Bank Partners

  • Trust Leaver Application Form

    • Welcome 

    • Thank you for choosing to join bank upon the end of your substantive contract. Please find the following steps to update your profile with us. Upon completion we will be in contact for any further information that maybe required. Please note to be eligible for registration you must be available to work via the bank in the next 3 months.

      You will receive an online Hire Vue ID check this should only take 5 mins to complete and allows us to verify your right to work remotely.

      You will be asked to provide the below documentation to support your application:

      • Your right to work document (Passport/Visa)
      • Application form with your employment history (N.B. we will accept an up to date CV to support your application form).
      • GMC / NMC / HCPC / GDC or relevant professional pin – please include this on your application form
      • DBS – this must be issued within the last 3 years by the NHS or Acacium Group or be registered with the update service, this DBS must be Enhanced with Child and Adult workforce for clinical patient facing workers or standard for non-clinical patient facing workers
      • 2 proofs of address, i.e. a bank or credit card statement or utility bill (all must be dated less than 3 months old). A Driving Licence, current Council Tax Statement (current period) (N.B. we cannot accept mobile phone bills or online printed bank statements)
      • Occupational Health – Please note you will receive a separate link to complete your questionnaire via Healthier Business. 
      • Core Skills Training – We can accept valid training records/certificates otherwise we can support via our training portal.

      Please note, you can upload more than one document to each section if required.

    • Are you able to work for the trust via the bank over the next three months?*

    • Unfortunately to be eligible for Trust Leaver registration you must be able to work shifts at the trust via the bank in the next three months. 

      We are unable to move forward with your application at this time, please contact us for registration when you are available for work.

    • Personal Details 
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    • These can be bank or credit card statement or utility bill (all must be dated less than 3 months old), a Driving Licence (front and back), or a current Council Tax Statement (current period).

      Please note that we cannot accept mobile phone bills or online printed bank statements

      See here for acceptable proof of address: https://www.gov.uk/government/publications/dbs-identity-checking-guidelines

       

    • Sex*
    • Format: (000) 000-0000.
    • Date of Birth*
       - -
      2 digit day, 2 digit month, 4 digit year
    • Format: (+44) 00000000000.
    •  -
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    • Next of Kin

    • Format: (+44) 00000000000.
    • Right to work 
    • Do you hold a British or Irish citizenship?*
    • If not, do you hold any of the following?

    • This can be generated here: https://www.gov.uk/prove-right-to-work/get-a-share-code-online

    • Expiry Date
       - -
      2 digit day, 2 digit month, 4 digit year

    • For a full list of acceptable NHS ID, please visit this link: https://www.nhsemployers.org/publications/identity-checks-standard

    • For a full of acceptable ID for DBS, please visit this link: https://www.gov.uk/government/publications/dbs-identity-checking-guidelines/id-checking-guidelines-for-standardenhanced-dbs-check-applications-from-22-april-2025#document-lists

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    • Please include all four corners of this document. If you are uploading a Biometric Residence Permit please upload both the front and the back of the document. If you are using a UK Birth Certificate, you will also need to provide a proof of National Insurance. n.b. we are not able to accept payslips. Further verification of these documents maybe required. 

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    • Do you have professional indemnity insurance?*

    • Bank Partners strongly advises you to have your own Professional Indemnity insurance.

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    • Work Requirements 

    • Moorfields

    • What staff group did your substantive position hold?*

    • North Mids

    • What staff group did your substantive position hold?*

    • Barts

    • What staff group did your substantive position hold?*

    • Whittington & UCLH

    • What staff group did your substantive position hold?*

    • GOSH

    • What staff group did your substantive position hold?*

    • Portsmouth

    • What staff group did your substantive position hold?*
    • Which Trust(s) do you currently work at?*
    • What Staff Group are you a member of?*
    • Please confirm your last working day as a substantive member of the trust*
       - -
      2 digit day, 2 digit month, 4 digit year
    • Professional registrations
    • Professional Body*
    • Expiry Date
       - -
      2 digit day, 2 digit month, 4 digit year
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    • What is your availability to work?*
    • When are you available from?
       - -
      2 digit day, 2 digit month, 4 digit year
    • When are you available until?
       - -
      2 digit day, 2 digit month, 4 digit year
    • Line Manager Details 

    • Please supply contact details for your most recent line manager at the trust you have left / are leaving, so that we can obtain confirmation for you to remain on the bank. We only require one person’s details. Kindly note that confirmation from your line manager is required before we are able to progress with your application.

    • Employed From*
       - -
      2 digit day, 2 digit month, 4 digit year
    • Employed To*
       - -
      2 digit day, 2 digit month, 4 digit year
    • Format: +44 00000000000.
    • Professional Qualifications & Training 
    • List your qualifications
    • Do you have access to your qualification certificate?
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    • Do you hold current core skills training certification?*

    • Note that if you do not hold current certification, Bank Partners will be able to provide you with the required training. 

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    • Do you give permission for Bank Partners to obtain your core skills training record from the trust?*
    • Date*
       - -
      2 digit day, 2 digit month, 4 digit year

    • How to get a copy of your training history from Barts Health Learning Portal

      For those members of staff with an active nhs.net email address:

      Please visit: https://learning.bartshealth.nhs.uk

      2. Log in to the Portal using your ProfileID
      2.a. If you cannot remember your ProfileID click on the Forgot ProfileID button and follow the instructions
      3. Click on any staff group
      4. Choose the Completion Dashboard

       

      5. Click on each of the boxes for the different types of training undertaken

       

      6. Click on the envelope icon

       

      7. Click confirm and a copy of your training record will be sent to your registered email address

    • Have you entered new employment since leaving your substantive position?*
    • Do you have an up to date CV you can upload to this form?*

    • You will be required to upload proof of this on the submission page if you click 'Yes'.

    • Please provide us with your employment history using the form below from age 18 to present. You can upload a CV by selecting yes to the above question.

    • Reference Details

    • We will be required to obtain a reference from your current place of employment please supply Professional Referee from your most recent employer. Bank Partners can only accept references from your line manager or someone working in a more senior capacity. At least two must be relevant to the specialty or role you are applying for. This may include another Recruitment Agency if you have been undertaking temporary positions but please also provide the details someone within one of your placements that can comment on your clinical ability if applicable to your role.

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    • Referees*
    • Employment History*
    • Revalidation & Appraisals 

    • Appraisals

      Bank Partners will require you to be appraised at least annually by a senior practitioner of the same discipline who is entered on the NMC/HCPC.

      The appraiser must be appropriately trained to complete an appraisal. The appraisal should be completed inline with the Approved NHS Appraisal System, which includes 360 Feedback (NHS Work).

