Performers List Application Form and Notes

8/12/2019 Performers List Application Form and Notes

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NOTES FOR APPLICANTS

The application process and associated documentation has been produced in accordance with the NHS(Performers List) Regulations 2013. Any application submitted will be considered under the provision ofthese Regulations. Performers who appear on a Performers List should be aware of the requirementsplaced upon them by these Regulations.

Your application should be made in person to the Operations Department of the NHSCB Local AreaTeam. Locality is determined as follows:

The practice where you undertake the majority of the work which requires you to be on a performerslist;

If you are not attached to a practice, this is the address held by your registration body; If your registered address is outside England, but you wish to practice in England and are applying to

join the NHS CB’s national performers list, your application should be directed to :- Cumbria, Northumbria and Tyne and Wear AT for performers whose address is in Scotland;

Shropshire/Staffordshire AT for performers whose address is in North Wales; Arden, Hereford and Worcester AT for performers whose address is in South Wales; Wessex AT for performers whose address is in the Channel Islands; Merseyside AT for performers whose address is in Northern Ireland; and London North West AT for performers whose address is outside the UK.

Disclosure and Barring ServiceYou will be required to provide a recent DBS Enhanced Disclosure Certificate, PIN for update or Fee andForm to enable a check to be undertaken.

Applicants who cannot provide UK residency details for the last 5 years must undergo a Police HomeCheck. This can be arranged by contacting your Home Office or Embassy.If the document you provide is not in English, you will need to provide a translation that has been issuedin the UK and signed by an official translator.

Further information can be obtained fromhttp://www.homeoffice.gov.uk/agencies-public-bodies/dbs/

http://www.homeoffice.gov.uk/agencies-public-bodies/dbs/




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Documents Required to Support Your Application

The following documents should be brought along with you at the time of your application. (See also therequirements of the Disclosure and Barring Service).

All Documents must be ORIGINALS (photocopies cannot be accepted).

Passport or photo ID driving licence

Your certificate of Full Registration with the GMC/GDC/GOC

Your graduation certificate

Your Vocational Training Certificate – not applicable to Trainee applicants Or

Certificate of Prescribed/ Equivalent Experience e.g. JCPTGP, PMETB or Evidence of Equivalency

Ophthalmic Qualification Committee document – OMP’s only

Recent Occupational Health Report - if available

A detailed Curriculum Vitae of your complete work history

Language Knowledge Certificate, OR alternative - if applicable

A copy of your most recent appraisal/outcome statement - if available

Work permit - if applicable

Evidence of Membership of a recognised professional defence organisation at appropriate level

Completed DBS form and appropriate fee if applicable, OR your current DBS Enhanced DisclosureCertificate if it was issued within the last 3 months, OR PIN for update service

Additional Identity Documents will be required. See the DBS Checklist for details.


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SECTION 1: Personal details

1. Surname (This should be the name in which

you are known by your registration body) 2. Forenames

3. Any other surname previously used(including Maiden Name)

4. Gender Male /X Female /X

5. Title

6. Date of Birth D D M M Y Y Y Y

7. National Insurance Number

8. UK Contact Address

(This should your home address which should be inlocal NHSCB’s locality. If you are relocating andcurrently live in another part of the country, orabroad, please include details of your intentions,using Section 6 Additional information.)

Postcode

9. Private Telephone Number

10. Mobile Telephone Number

11. Preferred Contact Number

12. Email Address

13. GMC/GDC/GOC Registered Address (Ifdifferent to UK Contact Address)

Postcode



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SECTION 1: Personal details (cont)

14. Please indicate in what capacity you wish to join the performer list

Medical List Medical List Dental List

GP Performer GP Returner Scheme Dental Locum

Salaried GP by practice GP Retainer Scheme Ophthalmic List

Salaried GP by CCG Armed Services Optometric Performer

GP Trainee Dental List Ophthalmic Medical

Practitioner

GP Locum Dental Performer Optometric Locum

Flexible Career Scheme Dental Trainee Optometric Trainee

15. Nationality Yes ( ) No ( X )

15.1. Are you a full British Citizen or an EC National? If No go to nextQuestion

15.2. Do you have evidence of entitlement to enter and work in the UnitedKingdom (e.g., settled status, spouse of a British Citizen?) If No go to nextquestion.

