent” convictions under the provisions of this Act. Failure to declare a conviction may require us to exclude you from our register or terminate an assignment. Any information given will be treated in the strictest of confidence and only considered where, in the reasonable opinion of Medecho, the offence is relevant to the post which you are applying.

If you have lived or worked outside of the UK for 6 months or more in the last 5 years, please confirm each instance below

The Working Time Directive 1998 requires Medecho to limit your average weekly working hours unless you agree with Medecho that the limit shall not apply to you. By Opting Out you are not committing to a working week of more than 48 hours, but rather allowing yourself to be offered assignments that could take you over this threshold. You may terminate this agreement (so the 48-hour limit would apply to you) by giving Medecho 7 days written notice.

I declare the information provided within this form is true and correct. I will inform Medecho immediately of any circumstances that may affect my work, such as changes to health, subsequent pending criminal investigations, prosecutions, convictions or suspended from duty by any other employer/agency. I give consent to my references being sought and passed onto potential employers. I will also ensure I am inducted and orientated by all Clients prior to starting an assignment. Confidentiality. I agree any patient information obtained during the course of my duties is confidential and should not be disclosed to any third party if it is not legitimately in connection with their treatment or any other official investigation. I will take particular care with patient records when on assignment to ensure that they are not in undue danger of being accessed by unauthorised individuals. (Further information relating to Confidentiality / Data Protection can be found in your Staff Handbook below). I declare that I will keep Medecho apprised of the arrangements I make to remain on the GMC’s List of Registered Medical Practitioners and will advise immediately if there is any change to my GMC registration status including investigation or suspension. I agree that the limit specified in Regulation 4 (1) of the Working Time Regulations 1998 shall not apply in my case (if Opted Out as detailed above). I give consent for Medecho to apply to the Disclosure and Barring Service (DBS)/Disclosure Scotland/Access Northern Ireland for the relevant Enhanced Disclosure or a DBS Status Update Checks where they consider it necessary and that any details from this, or any other police checks provided, may be forwarded to a potential employer. I hereby consent disclosure of my personal data for the purpose of external audits in accordance with the NHS. By signing below, I confirm that I have received, read and accepted the contents of the Medecho Staff Handbook and Terms of Engagement located at: www.medecho.com/wp-content/uploads/2022/02/Staff-Handbook.pdf www.medecho.com/wp-content/uploads/2022/02/Terms-of-engagement.pdf

Hepatitis B Surface Antigen Evidence of Hepatitis B Surface Antigen Test (Inc. ‘e’ antigen and DNA viral loads if applicable Report must be an identified validated sample. (IVS) Hepatitis C Evidence of a Hepatitis C antibody test (Inc. Hepatitis C RNA/PCR if applicable) Reports must be an identified validated sample. (IVS) HIV Evidence of a HIV I and II antibody test (Inc. DNA viral loads if applicable) Reports must be an identified validated sample. (IVS)

All information supplied by you will be held in confidence. Records will be retained electronically in accordance with best practice and the requirements of the General Data Protection Regulations at which time it may be subject to audit. Your data may also be cross referenced should you have registered with other clients of Healthier Business UK Ltd. Your personal data may be required to be seen by an occupational health advisor or physician; however it will not be shown, nor their contents shared with anyone - including Managers, Human Resources Advisors, GP’s, Specialists or third party’s - without your explicit consent. You have the right of erasure (the right to be forgotten), refusal of consent and withdrawal of consent without detriment (withdrawal of consent can be exercised at any stage of the process). The only exceptions to this may be a court order for release of records in a judicial dispute or where there is a public responsibility obligation. Further information regarding your rights under GDPR can be found on the following: https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulationgdpr/individual-rights/ If you wish to have sight of our privacy policy, please send your request to support@hbcompliance.co.uk

Consent is a process rather than a one off decision, for consent to be valid, it must be voluntary and informed. You have the right to withdraw your consent at any stage of the process, either verbally or in writing. Further information regarding consent is available on the ‘Candidate Screening Leaflet’.

I will inform my employer if I am planning to or leave the UK for longer than a three-month period to enable a reassessment of my health to be conducted on my return. I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.