      You should maintain a written portfolio of your professional experience and attendance at professional development courses, which should also include a written and agreed Personal Development Plan as agreed at your appraisals.

    • Date of most recent appraisal
       - -
      2 digit day, 2 digit month, 4 digit year
    •  -

    • Revalidation for Nurses

    • Date of Revalidation
       - -
      2 digit day, 2 digit month, 4 digit year

    • Revalidation for Doctors

    • Date of Revalidation*
       - -
      2 digit day, 2 digit month, 4 digit year
    • Criminal Records Declaration 

    • Criminal Records

    • Please note that under new filtering rules - certain offenses may be removed from your criminal record after 11 years (5.5 years if you were under the age of 18) Cautions will be removed after 6 years (2 years if you were under the age of 18); providing that this was your only offence and did not result in a custodial sentence. Serious offences will never be filtered. If you are unsure of whether your conviction, caution, or reprimand is filtered, please see the DBS website for more information before signing the declaration. If you do not declare a conviction/caution/reprimand that later appears on your DBS this could result in dismissal or non-employment.

    • Are you aware of any Police enquiries undertaken following allegations made against you, which may have a bearing on your suitability for this post?*
    • Have you ever had a police check in another country?*
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    • Note that if you answer 'No', Bank Partners will be able to give you guidance on how to obtain a DBS.

      Your selected BSW Trust will accept a DBS at the correct level that has been completed by an NHS employer within the last three years or a DBS registered with the update service.

      Please also note that if at any stage whilst working for Bank Partners we receive a DBS Enhanced Disclosure that highlights information you have not declared, then you will be removed from your assignment.

    • Do you currently hold an up-to-date DBS you can provide?*
    • Do you have an up to date DBS or are able to obtain this?*

    • Barts

    •  DBS - please follow these instructions:

      • Follow this link to complete your DBS application: UCheck DBS
      • You will then need to provide information about yourself, address and employment history, as well as additional information including and previous names you have used.


      Once complete, we will use documents you have uploaded to this form to support the new application. Please note once you have applied a payment link for this new DBS will be provided to you for completion. 

    • UCLH

    •  DBS - please follow these instructions:

      • Follow this link to complete your DBS application: UCheck DBS
      • You will then need to provide information about yourself, address and employment history, as well as additional information including and previous names you have used.


      Once complete, we will use documents you have uploaded to this form to support the new application. Please note once you have applied a payment link for this new DBS will be provided to you for completion. 

    • Moorfields

    •  DBS - please follow these instructions:

      • Follow this link to complete your DBS application: UCheck DBS
      • You will then need to provide information about yourself, address and employment history, as well as additional information including and previous names you have used.


      Once complete, we will use documents you have uploaded to this form to support the new application. Please note once you have applied a payment link for this new DBS will be provided to you for completion. 

    • North mids

    •  DBS - please follow these instructions:

      • Follow this link to complete your DBS application: UCheck DBS
      • You will then need to provide information about yourself, address and employment history, as well as additional information including and previous names you have used.


      Once complete, we will use documents you have uploaded to this form to support the new application. Please note once you have applied a payment link for this new DBS will be provided to you for completion. 

    • Whitington

    •  DBS - please follow these instructions:

      • Follow this link to complete your DBS application: UCheck
      • You will then need to provide information about yourself, address and employment history, as well as additional information including and previous names you have used.


      Once complete, we will use documents you have uploaded to this form to support the new application. Please note once you have applied a payment link for this new DBS will be provided to you for completion. 

    • GOSH

    •  DBS - please follow these instructions:

      • Follow this link to complete your DBS application: UCheck
      • You will then need to provide information about yourself, address and employment history, as well as additional information including and previous names you have used.


      Once complete, we will use documents you have uploaded to this form to support the new application. Please note once you have applied a payment link for this new DBS will be provided to you for completion. 

    • Portsmouth

    •  DBS - please follow these instructions:

      • Follow this link to complete your DBS application: UCheck
      • You will then need to provide information about yourself, address and employment history, as well as additional information including and previous names you have used.


      Once complete, we will use documents you have uploaded to this form to support the new application. Please note once you have applied a payment link for this new DBS will be provided to you for completion. 

    • You've advised earlier within this form that you require support in obtaining a DBS - please follow these instructions:

      • Follow this link: https://www.hr-platform.co.uk/individual/application-login/?87%2B7CpgP0nnBgenmqZ1dCGvxljEyYn0JEYoEuPchm6%2FUejIC7rSTGuhXBC4t8WD2bQfXI2BwRKNdvQ6ik6a9UdNS2rykoFps3AdseWU3YF6AGF84ajHbCRWtjxVNeqN4
      • You will then need to provide information about yourself, address and employment history, as well as additional information.

      Once complete, please also attach two proofs of address to this application so we can verify your DBS.

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    • Declaration 

    • 1. I understand that if I am charged or cautioned after signing this declaration, I must inform Bank Partners.

    • Have you ever been subject to disciplinary action or are currently being investigated due to alleged misconduct?*

    • 1. I understand that if I am charged or cautioned after signing this declaration, I must inform Bank Partners.

      2. I have answered questions regarding disciplinary action or alleged misconduct truthfully.

      3. I acknowledge that I will be given a copy of the Terms and Conditions of Service issued by the Trust, at the end of the registration process, which is mine to keep and to abide by.

      4. I am not aware of any condition, medical or otherwise, which would affect or limit my employment or performance, other than those declared in my Occupational Health Questionnaire.

      5. I declare that the information given herein is true and complete and is not presented in a way intended to mislead. I agree that if I have given false or misleading information or omit to give relevant information now or in the future, that Bank Partners may cease to offer me further agency placements without notice, as well as a claim for recovery of any payments I have received, together with a claim for a loss of profit to Bank Partners.

      6. I acknowledge and confirm that Bank Partners is authorised to apply for and obtain a Disclosure and Barring Service Check (including the online status update service check if app) and references from any previous employers and educational establishments.

      7. I acknowledge that my personal details will be stored and handled correctly by Bank Partners in accordance with the Data Protection Act 2018 however, I agree that they may be made available for audit/review by relevant parties. (This is relevant for all information including all documents – DBS, Occupational Health, References).

      8. I understand that if I am on a student visa, I can only work for 20 hours per week during term time. I understand that I have a responsibility to monitor this. In addition, if my position as a student changes, I must inform Bank Partners

      9. I understand that if I am on a Tier 2 Sponsorship Visa, I can only work for a maximum of 20 hours per week at the same professional level as my sponsorship. I understand that I have a responsibility to monitor this. In addition, if my position with my sponsored company changes, I must inform Bank Partners.

      10. I acknowledge that if any of my details stated on this Application Form change, or my circumstances change, which may affect my ability to work for, I must inform Bank Partners immediately.