15.3. Were you admitted to the United Kingdom as a doctor before 1 st April1985?

If not, what is your immigration status – please tick appropriately

15.4. Student

15.5. Visitor (including if you are taking the PLAB test)

15.6. Subject to work permit provisions

15.7. Self employment

15.8. Is there a time limit placed on your stay in the United Kingdom and if so what is this? Please givefull details and state visa period or period of leave to remain

15.9. Please state your country of birth



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SECTION 2: Practice Details

16. If you are linked to a practice, pleaseprovide the full name and address.N.B. Trainees and Students should providetheir training practice details

17. Practice Telephone Number

18. Practice Fax No

19. Practice email address

20. Level of CommitmentPlease indicate the basis you will be working inthe practice. If not full time, state the number ofsessions – For guidance:-1 Session = 4 hours and 10 minutesFull-time = 37 hours and 30 minutes per weekThree-quarter time = up to 6 sessions, but notmore than 25 hours per week

This section is for Trainees and Students only

21. Date of Commencement D D M M Y Y Y Y

22. Expected end Date D D M M Y Y Y Y

23 Name of Approved Trainer



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SECTION 3: Professional details

24. Professional Council RegistrationNumber (e.g. GMC/GDC/GOC)

25. Date of First Registration D D M M Y Y Y Y

26. Date of Full Registration D D M M Y Y Y Y

27. GPs only

Date of Inclusion in GP Register (nonRegistrars)

D D M M Y Y Y Y

28. Do you have a license to practise? Yes No

If you answered “ no ” to the above question please provide details and a supporting explanation

29. Please give details of your Professionalindemnity/Insurance at a levelcommensurate with the performer listapplication

30. Ophthalmic Medical Practitioners onlyOQC Number

31. Date of Qualification D D M M Y Y Y Y

32. Please list all your primary, vocational and postgraduate qualifications

Qualification Institution (give name & place) Date of Qualification



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SECTION 3: Professional details (cont)

33. Please list in chronological order all your professional experience:-

Explain any gaps between appointments Explain any dismissals from posts Any additional supporting particulars – Please use Section 6 Additional Information or

continue on a separate sheet(s) as appropriate A period of locum work should be indicated with a statement indicating the period of

locum work and the type of work undertaken – every appointment should be listed. Where a period of locum work has been interrupted by a permanent or semi-permanent

post this should be reflected accordingly. Leave of absence for matters such as maternity leave or study leave whilst in a

permanent post do not need to be shown

List all Appointments held and if as a performer, indicate your status i.e. Principal,Non Principal, Locum or Trainee)

Post Location and Specialty Start and finish date WT PT



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SECTION 3: Professional details (cont)

The provide the fol lowing inform ation relat ing to assessments or appraisals

38. Please provide details of your current revalidation cyclee.g. 2012 – 2017

AppraisalNo

Appraisal Year Date of appraisal orgrounds ofexemption

Organisation thatundertook the

appraisal

Name of your appraiser

1

2

3

4

5

If you have not undertaken appraisal, please provide the reasons for this:

Please provide details of your compliance with the core CPD requirements of your professional body:



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SECTION 4: English Language Knowledge (cont)

Table of Recognised Institutions and Pass/Score Required

Awarding Body Title of Qualification Pass/MinimumAverage Score

Cambridge UniversityCertificate in English (ESOL)www.cambridgeesol.org

Business English Certificate (BEC BEC Vantage

London Chamber of CommerceInstitute Examination (LCCIEB)www.lccieb.com

English for Business (EFB) EFB Level 2

National Open College NetworkNOCNwww.nocn.org.uk

NOCL Entry Level Certificate inESOLSkills for Life

Entry 2

Pitmanswww.pitmanqualifications.com Certificate in English Achiever B2 *CEF Leve

Trinitywww.trinitycollege.co.uk

Certificate in IntegratedSkills in English (ISE I) B2 *CEF Level

Avalon/University of Bathwww.bath.ac.uk/ubelt/

English Language Assessment 2.5

Linguaramawww.linguarama.com

Linguarama English Test2.0

International English LanguageTesting Systemwww.ielts.org

General International EnglishLanguage Testing System 7

International English LanguageTesting Systemwww.ielts.org

International English Language TSystem Academic 6

Educational Testing Servicewww.ets.org

Test of English as a Foreign Lang(TOEFL) Internet Based Test 80

Educational Testing Servicewww.ets.org Test of English as a Foreign Lang(TOEFL) Computer Based Test 200


