RMR | User Registration

Personal Details

Email address*

Title*

First Name:*

Last Name:*

Have you ever been known by any other name?*

Have you changed your name through marriage/by deed poll, etc

Other Name

If you have changed your first name or family name/last name, please provide all previous names above

Address 1:*

Address 2

Town/City:*

Postal Code:*

Date of Birth (enter in format DD/MM/YYYY):*

National Insurance number?*

National Insurance Number must be entered in format AB123456C or 1234567A without any gaps

Gender*

Mobile number*

Valid mobile number would be: 07985123456

Nationality:*

Do you have EU Settlement Scheme status granting either Settlement or Pre-settlement status?*:

Emergency Contact

Emergency contact name:*

Relationship to you:*

Emergency contact number:*

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Your Profession

Profession:*

N&M Speciality:*

DR Speciality:*

Select your professional registration body:*

Select your professional registration status:*

Are you seeking a Paediatric role?:*

Click here to attach Your CV

Have you had an appraisal before?*

What was the date of your last appraisal?*

At which establishment was the appraisal completed?*

Please list any qualification(s) you hold*

If none, please enter N/A

NHS Employee

Are you permanently employed by the NHS in either a full time of part time capacity (excluding bank)?:*

If yes, is it full time or part time?

Are you registered with any NHS staff banks?:*

Professional History and References

Please provide details of all referees within the last 3 years. Please be aware that Robinson Medical Recruitment is unable to offer you work until satisfactory references have been obtained, and that Robinson Medical Recruitment is required to obtain references for you on an annual basis. We are required to obtain references to cover the last 3 years without gaps. If provided here, this will speed up your clearance.

Important notes to consider when entering your referee details:
- Referees must have worked in a supervisory position to yourself.
- Referee emails entered must be business emails and not personal email accounts. Think @nhs.net rather than Gmail/Hotmail/Yahoo.
- Please note that the referees you have provided will be contacted once the compliance process has begun.

Referee 1

Organisation:*

Your Job Title:*

Ward/Dept:*

Grade/Band:*

Date Employed From:*

Date Employed To:*

Referee Name:*

Referee Job Title:*

Referee Email:*

Referee Telephone:*

Valid mobile number would be: 07985123456

Capacity Which Known:*

Referee 2

Organisation:*

Your Job Title:*

Ward/Dept:*

Grade/Band:*

Date Employed From:*

Date Employed To:*

Referee Name:*

Referee Job Title:*

Referee Email:*

Referee Telephone:*

Valid mobile number would be: 07985123456

Capacity Which Known:*

Referee 3

Organisation:

Your Job Title:

Ward/Dept:

Grade/Band:

Date Employed From:

Date Employed To:

Referee Name:

Referee Job Title:

Referee Email:

Referee Telephone:

Valid mobile number would be: 07985123456

Capacity Which Known:

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Medical Declaration/GP Details

CONFIDENTIAL - Due to the nature of the role you have applied for we need to carry out an assessment of a new starter health questionnaire – even if you have been employed in UK health services before. The health of each candidate is considered individually and a decision regarding fitness for work in the prospective job role will be based on the functional effects of any underlying health condition/disability/impairment as well as health service requirements for fitness and immune status.

Before health clearance is given for employment you may be contacted by telephone from a clinician at Healthier Business UK Ltd, however you may also need to be seen by an occupational health advisor/specialist or physician, arrangements for face to face consultations will be arranged by your employer or agency. We may recommend adjustments or assistance following an assessment to enable you to carry out your proposed duties safely and effectively. Recommendations to your employer will be directed to essential information regarding your health and the hazards and risks of your employment and with due reference to other relevant statutory requirements and professional practice. Our aim is to promote and maintain the health of all individuals in the workplace: staff, service users and third parties. Your records will be retained electronically in accordance with best practice and the requirements of the General Data Protection Regulations. Your records will be held on file for the purposes of processing your request only and for no longer than is necessary, however your records may be subject to internal clinical audits. Your records may also be used to cross reference and ascertain your fitness should you register with other clients of Healthier Business UK Ltd.

GP Name:*

GP address line 1:*

GP address line 2:

GP address line 3:

GP Postcode:*

Medical History

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?*

Do you think you may need any adjustments or assistance to help you to do the job?:*

Are you having, or waiting for treatment (including medication) or investigations at present?:*

Chicken Pox/Shingles

Have you ever had chicken pox or shingles?:*

Have you suffered from any of the following?