      11. I confirm that I am not currently under investigation, or currently suspended, by my professional regulatory body (e.g. NMC/HCPC) or being investigated by my current or previous employer. I will inform Bank Partners if I am under investigation or suspended by my professional regulatory body or employer at any point whilst working for Bank Partners.

      12. I give my permission for Bank Partners to run a Right to Work check with the Home Office if I provide them a Biometric Residence Card for my Right to work in the UK.

    • 3. I acknowledge that I will be given a copy of the Terms and Conditions of Service issued by Bank Partners on behalf of Barking, Havering and Redbridge University Hospitals NHS Trust, at the end of the registration process, which is mine to keep and to abide by.

      4. I am not aware of any condition, medical or otherwise, which would affect or limit my employment or performance, other than those declared in my Occupational Health Questionnaire.

      5. I declare that the information given herein is true and complete and is not presented in a way intended to mislead. I agree that if I have given false or misleading information or omit to give relevant information now or in the future, that Bank Partners may cease to offer me further agency placements without notice, as well as a claim for recovery of any payments I have received, together with a claim for a loss of profit to Bank Partners.

      6. I acknowledge and confirm that Bank Partners is authorised to apply for and obtain a Disclosure and Barring Service Check (including the online status update service check if app) and references from any previous employers and educational establishments.

      7. I acknowledge that my personal details will be stored and handled correctly by Bank Partners in accordance with the Data Protection Act 2018 however, I agree that they may be made available for audit/review by relevant parties. (This is relevant for all information including all documents – DBS, Occupational Health, References).

      8. I understand that if I am on a student visa, I can only work for 20 hours per week during term time. I understand that I have a responsibility to monitor this. In addition, if my position as a student changes, I must inform Bank Partners

      9. I understand that if I am on a Tier 2 Sponsorship Visa, I can only work for a maximum of 20 hours per week at the same professional level as my sponsorship. I understand that I have a responsibility to monitor this. In addition, if my position with my sponsored company changes, I must inform Bank Partners.

      10. I acknowledge that if any of my details stated on this Application Form change, or my circumstances change, which may affect my ability to work for, I must inform Bank Partners immediately.

      11. I confirm that I am not currently under investigation, or currently suspended, by my professional regulatory body (e.g. NMC/HCPC) or being investigated by my current or previous employer. I will inform Bank Partners if I am under investigation or suspended by my professional regulatory body or employer at any point whilst working for Bank Partners.

      12. I give my permission for Bank Partners to run a Right to Work check with the Home Office if I provide them a Biometric Residence Card for my Right to work in the UK.

    • Date*
       - -
      2 digit day, 2 digit month, 4 digit year
    • Model Declaration 

    • Guidance for applicants – in confidence

      The position you have applied for is identified as exempt under the Exceptions Order of the Rehabilitation of Offenders Act 1974 (as amended in England and Wales).

      This means that when considering any such appointment, the employing organisation is legally permitted to request a standard or enhanced disclosure through the Disclosure and Barring Service (known as a DBS check).

      Standard and enhanced disclosures will include information about all SPENT (old) and UNSPENT (current) convictions, cautions, reprimands and final warnings that are not protected (i.e. are not filtered out) as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2013.

      Enhanced disclosures may also include other relevant police information where this is deemed relevant to the position you are applying for.

      Before you complete this form, it is important to understand which convictions or cautions are now protected (or filtered) under an amendment to the Exceptions Order to the Rehabilitation of Offenders Act (as amended in England and Wales) which came into force from 29 May 2013.

      Protected convictions and cautions will never be included in a standard or enhanced DBS disclosure. Applicants are not legally required to declare any such convictions or cautions to an employer, and the employing organisation is not entitled to consider any such offences as part of their recruitment process.

      If you have a criminal record and have any queries or concerns about the type of information you may be asked to declare, please refer to the following sources for further guidance.

      https://unlock.org.uk/information-and-advice/ - Unlock
      https://www.nacro.org.uk/about-us/volunteering/ – NACRO
      https://www.gov.uk/government/publications/dbs-filtering-guidance/dbs-filtering-guide – Unlock
      https://www.nacro.org.uk/nacro-services/criminal-record-support/advice-for-employers/ - NACRO

      Our commitment to you

      Before you can be considered for appointment with your Trust we need to be satisfied about your character and suitability.

      If the position has, in addition, been identified as a regulated activity under the Safeguarding Vulnerable Groups Act (2006) (as amended by the Protection of Freedom's Act 2012) an enhanced DBS disclosure will include information which is held on the Children's and/or Adults barred list(s), as applicable to the position.

      Bank Partners aims to promote equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of ethnicity, disability, age, gender or gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity, marriage or civil partnership. We undertake not to discriminate unfairly against applicants on the basis of criminal conviction or other such information declared.

      Prior to making a final decision concerning your application, we shall discuss with you any information declared by you that we believe may have a bearing on your suitability for the position.

      If we do not raise this information with you, this is because we do not believe that it should be taken into account. In that event you still remain free, should you wish, to discuss the matter with the recruiting manager. As part of assessing your application, we will only take into account criminal records and other information declared which is relevant to the position being applied for.

      The information that you provide in this declaration form will be processed in accordance with the Data Protection Act 1998. It will be used for the purpose of determining your application for this position. It will also be used for purposes of enquiries in relation to the prevention and detection of fraud.

      Please answer all of the questions within this form.

      If you answer ‘YES’ to any of the questions, please use the space indicated to provide any information that you believe may have a bearing on your suitability for the position for which you are applying.

      Please use the continuation sheet provided in this form to include any additional information or supplementary comments you wish us to consider in support of your application. You may continue on a separate sheet if necessary.

      It is important to stress that answering ‘yes’ to any of the questions below will not necessarily prevent you from taking up an appointment in the NHS. This will depend on the relevance of the information you provide in respect of the nature of the position for which you are applying, and the particular circumstances.

      It is important to stress that answering ‘yes’ to any of the questions below will not necessarily prevent you from taking up an appointment in the NHS. This will depend on the relevance of the information you provide in respect of the nature of the position for which you are applying, and the particular circumstances.

      All cases will be examined on a case by case basis, and will consider the following.

      • If the conviction is relevant to the position applied for.
      • The seriousness of the offence.
      • The age of the applicant at the time of the offence(s).
      • The length of time since the offence(s) occurred.
      • If the applicant has a pattern of offending behaviour.
      • The circumstances surrounding the offence(s) and the explanation(s) offered by the applicant.
      • If the applicant’s circumstances have changed since the offending behaviour.
         

      It is important to be aware, that the failure to disclose all unspent and unspent convictions which you are legally obliged to declare (i.e. those that are not protected under the DBS filtering rules), could result in disciplinary proceedings or dismissal.