Test of English as a Foreign Lang(TOEFL) Paper Based Test 450


Test of English for InternationalCommunication (TOEIC) 660

Eutopia Medical Solutionswww.eutopiamedical.com

Eutopia Certificate in Dental EngliLanguage 60%

* CEF: Common European Framework

http://www.cambridgeesol.org/

http://www.lccieb.com/

http://www.nocn.org.uk/

http://www.pitmanqualifications.com/

http://www.trinitycollege.co.uk/

http://www.bath.ac.uk/ubelt/

http://www.linguarama.com/

http://www.ielts.org/


http://www.ets.org/

http://www.ets.org/

http://www.ets.org/

http://www.ets.org/

http://www.eutopiamedical.com/

http://www.eutopiamedical.com/

http://www.ets.org/

http://www.ets.org/

http://www.ets.org/

http://www.ets.org/



http://www.linguarama.com/

http://www.bath.ac.uk/ubelt/

http://www.trinitycollege.co.uk/

http://www.pitmanqualifications.com/

http://www.nocn.org.uk/

http://www.lccieb.com/

http://www.cambridgeesol.org/



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SECTION 5: Clinical References

You must provide details of two referees who have consented, if requested, to provide aclinical reference i.e. which relates to your clinical competence and abilities. The refereesshould be professional colleagues; one in your current role and one from your most recentpost within the previous two years in which you have worked for 3 continuous months ormore, at least one of which should not be someone with whom you have a financial orpersonal connection. If this is not possible because posts have been of shorter duration or you have worked as alocum with numbers of casual posts, you may include a referee from a frequently-held,recurrent post, for example. If you still have difficulty with identifying two referees, you maychoose alternatives, but you are required to supply written reasons for this.

Referee 1

Name

Address

Telephone Number

Email Address

Relationship/ Capacity Known

Length of Time Known

Referee 2

Name

Address

Telephone Number

Email Address

Relationship/ Capacity Known

Length of Time Known



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SECTION 6: Additional Information

Please provide any other information that the Commissioning Board may reasonably requireto determine your application

Please continue any of the above information on a separate sheet if necessary



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SECTION 7: Declarations – The NHS (Performers Lists) Regulations 2013

Under regulation 9, paragraph 2, all practitioners must make a declaration within 7 days ifthe practitioner:

a. Is convicted of a criminal offence in the United Kingdom;b. is bound over following a criminal conviction in the United Kingdom;c. accepts a police caution in the United Kingdom;d. has accepted a conditional offer under section 302 of the Criminal Procedure

(Scotland) Act 1995 (fixed penalty: conditional offer by procurator fiscal) or acompensation offer under section 302A of that Act (compensation offer by procuratorfiscal) or agreed to pay a penalty under section 115A of the Social Security

Administration Act 1992 (penalty as alternative to prosecution);e. has, in proceedings in Scotland for an offence, been the subject of an order under

section 246(2) or (3) of the Criminal Procedure (Scotland) Act 1995 (admonition andabsolute discharge) discharging the Performer absolutely;

f. is convicted elsewhere of an offence which would constitute a criminal offence ifcommitted in England and Wales;

g. is charged in the United Kingdom with a criminal offence, or is charged elsewherewith an offence which, if committed in England and Wales, would constitute acriminal offence;

h. is involved in any inquest as a person who falls within rule 20(2)(d) (entitlement toexamine witnesses) or rule 24 (notice to person whose conduct is likely to be calledinto question) of the Coroners Rules 1984;

i. is informed by any regulatory or other body of the outcome of any investigation whichincludes a finding adverse to the Performer;

j. becomes the subject of any investigation by any regulatory or other body;k. becomes the subject of any investigation in respect of any current or previous

employment, or is informed of the outcome of any such investigation which includesa finding adverse to the Performer;

l. becomes the subject of any investigation by the NHS Business Services Authority inrelation to fraud, or is informed of the outcome of such an investigation whichincludes a finding adverse to the Performer;

m. becomes the subject of any investigation by the holder of any list which could lead tothe Performer ’s removal from the list;

n. is removed or suspended from, refused inclusion in, or included subject to conditionsin, any list; or

o. becomes subject to a national disqualification.