Methicillin resistant staphylococcus aureus (MRSA)*

Clostridium Difficile (C-Diff)?*

BBV (Blood Borne Virus)

Have you ever come into contact with any BBV's (Blood Borne Virus)? Including Needle Stick Injuries?:*

Tuberculosis

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?*

Do you have a cough which has lasted for more than 3 weeks?*

Do you have unexplained weight loss?*

Do you have unexplained fever?*

Have you had tuberculosis (TB) or been in recent contact with open TB?*

Immunisation History

Have you had triple vaccination as a child (Diphtheria/Tetanus/Whooping Cough):*

Have you had a vaccination against polio?*

Have you had a vaccination against tetanus?:*

Have you had a vaccination against Hepatitis B?:*

Influenza

Have you received the vaccine for influenza in the past 12 months?:*

Night Workers

The Working Time Regulations 1998 Health Assessment

A night worker is an employee who is scheduled to work at least 3 hours of his/her daily working time during night-time on the majority of days on which he/she is scheduled to work. Night-time is defined as the period between 11 pm and 6 am. Night workers are entitled to a health assessment to check whether they are fit for the work to be done. Very few health problems will prevent people being able to work at night, and where there is a medical problem which could be relevant it will almost always be possible for the person to be able to work during night hours with suitable modifications to their treatment programme.

The purpose of the questionnaire is to ask whether you have any health problem which could be affected by night work, so that where necessary an appropriate medical review can be arranged. The questionnaire will be confidential to the Occupational Health Department but a report on your fitness will be provided to your manager who is responsible for work assignments and for the arrangements for health and safety at work. Please complete the form and tick the appropriate box for the questions listed; if you have any other condition which you believe should be considered please write brief details at the bottom of the page or continue on a separate sheet of paper.

Is it expected that during your employment you will be undertaking night work?:*

If you answered YES please complete the following questions, failure to do so may result in this form being rejected.

Health Assessment

Have you had any medical problem in the past which has prevented you from working at night?:*

Are you diabetic?:*

Are you subject to angina, or other heart problems which may affect your fitness?:*

Are you suffering from any circulatory problems which affect your activities?:*

Have you had duodenal or stomach ulcers in the past, or under treatment at present?:*

Have you had any continuing bowel problem, for instance following major surgery?:*

Do you have any chronic chest problem such as asthma, emphysema or bronchiectasis?:*

Do you have any disability affecting mobility which will cause difficulties in arranging night work?:*

Do you have any recurrent or continuing sleep disturbance requiring medical advice?:*

Are you having specialist care requiring your attendance at hospital clinics for treatment?:*

Do you have any other health problem which affects your fitness for night work?:*

Are you taking any medication to a strict timetable?:*

Medical Declaration - Consent

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'. This is available upon request.

Do you consent to this questionnaire and your immunisation reports being assessed by an occupational health advisor for the purpose of providing a fitness to work certificate?:

Do you consent to our occupational health advisers making recommendations to your employer/agency to assist with your ability to carry out your perspective role?:

Do you consent to our occupational health advisers speaking with you regarding any declaration you may have made relating to your medical history?:

Declaration

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.

The General Data Protection Regulation (GDPR) (EU) 2016/679

All information supplied by you will be held in confidence by Healthier Business UK Ltd. 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, Specialist’s or third party’s - without your explicit consent. You have the right of erasure (the right to be forgotten), withdrawal of consent and refusal 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-regulation-gdpr/individual-rights/

If you wish to have sight of our privacy policy, please send your request to [email protected]

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User Registration

Personal Details

Emergency Contact

Your Profession

NHS Employee

Professional History and References

Referee 1

Referee 2

Referee 3

Medical Declaration/GP Details

Medical History

Chicken Pox/Shingles

Have you suffered from any of the following?

BBV (Blood Borne Virus)

Tuberculosis

Immunisation History

Influenza

Night Workers

Health Assessment

Medical Declaration - Consent

Declaration

The General Data Protection Regulation (GDPR) (EU) 2016/679

Declarations

Declarations of Criminal Convictions

Declaration of Confidentiality

Declarations – Working Time Regulations

Candidate Signature and Authorisation