      If you have a criminal record and have any queries or concerns about the type of information you may be asked to declare, please refer to the following sources for further guidance.

      https://unlock.org.uk/information-and-advice/ - Unlock
      https://www.nacro.org.uk/about-us/volunteering/– NACRO

    • 1. Are you currently bound over, or do you have any convictions, cautions, reprimands or final warnings that would not be protected (filtered) as defined by the Exceptions Order 2013 - that have been issued by a Court or Court-Martial in the United Kingdom or in any other country?*

    • Please provide details of the order binding you over and/or the nature of the offence, penalty, sentence or order of the Court, the date and place of the Court hearing.

      It is important for you to understand which convictions or cautions are now protected (or filtered) under an amendment to the Exceptions Order to the Rehabilitation of Offenders Act (as amended in England and Wales) which came into force from 29 May 2013 – see further information in the ‘guidance for applicants’ which accompanied this form.

      You are not required to tell us about parking offences.

      Please include any additional information, or other supplementary comments that you believe to be relevant. 

    • 2. Have you been charged with any offence in the United Kingdom or in any other country that has not yet been disposed of?*

    • Please include details of the nature of the offence with which you are charged, date on which you were charged, and details of any on-going proceedings by a prosecuting body.

      You are reminded that, if you are appointed, you have a continued responsibility to inform us immediately where you are charged with any new offence, criminal conviction or fitness to practise proceedings in the United Kingdom or in any other country that might arise in the future, while you are in our employment.

      You are not required to tell us about parking offences.

      Please include any additional information, or other supplementary comments that you believe to be relevant.

    • 3. Are you aware of any current investigations being undertaken by NHS Counter Fraud and Security Management Service (NHS CFSMS) following allegations of made against you?*

    • Please provide details of the nature of the allegations made against you, and if known to you, any action to be taken against you by NHS CFSMS.

      Please include any additional information, or other supplementary comments that you believe to be relevant.

    • 4. Have you been investigated by the Police, the NHS Counter Fraud and Security Management Service (NHS CFSMS), or any other investigatory body resulting in a current or past conviction or dismissal from your employment or volunteering position?

    • Please provide details of the nature of the allegations made against you, and if known to you, any action to be taken against you by the investigatory body.

      Investigatory bodies include: HM Customs and Excise, Inland Revenue, Financial Service Authority, Department of Trade and Industry, Department of Work and Pensions, immigration and border force, security agencies, local authorities etc. This list is not exhaustive and you must declare any investigation conducted by an investigatory body.

      Please include any additional information, or other supplementary comments that you believe to be relevant.

    • 5. Have you ever been dismissed by reason of misconduct from any employment, volunteering, office or other position previously held by you?*

    • Please provide details of the employment, office or position held, the date that you were dismissed and the nature of allegations of misconduct made against you.

      Please include any additional information, or other supplementary comments that you believe to be relevant.

    • 6. Have you ever been disqualified from the practise of a profession, or required to practise subject to specified limitations following fitness to practise proceedings, by a regulatory or licensing body in the United Kingdom or in any other country?*
    • 6. Have you ever been removed from the register or have conditions or undertakings been made on your registration by a fitness to practice committee, regulatory or licensing body in the United Kingdom or in any other country?*

    • Please provide details of any conditions or undertakings which have been applied to your professional registration and the name and address of the regulatory or licensing body concerned.

      You are not required to provide details where any right to appeal has been upheld AND where that appeal has resulted in your case being fully exonerated.

      Please include any additional information, or other supplementary comments that you believe to be relevant.

    • 7. Are you currently or have you ever been the subject of any investigation or fitness to practise proceedings by any licensing or regulatory body in the United Kingdom or in any other country?*
    • 7. Are you currently subject to a fitness to practice investigation and/or proceedings by a regulatory or licensing in the United Kingdom or in any other country?*

    • Please include the reasons given for the investigation and, where applicable, the details of any proceedings, limitations or restrictions that currently apply to your professional registration, and the name and address of the regulatory or licensing body concerned.

      Please include any additional information, or other supplementary comments that you believe to be relevant

    • 8. Are you subject to any other prohibition, limitation, or restriction that means we are unable to consider you for the position for which you are applying?*

    • Please include details.

      Please include any additional information, or other supplementary comments that you believe to be relevant

    • 9. Are there any other matters in your background that may be relevant to the position being applied for, which might cause your reliability or suitability to be called into question?*

    • Please include details.

      It is important for you to understand which convictions or cautions are now protected (or filtered) under an amendment to the Exceptions Order to the Rehabilitation of Offenders Act (as amended in England and Wales) which came into force from 29 May 2013 – see further information in the ‘guidance for applicants’ which accompanied this form.

      Please include any additional information, or other supplementary comments that you believe to be relevant.

    • IMPORTANT
      The Data Protection Act 1998 requires us to advise you that we will be processing your personal data. Processing includes: holding, obtaining, recording, using, sharing and deleting information. The Data Protection Act 1998 defines ‘sensitive personal data’ as racial or ethnic origin, political opinions, religious or other beliefs, trade union membership, physical or mental health, sexual life, criminal offences, criminal convictions, criminal proceedings, disposal or sentence.

      Where you are applying for a position which involves regulated activity, this will also include any barring decisions made by the Disclosure and Barring Service (DBS) against the Children’s or Adults barred lists under the terms of the Safeguarding Vulnerable Groups Act 2006 (as amended by the Protection of Freedom's Act 2012).

      The information that you provide in this declaration form will be processed in accordance with the Data Protection Act 1998. It will be used for the purpose of determining your application for this position. It will also be used for purposes of enquiries in relation to the prevention and detection of fraud.

      Once a decision has been made concerning your appointment, Bank Partners will not retain this declaration form any longer than necessary [see further details in ‘Guidance Notes for Applicants’ which was provided with your application form. This declaration will be kept securely and in confidence.  Access to this information will be restricted to designated persons within the organisation who are authorised to view it as a necessary part of their work.

      In signing the declaration on this form, you are explicitly consenting for the data you provide to be processed in the manner described above.

       

      I have read the ‘Guidance Notes for Applicants’ that accompanied my application form, and I consent to the information provided in this declaration form being used by Bank Partners for the purpose of assessing my application, and for enquiries in relation to the prevention and detection of fraud.

      I confirm that the information that I have provided in this declaration form is correct and complete. I understand and accept that if I knowingly withhold information, or provide false or misleading information, this may result in my application being rejected, or if I am appointed, in my dismissal, and I may be liable to prosecution.

      Please sign and date this form.