Note: The Rehabilitation of Offenders Act 1974 does not apply for the purpose of this

declaration. Offences considered “spent” under that Act must be declared.

Under regulation 9, paragraph 4, a practitioner must make a declaration within 7 days if thepractitioner is, has in the preceding 6 months been, or was at the time of the originatingevent, a director of a body corporate that:

a. Is convicted of a criminal offence in the United Kingdom;b. is convicted elsewhere of an offence, which would constitute a criminal offence if

committed in England and Wales;c. is charged in the United Kingdom with a criminal offence, or is charged elsewhere

with an offence which, if committed in England and Wales, would constitute a criminaloffence;

d. is informed by any regulatory or other body of the outcome of any investigation whichincludes a finding adverse to the body corporate;

e. becomes the subject of any investigation by any regulatory or other body;



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SECTION 7: Declarations – The NHS (Performers Lists) Regulations 2013(cont)

f. becomes the subject of any investigation in relation to fraud, or is informed of theoutcome of any such investigation, which includes a finding adverse to the body

corporate;g. becomes the subject of any investigation by the holder of any list which might lead to

its removal from that list;h. is removed or suspended from, refused inclusion in, or included subject to conditions

in, any list;i. is involved in an inquest as a person who falls within rule 20(2)(d) (entitlement to

examine witnesses) or rule 24 (notice to person whose conduct is likely to be calledinto question) of the Coroners Rules 1984; or

j. becomes subject to a national disqualification.

Note: Originating events are the events that gave rise to the conviction, investigation,

proceedings, suspension, refusal to admit, conditional inclusion, removal orcontingent removal took place

Do any of the twenty five circumstances listedapply?

Yes No

If Yes, please enter the appropriate identifying number(s)

from the above list, and provide the informationrequested below

Please provide full details of any investigation or proceedings brought or about to bebrought, including approximate dates, the nature of such investigations or proceedings and,where known, their outcome. If giving details of a body corporate you should also providethe name and registered office of the body corporate.



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SECTION 8: Undertakings

I Undertake:

to provide the declarations and documents ,if applicable, required by Regulation 9 of theNHS Performer List Regulations 2013;

to notify the NHSCB in writing within seven days of the occurrence of any eventsspecified in Regulation 9 of the NHS Performer List Regulations 2013;

to supply an enhanced criminal record certificate under Section 115 of the Police Act1997 PIN Update or application form in respect of this performer list application and atany time, for reasonable cause if the NHSCB requests me to do so;

to notify the NHSCB within seven days of any material changes to the informationprovided in the application until the application is finally determined, or at any time whenmy name is included in the list, including if there is any change in the circumstances ofmy working arrangements;

to maintain adequate and appropriate indemnity arrangements which provide cover inrespect of liabilities which may be incurred in carrying out the work as a performer at alltimes and to provide existence of such an indemnity arrangement to the Board onrequest;

to give notice to the NHSCB within 28 days of any occurrence requiring a change in theinformation recorded about me on the Performer List and of any change to my privateaddress.

to notify the NHSCB at least 3 months in advance of my proposed date of withdrawl fromthe Performers List;

to notify the NHSCB if I am included, or apply to be included, in any other list held by anequivalent body;

to co-operate with an assessment by the National Clinical Assessment Authority ifrequested to do so by the NHS Commissioning Board;

to co-operate with an assessment by the NHS Litigation Authority where appropriate andif requested to do so by the NHS Commissioning Board;

to participate with the appraisal system provide by the NHSCB (excluding optometrists,Type 1 & Type 2 Armed Services GP’s );

where the relevant Part provides to the contrary and the appraisal is not conducted bythe NHS, to provide a copy of the appraisal undertaken.

I am a GP, Optometrist, Dental Trainee undertaking Vocational Training andUndertake:

not to perform any primary care services, except when acting for and under the directionof my approved trainer

to withdraw from the Performers List if I fail to complete my Vocational Training

to provide on completion of my training, satisfactory evidence to the NHSCB that I havecompleted my training



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SECTION 8: Undertakings (cont)

I Declare That :

I am in good health and know of no health issues which could impact on myperformance.

