Registration Form

Please complete all details clearly and submit the application form

Personal Details

Professional Membership

Please confirm you are aware of the GMC’s performance monitoring process and have made arrangements to be appraised regularly by an appropriate trained medical practitioner entered in the Specialist Register?
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Professional Indemnity

We recommend that you take membership of a Medical Defence Organisation. If you are already a member please provide details of your membership. Please forward a copy with your application.

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Next Of Kin Details

Medical Questionnaire

Please complete all details clearly and submit the application form

This confidential health screening is undertaken to limit the risk of your health being detrimentally affected by your work and to ensure you are fit to undertake the duties of the role for which you have applied. You may be contacted by our Occupational Health Department for further information if required. This information is assessed by Medecho Ltd Occupational Health Department and is governed by the Data Protection Act 1998.

Medical History

Please complete the following questionnaire:
Do you have any illness/impairment/disability (physical or psychological) which may affect your work?
Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?
Are you having, or waiting for treatment (including medication) or investigations at present?
Do you think you may need any adjustments or assistance to help you to do the job?

Have you suffered from any of the following?

Methicillin Resistant Staphylococcus Aureus (MRSA)
Clostridium Difficile (C-Diff)
If you have answered yes to any of the above medical questions please provide details including dates, diagnosis, and treatment.
Have you ever had chicken pox or shingles?
Have you ever come into contact with any BBV’s? Including Needle Stick Injuries?

Immunisation History

Have you have any of the following immunisation?
Triple vaccination as a child (Diptheria / Tetanus / Whooping cough)
Polio
Tetanus
Hepatitis B
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Tuberculosis

Clinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE 2016)
Have you lived outside the UK or had an extended holiday outside the UK in the last year?
Have you had a BCG vaccination in relation to Tuberculosis?
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Do you have any of the following?

A cough which has lasted for more than 3 weeks
Unexplained weight loss
Unexplained Fever
Have you had tuberculosis (TB) or been in recent contact with open TB

Proof of Immunity

Please send all proof of immunity and pathology reports

Varicella:You must provide a written statement to confirm that you have had chicken pox or shingles however we strongly advise that you provide serology test result showing varicella immunity.

Tuberculosis:We require an occupational health/GP certificate of a positive scar or a record of a positive skin test result. (Do not Self Declare) .

MMR:Certificate of “two” MMR vaccinations or proof of a positive antibody for Rubella and Measles. .

Hepatitis B:You must provide a copy of the most recent pathology report showing titre levels of 100lu/l or above.

Exposure Prone Procedures Only

For doctors undertaking exposure prone procedures (EPPs) please address items below. Exposure prone procedures are those where there is a risk that injury to the doctor could result in their blood contaminating a patients open tissues. Exposure prone procedures occur mainly in surgery.

Are you likely to undertake exposure prone procedures (EPPs) in your work?

Hepatitis B Surface Antigen:Evidence is required of a negative Surface Antigen Test for Hepatitis B.

Hepatitis C:Evidence of a negative antibody test for Hebatitis C.

HIV:Evidence of a negative antibody test for HIV.

Report must be marked as an identified validated sample. (IVS)

Declaration

Applicants for locum medical positions are exempt from the Rehabilitation of Offenders Act 1974. You are required to declare prosecution or conviction, including those considered ‘spent’ under this Act.

Have you ever been convicted of a criminal offence or the subject of any investigations which might lead to a conviction?
Have you ever been the subject to any ‘Fitness to Practice’ proceedings?
Have you ever been suspended from duty with any organisation or with the GMC?
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.

Regulation 4 of the Working Time Directive requires that a worker’s average working time must not exceed 48 hours per week unless the worker agrees in writing to exceed the limit. By signing this document, you are agreeing with Medecho Ltd to opt-out of the Working Time Directive al-lowing you to lawfully work more than 48 hours per week. The 48-hour limit on average weekly time will not apply to you. You may terminate the agreement (so the 48-hour time limit would apply to you) by giving Medecho Ltd 1 weeks’ notice. I confirm that I have read this document fully and that all the information given to Medecho is correct to the best of my knowledge. I am not aware of any condition, medical or otherwise, which would limit or affect my employment or performance. I acknowledge that I have been given a copy of the current terms and conditions of service and Staff Handbook issued by Medecho Ltd, and that I have read, understood and agree to abide by them. I can confirm that I am happy to agree with the Working Time Regulation notes as detailed within this document. I understand that Medecho Ltd will process my personal data in accordance with General Data Protection Regulations for the purposes of seeking employment opportunities. I authorise disclosure of my personal data to such third parties as Medecho Ltd sees appropriate.

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