    • IMPORTANT


      The Data Protection Act 1998 requires us to advise you that we will be processing your personal data. Processing includes: holding, obtaining, recording, using, sharing and deleting information. The Act defines ‘sensitive personal data’ as racial or ethnic origin, political opinions, religious or other beliefs,
      trade union membership, physical or mental health, sexual life, criminal offences, criminal convictions, criminal proceedings, disposal or sentence.

      The information that you provide in this declaration form will be processed in accordance with the Data Protection Act 1998. It will be used for the purpose of determining your application for this position. It will also be used for purposes of enquiries in relation to the prevention and detection of fraud. 

      Once a decision has been made concerning your appointment, Bank Partners will not retain this declaration form any longer than is necessary - see further details in the supplementary guidance notes for applicants which we provided with your application form. This declaration will be kept securely and in confidence. Access to this information will be restricted to designated persons within the organisation who are authorised to view it as a necessary part of their work.

      In signing the declaration on this form, you are explicitly consenting for the data you provide to be processed in the manner described above.

       

      I confirm that the information that I have provided in this declaration form is correct and complete. I understand and accept that if I knowingly withhold information, or provide false or misleading information, this may result in my application being rejected, or if I am appointed, in my dismissal, and I may be liable to prosecution.

    • Date*
       - -
      2 digit day, 2 digit month, 4 digit year
    • Bank/Agency Worker Access to Trust Clinical Systems 

    • You are being provided with access to Portsmouth Hospitals University NHS Trust (The Trust) clinical systems. The Trust uses various paper and computer systems which contain confidential, sensitive, or personal data.

      This information needs to be kept secure and only shared where appropriate. It is vital that only people who need such information to carry out their work have access to the information.

      Paper records need to be carefully stored, with controlled access. Security of the information held on the Trust’s computer systems is achieved by the issue of personal usernames and passwords.  Where applicable, these usernames and passwords control the level of access granted in each system.  Data protection training will be included in your induction.  You may also receive additional training and guidance whilst undertaking your role at the Trust.

      It is essential that you read and understand the Confidentiality and Data Protection Policy and the Safe Handling of Personal Information Policy and guidance.  A copy is available from your Trust Manager or the Trust’s intranet page.   

    • Confidentiality Statement

    • I acknowledge that I must abide by the Confidentiality and Data Protection Policy and the Safe Handling of Personal Information Policy and guidance.  I will complete Data Protection training as part of my induction. 

      I understand that I may be required to sign additional declarations in order to obtain access to specific computer systems and that any passwords for access to computer systems are personal to me, must be kept securely and must not be divulged to any other person.

      I understand the Trust will monitor my usage of Information Systems and in the event of my absence or leaving, my Trust user account may be accessed.

      I agree:

      To comply with Portsmouth Hospitals University NHS Trust policies and procedures when accessing patient or staff records.
      To ensure that data entered is accurate and up to date.
      That I shall only access the records that are necessary in order to perform the role for which access has been agreed.
      To keep all information obtained from patient or staff records confidential.
      I understand that inappropriate accessing or use of the Trusts recorded information (including computer systems) may amount to gross misconduct and may lead to summary dismissal and that where my employer is not the Trust that this has also been agreed with my employer.

      I agree to co-operate with the Trust’s supervision of my work on the Trust’s records and systems including co-operating with requests for information relating to that work.

      I understand breaches of this agreement could result in termination of my work at Portsmouth Hospitals University NHS Trust and in cases of severe breaches of confidentiality, the reporting to the Information Commissioner’s Office with the potential for legal prosecution under the Data Protection Act 2018 and the General Data Protection Regulations 2016.

      By signing this form, you are indicating to the department and the Trust that you have read and understood the above.

    • Date*
       - -
      2 digit day, 2 digit month, 4 digit year

    • Trust to input information - System Requirements

    • New Starter Appointment Form 

    • Part 1

    • Sex*
    • Date of Birth*
       - -
      2 digit day, 2 digit month, 4 digit year
    • Format: (+44) 00000000000.
    •  -

    • Bank Details

    • Account Type*
    • Start date with Trust
       - -
      2 digit day, 2 digit month, 4 digit year

    • Previous Substantive Employer

      (if applicable)
    • Start Date
       - -
      2 digit day, 2 digit month, 4 digit year
    • End Date
       - -
      2 digit day, 2 digit month, 4 digit year

    • Bank Joiners Only

    • Are you newly qualified?
    • Substantive Trust Leave Date
       - -
      2 digit day, 2 digit month, 4 digit year
    • Date
       - -
      2 digit day, 2 digit month, 4 digit year

    • Equality Monitoring Information for all new starters

      Why do we need accurate equality data?

      The Trust needs credible, robust and up-to-date workforce data with integrity for monitoring and evaluation purposes. The result of the equality monitoring will inform the effective use of resources to improve competitiveness and make a valuable contribution to strategic planning processes and development of services. We currently have over 50% of our employee equality records showing not declared/undefined which makes it difficult to make informed decisions about the workforce.

      What do we need from you?

      The Trust needs you to update all your personal details so that we can hold accurate records on our ESR system, in particular those details relating to all protected characteristics as set out below:

      1. Age

      2. Disability

      3. Sex (Male or female)

      4. Gender re-assignment

      5. Race

      6. Religion or belief

      7. Sexual Orientation

      8. Pregnancy and Maternity

      9. Marriage or civil partnership (Marital Status)

      How would we use this data?

      The data collated will be used to up-date the ESR workforce data. All monitoring reports do not identify individual staff and confidentiality is maintained. The data will help enhance the integrity of the Trust’s workforce data.

      Data Protection Act 1998

      The information you have provided will be stored and processed by North Middlesex University Hospital NHS Trust in line with the Data Protection Act 1998.

      What is the benefit of a robust and complete workforce equality data?

      For staff, the benefits in disclosing equality related information about themselves and the Trust include:

      High quality recruitment analysis, equal pay review, access to training attendance, employee relations and salary information to ensure the Trust is paying due regard to the impact of its policies, functions and processes on its workforce. Where gaps are identified, it takes actions to address them equitably, fairly and promptly.
      An accurate analysis of the Trust’s workforce to assist with planning of facilities, support structures, disability related adjustments, meet the diverse needs and requirements of its workforce.

    • Part 2

    • Do you regard yourself to have a disability?

    • Emergency Contact

    • Format: 00000000000.
    • Format: 00000000000.
    • Format: (+44) 00000000000.
    • Date
       - -
      2 digit day, 2 digit month, 4 digit year
    • Do you already have an NHS.net email address?*
    • Have you worked for the NHS before?*
    • If you have worked for the NHS before, please state details below.*

    • Doctors Only - Training Details for Specialist Registrars/ST

    • CCST date
       / /
      2 digit day, 2 digit month, 4 digit year

    • Throughout the tenure of the appointment, it is the employee’s responsibility to ensure that their registration is up to date.