I am a fully registered with my Professional Registration Body with a Licence to Practisein the name shown at the beginning of this form.

The information given in this application form, including any continuation sheets, is trueand complete

I agree to provide the declarations and documents, if applicable, as required byRegulations.

I will inform the Commissioning Board if I change my private address and privatetelephone number and any change in my employment arrangements or name (e.g. as aresult of change in marital status).

I Consent:

to the NHSCB requesting from any employer, former employer, licensing, regulatory orother body in the United Kingdom or elsewhere, information relating to a currentinvestigation, or an investigation, where the outcome was adverse, by that employer orbody regarding myself or any body corporate of which I am or was a director and to thedisclosure of such information by that person or body;

to the disclosure of information in accordance with Regulation 9.

to the disclosure of information to the NHSCB in relation to my appraisal and revalidationhistory which includes release of appraisal and revalidation documentation.

I Understand:

that my failure to comply with the requirements outlined in this declaration that I haveagreed to abide by may result in conditions being placed upon my name on the NHSCBPerformers List or may result in removal of my name from the List.

Name: (please print)

Signature:

Professional Registration Number:

Date: D D M M Y Y Y Y



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SECTION 9: Equal Opportunities

The Equality Act 2010 requires all public sector organisations to ensure they eliminatediscrimination and advance equality of opportunity. The act outlaws discrimination based onnine protected characteristics: race, sex, disability, age, sexual orientation, religion or belief,gender re-assignment, marriage and civil partnership, pregnancy and maternity. Monitoringof access to the performers list will assist the NHSCB to address any potential ofdiscrimination. We would request that you complete this form, however, this is not amandatory requirement. The information you provide will be treated in the strictestconfidence and will be used for monitoring and reporting access to and removal from theNHSCB Performers List. It will be stored electronically with restricted access to named staff.Your data will not be shared by others. The information you provide will be removed fromstorage twelve months after you are removed from the performers list, or twelve months fromthe notification that your application has been rejected.

What is your ethnic group 1 ?Ethnic origin categories are not about nationality, place of birth or citizenship. They are about

the group to which you as an individual perceive you belong. Please choose one section andthen tick one box to best describe you ethnic origin. White

English Welsh Scottish Northern Irish

Irish Gypsy or Irish Traveller Other White background

Mixed/multiple ethnic groups

White and Black Caribbean White and Black African

White and Asian Any other mixed background

Asian/Asian British Indian Pakistani

Bangladeshi Chinese

Any other Asian background

Black/ African/ Caribbean/ Black British

African Caribbean

Any other Black/African/Caribbean background

Other ethnic group Arab Any other ethnic group

Do you consider yourself to be a disabled person? Yes/No

If ‘Yes’, please describe the nature of your disability.



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OCCUPATIONAL HEALTH QUESTIONNAIRE

Surname: First Name: Date of birth:

Profession: Doctor/Dentist/Optometrist (delete as appropriate)

Street Address:

Town/City: County: Postcode:

Phone No: E-mail Address:

1. Have you lived or worked in a country other than the UK, Europeancountries, New Zealand, USA and Canada?

YES/NO(delete as

appropriate)

If YES, which countries?

Dates:

2. Do you have any health issues that may affect your ability to undertakethe duties of your role?

YES/NO(delete as

appropriate)If YES, please give details.

3. Infectious diseases:

3.1. Tuberculosis

Have you lived continuously in the UK for the last 5years? YES/NO (delete as appropriate)

If NO, please list all the countries that you have lived in or visited for more than 4 weeks over thelast 5 years:

Do you have reason to believe that you may have beenexposed to tuberculosis? YES/NO (delete as appropriate)

Have you had TB? YES/NO (delete as appropriate)

THIS DOCUMENT SHOULD BE PLACED IN A SEALED ENVELOPE MARKED PRIVATE & CONFIDENTIALAND RETURNED FOR THE ATTENTION OF THE RO (________________) AREA TEAM.

YOU WILL BE REQUIRED TO UNDERGO TESTING FOR BLOOD BORN VIRUSES AT YOUR OWN COST.

Performers List Application Form and Notes

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