Step 1 of 3 - Personal Details

Name

Next of Kin in Case of Emergency

Right to Work in the United Kingdom

Professional Registration

Professional Indemnity

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

Appraisal and Revalidation

Please confirm if you have arrangements in place to be appraised regularly by an appropriate trained medical practitioner entered in the Specialist Register and that you have a Responsible Officer as part of the GMC’s Revalidation procedures.

Disclosure and Barring Services

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.
Do you have any spent or unspent criminal convictions?
Do you hold a current Enhanced DBS Certificate issued within 12 months?
Are you currently registered with the DBS Update Services?

Overseas Police Check

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
I have not lived outside UK in the last 5 years

Fitness To Practice

Have you ever been suspended from duty or the subject of a professional conduct/competence enquiry?
Are you aware of any professional conduct/competence enquiries being considered against you?

Working Time Directive Opt Out

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 allowing you to lawfully work more than 48 hours per week. The 48-hour weekly limit will not apply to you. You may terminate this agreement (so the 48-hour limit would apply to you) by giving Medecho 7 days written notice.

Declaration

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. If, before the first Assignment, during the course of an Assignment or within the Relevant Period the Client wishes to employ me directly or through another employment business, I acknowledge that Medecho Ltd may be entitled, either to charge the Client a fee or to agree an extension of the hiring period with the Client at the end of which I may be engaged directly by the Client or through another employment business without further charge to the Client. In addition, I understand that Medecho Ltd will be entitled to charge a fee to the Client if the Client introduces me to a third party who subsequently engages me within the relevant period. 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 of working 48 hours as Specified in Regulation 4 (1) of the Working Time Regulations 1998 shall not apply to me 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/doctors/staffhandbook.pdf www.medecho.com/doctors/terms-of-engagement.pdf