    • Important Information regarding set up of Bank assignment for permanent/fixed term staff to work additional shifts

    • If you are a substantive/fixed term member of staff you will automatically be set up with a Bank assignment in order to work any additional shifts in the same role as your substantive/fixed term post.  This may have implications regarding tax as HMRC consider this a second job and will tax you accordingly. You should seek confirmation from HMRC of your tax code for this assignment to ensure the correct tax code is applied.

       

      PLEASE NOTE THIS DOES NOT APPLY TO FY1 DOCTORS WHO WILL REQUIRE MANAGEMENT SIGN OFF TO WORK ADDITIONAL SHIFTS IN THEIR OWN AREA OF WORK ONLY

    • Important information regarding the NHS Pension scheme.  

      You will automatically be entered into the NHS Pension Scheme upon commencement of employment. Should you wish to opt out, you must confirm that you are fully aware of the implications of opting out and have reviewed these using the online calculator available on the NHS Pensions website via the following link  https://www.nhsbsa.nhs.uk/member-hub.  The website will also provide you with information regarding future potential pension contributions. If you still wish to opt out you will need to complete and return the SD502 opt out form.

       

      Please note under pension auto enrolment rules, anyone who opts out or stops making payments will be automatically enrolled back into a pension scheme at a later date (usually every three years). This is because your circumstances may have changed and it may be the right time for you to start saving. We will contact you when this happens, and you can opt out if it’s still not right for you.

       

      Please note that you may not be eligible to join the NHS Pension Scheme and you may be automatically be enrolled in to NEST instead.  NEST is our alternative workplace pension scheme.  An example of someone that would not be eligible for enrolment into NHS Pensions is where they are already in receipt of their NHS Pension. Further information on auto enrolment can be found via the following link  http://www.nestpensions.org.uk/ 

    • Inter Authority Transfer

    • I authorise Barking, Havering & Redbridge University Hospitals NHS Trust to obtain and release employment history, including pay information by any previous or future NHS employers.*

    • I declare that I have completed and checked the information above and it is to the best of my belief correct. I hereby authorise you to deduct from my salary/wage or Training Allowance, any amounts which shall be due from me.

    • Are you a member of a staff union
    • P45 Attached*
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    • Date
       / /
      2 digit day, 2 digit month, 4 digit year
    • New Employee Questionnaire 

    • As part of the recruitment process, all new employees, staff transferring in from another NHS employer and existing NHS employees must complete this questionnaire as fully as possible.

      The NHS Pension Scheme legislation requires employers to contractually enrol all new eligible employees into the NHS Pension Scheme on commencement of their employment. The Pensions Act 2008 requires those employees who cannot join the NHS Pension Scheme to be automatically enrolled into an alternative pension scheme. In order to ensure that you are correctly enrolled your employer needs to establish your current NHS pension status.

      Please note that the information provided will only be used for local and central pensions/payroll administration purposes to determine your eligibility criteria to join the NHS Pension Scheme.

      Please use the completion notes whilst completing the form.

       
       
    • Which NHS Pension Scheme did you take your benefits from?*

    • If you have never held MHO status your new post will not qualify for this status. (Go to Q10)

       

    • If your answer is ‘Yes’, you should download the Transfer In Guide and application pack from our website at: www.nhsbsa.nhs.uk/pensions. However, it is important to note that this can only be done in the first 12 months of joining the Scheme for members of the 1995 Section, or within the first 12 months of becoming eligible to join the 2008 Section or 2015 Scheme. (Go to Part 2)

      If you would like to consider your option to transfer benefits, please tick the ‘Yes’ box and download the Transfer In Guide and application pack. If you say no but decide at a later date that you wish to consider a transfer (within the 12 month deadline) then you can obtain the Transfer In Guide and application pack from your employer or the NHS Pensions website (www.nhsbsa.nhs.uk/pensions). If you have previous NHS pension membership within England and Wales this will be automatically added to any new membership in the NHS Pension Scheme. If you have previous membership of the NHS Pension Scheme in Scotland or Northern Ireland, this will not be automatically linked.  You must apply to transfer these benefits if you would like your membership to be added to your new membership in the NHS Pension Scheme (England and Wales).

      If you wish to transfer from a scheme that participates in the Public Sector Transfer Club, please note that you must 'elect to proceed' with this transfer within 12 months of becoming eligible to join the NHS Pension Scheme (an election to proceed is not a request for an estimate, it is the signed option form requesting payment of the transfer value).

      Once the assessment has been made, you will be notified by your employer by the first pay day which Scheme you have been enrolled in, what the Scheme features are, the contribution rates and your options.

      Assessment is not possible until your first payment is made.

       
       

    • I confirm I will inform my payroll team if my employment position with other NHS organisations changes.

       

    • NHS Pensions - New employee questionnaire

      As part of the recruitment process, all new employees, staff transferring in from another NHS employer and existing NHS employees must complete this questionnaire as fully as possible.

      The NHS Pension Scheme legislation requires employers to contractually enrol all new eligible employees into the NHS Pension Scheme on commencement of their employment. The Pensions Act 2008 requires those employees who cannot join the NHS Pension Scheme to be automatically enrolled into an alternative pension scheme. In order to ensure that you are correctly enrolled your employer needs to establish your current NHS pension status.

      Please note that the information provided will only be used for local and central pensions/payroll administration purposes to determine your eligibility criteria to join the NHS Pension Scheme.

      Please use the completion notes whilst completing the form.

    • The Pension Act 2008 requires employers to automatically enrol all new employees into a pension scheme on commencement of their employment.  In order to ensure that you are correctly enrolled your employer needs to establish your current NHS Pension Status.  As part of the recruitment process, all new employees, staff transferring in from another NHS employer and existing NHS employees must complete this questionnaire as fully as possible.

      Please note that the information provided will only be used for local and central pensions/payroll administration purposes to determine eligibility criteria.

      Please use the completion notes whilst completing the form.

      Name: {fullName3}

      NI Number: {nationalInsurance}

      Date of Birth: {dateOf}

    • Date of when new role will start
       - -
      2 digit day, 2 digit month, 4 digit year

    • Part 1

    • Q1: Have you ever had employment which is covered by the NHS Pension Scheme (agency work not applicable)?
    • Q2: Is this an employment that will continue at the same time as your new role?
    • Q3: Please indicate contract type of this other employment(s)

    • Important: If you change your hours or leave your other employment(s) it is your responsibility to advise the Payroll team as this may affect your eligibility to a pension scheme

    • Q5: When you were previously a member of the NHS Pension Scheme did you claim any retirement pension benefits?

