Medical Director Personal Details and Equalities Monitoring Form final

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Medical Director Personal Details and Equalities Monitoring Form final Powered By Docstoc
					                           PERSONAL DETAILS AND
                   EQUAL OPPORTUNITIES MONITORING FORM

                         Please complete Sections 1, 2 and 3 of this form.
            Please include this completed form with submitted CV and Covering Letter

          ALL INFORMATION WILL BE TREATED IN THE STRICTEST OF CONFIDENCE

Post:             Medical Director
Post Ref No:      23974S                        Closing Date:      Noon, Friday 4th November 2011

Section 1. Personal Details
Surname:                                 Forename:                                 Title:
Name known by (if different):
Address:

Postcode:                   E-mail address - work:
                            E-mail address - personal:
Please indicate your preference for email communication: Work   / Personal:
Contact Telephone           Day:                           Evening:
Numbers:                    Mobile:
Please state how you heard about this vacancy:

Current or Most Recent Employment Details
Job Title:                                                         From:                To:
Employer Name:
Current/Most Recent Salary per annum £                    Additional Financial Benefits: £
Additional Benefits (e.g. private healthcare)


Notice Period:

Recruitment Timetable
Please indicate any dates that you are unavailable for selection events or where you may
have difficulty with the recruitment timetable.

Comments:




Applicant Declaration

I confirm that the information I have submitted in my CV and Covering Letter to the best
of my knowledge is true and complete.
Name:                                     Date:

                                                                                                        1
              Completed form together with CV and Covering Letter can be emailed to
                                                                         th
 Lynne.Stockey@ggc.scot.nhs.uk. Postal applications to; Lynne Stockey, 5 Floor, Tara House, NHS
   Greater Glasgow and Clyde, 46 Bath Street, Glasgow, G2 1HJ quoting reference number 23974S
  
   please help the environment by requesting and returning your application by email where possible.
Section 2.      CRIMINAL CONVICTIONS DECLARATION
In line with the Rehabilitation of Offenders Act 1974 (Exclusions and Exceptions) (Scotland) Order
2003 as amended, the Authority requires you to declare all convictions defined as ‘unspent’ in terms
of the Act as the post is classified as an ‘excepted post’.

Prior to any offer of appointment a Disclosure check will be undertaken.

This post is exempt from the 1974 Rehabilitation of Offenders Act                                     (Exclusions and
Exceptions)(Scotland) Order 2003.

This means that unless stated in the job description, person specification or application pack,
you must tell us about any previous convictions either classed as ‘spent’ or ‘unspent’.

If you are offered employment, any failure to disclose such convictions could result in dismissal or
disciplinary action.

Any information you give will be considered only in relation to the post for which this form refers.

Information will be verified by Disclosure Scotland for relevant posts.

I declare that I have:                        No previous convictions

                                              Previous convictions – details of which I give below




Please read the following statements, you will be asked to sign a declaration if you are
appointed.

    I understand if appointed to this post this information will be kept as part of my
     personal file record.
    I consent to my details being kept confidentially and used for specific and lawful
     purpose as specified in the Data Protection Act 1998
    I declare that I have no previous convictions, or have identified any I have above
 Name:

 Signature:                                                   Date:
If you are completing this application form electronically you can type your name in the space provided for your signature.




                                                                                                                      2
                 Completed form together with CV and Covering Letter can be emailed to
                                                                            th
    Lynne.Stockey@ggc.scot.nhs.uk. Postal applications to; Lynne Stockey, 5 Floor, Tara House, NHS
      Greater Glasgow and Clyde, 46 Bath Street, Glasgow, G2 1HJ quoting reference number 23974S
    
     please help the environment by requesting and returning your application by email where possible.
Section 3. Equal opportunities monitoring
We want to ensure that our job opportunities are open to all. The only way we can ensure there is
equal opportunity is to measure applications we receive. Therefore this form asks you for your ethnic
origin, gender, disability, religion, sexuality and age. The information you provide in this section
is confidential and is not used in the shortlisting and selection process. It will not be stored in
your personal file. The information will be logged in a secure database and the paper copies
will be destroyed.
1) If you are currently an employee of NHS Greater Glasgow and Clyde, will getting this job be
a promotion?

 Yes         No            Please Select
2) You are:

Female                 Male        Please Select
3) Have you undergone, are you undergoing or do you intend to undergo gender
reassignment? For example, this includes having changed your sex (gender).?

Yes                     No             Prefer not to say       Please select

4) What is your age?

I am          years old and my date of birth is
5) Do you have a physical or mental health condition or disability that :

       has a substantial effect on your ability to carry out day to day activities?
       has lasted or expected to last 12 months or more?


Yes                     No              Prefer not to say      Please select

       If you answered ‘yes’, please tick if it is either of the following:

Learning Disability                                 Physical impairment
Long Standing Illness                               Sensory impairment
Mental Health Condition

       Again if yes, please describe any particular arrangements that you would need for your work
        location




   Continued on next page

                                                                                                            3
                Completed form together with CV and Covering Letter can be emailed to
                                                                           th
   Lynne.Stockey@ggc.scot.nhs.uk. Postal applications to; Lynne Stockey, 5 Floor, Tara House, NHS
     Greater Glasgow and Clyde, 46 Bath Street, Glasgow, G2 1HJ quoting reference number 23974S
      
       please help the environment by requesting and returning your application by email where possible.
6) What is your ethnic group?
Choose one section from A to F, then tick the appropriate box to indicate your cultural background

A: White               Scottish             Irish              Other British

                       Other White Background

B: Mixed               Any mixed background

C: Asian; Asian Scottish; Asian .British:
                    Pakistani          Indian                  Chinese

                       Bangladeshi            Other Asian background

D: Black; Black Scottish; Black British
                    Caribbean                                  African
                    Other Black background

E: other ethnic background
                    Any other background

F: Prefer not to answer

7) To which religion, religious domination or body to you actively belong?

                 (Christianity) – Church of Scotland              Hinduism

                 (Christianity) – Roman Catholic                  Sikhism

Please Select    Christianity (other)                             Judaism

                 Other faith / belief                             Islam

                 Buddhism                                         No Religion (none)



                 Prefer not to answer
8) Which of the following best describes your sexual orientation?

                       Bi Sexual                               Gay Man
Please Select          Heterosexual (straight)                 Lesbian/Gay Woman
                       Other                                   Prefer not to answer




                                                                                                          4
                Completed form together with CV and Covering Letter can be emailed to
                                                                           th
   Lynne.Stockey@ggc.scot.nhs.uk. Postal applications to; Lynne Stockey, 5 Floor, Tara House, NHS
     Greater Glasgow and Clyde, 46 Bath Street, Glasgow, G2 1HJ quoting reference number 23974S
    
     please help the environment by requesting and returning your application by email where possible.

				
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