    • Important: If you change your hours or leave your other employment(s) it is your responsibility to advise the Payroll team as this may affect your eligibility to a pension scheme

    • Please indicate which NHS Retirement Benefit you are in receipt of
    • Please indicate which Section of the scheme you were a member of
    • Q6: Have you previously been made redundant from an NHS Employment?

    • Important: If you change your hours or leave your other employment(s) it is your responsibility to advise the Payroll team as this may affect your eligibility to a pension scheme

    • Date of Redundancy
       - -
      2 digit day, 2 digit month, 4 digit year
    • Did you take an NHS Pension?
    • Q7. Do, or did you, have any NHS Money Purchase Additional Voluntary Contribution (NHS MPAVC) arrangements in place through the NHS Pension Scheme with Equitable Life, Prudential or Standard Life?*
    • Q7: Do or did you have any Additional Voluntary Contribution arrangements in place through the NHS Pension Scheme with Prudential, Standard Life?

    • If yes, please contact your AVC provider if you wish to continue to pay AVC contributions. You will need to advise them of your new employer so they can provide details for payroll deductions to continue.

    • Q8. Do you have an Added Years contract, Additional Pension purchase or Early Retirement Reduction Buy Out (ERRBO) in place?*
    • Q8: Do you have an added years contract or NHS Additional Pension purchase in place?
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    • Q9: In your new post will you be applying for Mental Health Officer Status (MHO)?
    • End date of MHO role*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Q10: Do you have any previous pension rights that you might be interested in transferring into the NHS Pension Scheme?

    • If your answer is “Yes” your employer will provide the Transfer of Benefits Booklet. However it is important to note that this can only be done in the first 12 months of joining the scheme, for members of the 1995 Section or within the first 12 months of becoming eligible to join the 2008 Section.

    • Declaration

    • I confirm that I have completed the above form to the best of my ability and knowledge and undertake to advise my payroll team in the event that I should alter the position stated above in respect of employment with any other NHS organisations.

    • Date*
       - -
      2 digit day, 2 digit month, 4 digit year
    • Q1. Have you ever been in the NHS Pension Scheme or worked in a role which you were entitled to be a member? (agency work is not applicable)*
    • Q2. Are you still in this employment?*
    • Will this continue at the same time as your new role?*
    • Q3. What date did you leave your last employment with the NHS?*
       - -
      2 digit day, 2 digit month, 4 digit year
    • Q4. Please indicate the contract type of any other employment(s)*

    • Important: If you change your hours or leave your other employment(s) it is your responsibility to advise the Payroll team as this may affect your eligibility to a pension scheme.

    • Q6. When you were previously a member of the NHS Pension Scheme did you claim any NHS retirement pension benefits (other than on redundancy or interest of efficiency grounds)?*
    • Please indicate which NHS retirement benefit you are in receipt of*
    • Please indicate which Section or Scheme you were a member of*
    • Q7. Have you previously been made redundant from an NHS employment?*
    • Date of redundancy*
       - -
      2 digit day, 2 digit month, 4 digit year
    • Did you take an NHS Pension?*
    • Which NHS Pension Scheme did you take your benefits from?*
    • Q8. Do, or did you, have any NHS Money Purchase Additional Voluntary Contribution (NHS MPAVC) arrangements in place through the NHS Pension Scheme with Utmost (previously Equitable Life), Prudential or Standard Life?*

    • Please contact your NHS MPAVC provider if you wish to continue to pay your additional contributions. You will need to advise them of your new employer so they can provide details for payroll deductions to continue.

    • Q9. Do you have an Added Years contract, Additional Pension purchase or Early Retirement Reduction Buy Out (ERRBO) in place?*
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    • Q10. In your new post will you be applying for Mental Health Officer status (MHO)?*
    • If you had previous MHO status, please provide the date the role ended
       - -
      2 digit day, 2 digit month, 4 digit year

    • If you have never held MHO status your new post will not qualify for this status.

    • Q11. In your new post will you be applying for Special Class status (SCS)?*
    • If you had previous SCS, please provide the date the role ended
       - -
      2 digit day, 2 digit month, 4 digit year

    • If you have never held SCS your new post will not qualify for this status.

    • Q12. Have you ever taken a refund of NHS Pension benefits?*
    • Q13. Do you have any previous pension rights that you might be interested in transferring into the NHS Pension Scheme?*

    • If your answer is Yes, you should download the Transfer In Guide and application pack from www.nhsbsa.nhs.uk/nhs-pensions. However, it is important to note that this can only be done in the first 12 months of joining the Scheme for members of the 1995 Section, or within the first 12 months of becoming eligible to join the 2008 Section or 2015 Scheme.

    • Part 2 Declaration

      I confirm I will inform my employer (or Employing Authority) if my employment position with other NHS organisations changes.

      Please make sure this form is provided by the commencement of your employment to enable the correct assessment of your pension position.

    • NHS Pensions questionnaire date*
       - -
      2 digit day, 2 digit month, 4 digit year

    • How we use your information

      The NHS Business Services Authority - NHS Pensions will use the information provided for administering your NHS Pension Scheme membership and processing payment of your NHS pension benefits. We may share your information to administer and pay your NHS pension, enable us to prevent and detect fraud and mistakes, for debt collection purposes, or as required by law.

      For more information about who we share your information with and how long we keep your personal data and your rights, please visit www.nhsbsa.nhs.uk/yourinformation.

    • Completion notes

      These completion notes are provided to assist you in completing the new joiner questionnaire.

      Please complete the questionnaire as fully as possible so that the correct assessment can be
      made.

      Q1 – This question is to establish if you have any previous NHS Pension Scheme membership at
      the date of starting this new employment.

      Q2 – This is to establish whether you will have any other NHS employments at the same time as
      your new role.

      Q3 – This is to ensure you do not have an overlapping employment.

      Q4 – You can only be pensionable in this Scheme up to whole time, therefore it is important that
      your employer knows how many hours you work in your other employment(s). Please make sure
      that you keep your employer/payroll informed if the situation changes.

      Q5 – If you are continuing to work in another NHS post we need to know who your other NHS
      employment is with. This is important as there are reasons why you may not be eligible for the
      NHS Pension Scheme in two employments. The name of your other employer may be the same as
      the one you are starting with. Please note that if you are working for an NHS organisation through
      an employment agency, this does not count as NHS employment.

      Q6 – If you are in receipt of any NHS pension benefits then you may not be eligible to rejoin the
      NHS Pension Scheme. However, by providing the information requested we will be able to make
      the correct assessment. We ask you to identify which Section or Scheme you were in (1995
      Section, 2008 Section or 2015 Scheme) but if you are unsure then please tick the ‘Not known’.

      Q7 – NHS service that has been counted in the calculation of a redundancy payment needs to be
      declared to ensure the correct assessment of your service. If you are in receipt of an NHS Pension
      as the result of redundancy, this will impact the assessment.

      Q8 – If you have Additional Voluntary Contribution (AVC) arrangements with either Equitable life,
      Prudential or Standard Life through the NHS Pension Scheme then you need to inform the AVC
      provider that you are changing employer to ensure continuity can be considered.

      Q9 – If you have either Added Years, Additional Pension purchase or Early Retirement Reduction
      Buy Out (ERRBO) through the NHS Pension Scheme it is essential that you confirm the details
      and provide a copy of the contract that was provided to you when you commenced the
      arrangement to ensure continuity of the arrangement.

      Q10 – Please note that Mental Health Officer (MHO) status no longer applies to any post
      commenced after 6 March 1995. However, if you have previously held a post that attracted MHO
      status and you believe the new post also qualifies for MHO status then you need to indicate this by
      ticking ‘Yes’ and completing the details of the previous employment.

      Q11– Please note that Special Class status (SCS) no longer applies to any post commenced after
      6 March 1995. However, if you have previously held a post that attracted SCS status and you
      believe the new post also qualifies for SCS status then you need to indicate this by ticking ‘Yes’
      and completing the details of the previous employment.

      Q12 – Refunded membership may be included in your qualifying membership (membership
      counting towards your maximum allowed membership) but will not be included in the calculation of
      your pension benefits. Also, should you have taken your refund within the last 6 months you are
      entitled to pay it back should you wish to increase your current membership of the Scheme.

      Q13 – You may be able to transfer other pensions into the NHS Pension Scheme, however it is
      important to note that this can only be done:

      • in the first 12 months of joining the Scheme if you are member of the 1995 Section
      • within the first 12 months of becoming eligible to join the 2008 Section
      • within the first 12 months of becoming eligible to join the 2015 Scheme.

      If you would like to consider your option to transfer benefits, please tick the ‘Yes’ box and
      download the Transfer In Guide and application pack. If you say no but decide at a later date that
      you wish to consider a transfer (within the 12 month deadline) then you can obtain the Transfer In
      Guide and application pack from your employer or the NHS Pensions website
      (www.nhsbsa.nhs.uk/nhs-pensions). If you have previous NHS pension member ship within
      England and Wales this will be automatically added to any new membership in the NHS Pension
      Scheme. If you have previous membership of the NHS Pension Scheme in Scotland or Northern
      Ireland, this will not be automatically linked. You must apply to transfer these benefits if you would
      like your membership to be added to your new membership in the NHS Pension Scheme (England
      and Wales).

      If you wish
      to transfer from a scheme that participates in the Public Sector Transfer Club, please
      note that you must 'elect to proceed' with this transfer within 12 months of becoming eligible to join
      the NHS Pension Scheme (an election to proceed is not a request for an estimate, it is the signed
      option form requesting payment of the transfer value).

      Once the assessment has been made, you will be notified by your employer by the first pay day
      which Scheme you have been enrolled in, what the Scheme features are, the contribution rates
      and your options.

      Assessment is not possible until your first payment is made.

      Death Benefit Nomination Forms
      In the event of your death, the NHS Pension Scheme may provide for your family or a person you
      have nominated.
      You can nominate someone to receive a lump sum on death benefit if you die using the lump sum
      on death benefit nomination forms.
      If you have a partner, but are not married or in a civil partnership, you may also be able to
      nominate them to receive an adult dependant’s pension using a separate form.
      You can also cancel or change a previous nomination.
      For further information please visit our website at www.nhsbsa.nhs.uk/member-hub/nominations
      where you will also find the relevant forms.

    • Non-Substantive Payroll New Starter 

    • Please review the below for accuracy and correct where applicable at the beginning of this form:

    • Date of Birth*
       - -
      2 digit day, 2 digit month, 4 digit year
    • Format: (+44) 00000000000.
    •  -
    • Format: (+44) 00000000000.

    • Bank Details

    • I confirm the above information is correct and that I will not exceed 48 hours per week as a combination of contracted and Bank Hours. I also confirm that should I leave the permanent employment of the Trust, I will inform Bank Partners immediately

    • Date
       - -
      2 digit day, 2 digit month, 4 digit year
    • UCLH Pension 

    • IMPORTANT INFORMATION FOR APPLICANTS JOINING THE UCLH BANK – ALLIED HEALTH & SCIENTIFIC STAFF AND NON-CLINICAL STAFF 

      Please read the information below which details how any assignment you may undertake at UCLH is affected by:

      The European Working Time Regulations
      The Agency Worker Regulations
      Pension auto enrolment
      Individuals working through a Limited Company are not affected and should not sign this document.

      The European Working Time Regulations were introduced in 1998 to regulate working times including break periods and not working for more than an average of 48 hours over a 17 week period unless agreed otherwise.

      With regard to an assignment at UCLH, you need to be aware that holiday pay (a Regulation requirement) is paid on top of your standard hourly rate so you receive an element of holiday pay for every hour you are paid for. It is not accrued separately for you. You do however need to ensure that you are taking the European Working Time Regulations recommended annual leave. When an assignment is confirmed for you at UCLH you will receive a welcome pack which will include an assignment confirmation that contains instructions for your first day, the length of the assignment and the breakdown of your pay to clearly show your standard pay and holiday pay amounts.

      The Agency Worker Regulations also apply for any assignment that you undertake through the bank at UCLH  even though you will be working through the bank, not an agency. The regulations apply because your assignment is not classed as permanent employment. Under the Agency Worker Regulations, you are eligible for a series of entitlements from day one. These are listed below, and a copy of this table will be included in your welcome pack.

      Facilities – such as the staff canteen, 52 club, transport facilities, car parking and child care facilities.
      Vacancies – bank and agency workers will have the right to be notified of any job vacancies within the organisation including those that are advertised for internal applicants only.
      For further information about any of the facilities above, please speak to your bank consultant. Job vacancies are all advertised on the Trust’s website job pages.

      In addition to the day one entitlements, you are also eligible, after your twelfth paid week in your assignment, to be paid at an equivalent rate to that of a permanent employee AND have the equivalent holiday entitlement of a permanent employee - if you are not already receiving the equivalents on either or both counts. Your assignment confirmation in your welcome pack will clearly detail what rates you are receiving for your standard and your holiday pay, and what, if any changes you will automatically receive from your 12th week of payment. A change in rate, if applicable, will carry over from one assignment to the next as long as the assignments are at the same band.

      Pension auto enrolment has been implemented in companies across the UK in accordance with the government's directive throughout 2013 and will apply to you in your bank assignment if you are eligible to be auto enrolled. Every individual will be assessed for their eligibility on a case by case basis, and for those that are eligible, a 1% deduction from your salary will be applied, and a further 1% contribution will be made by us. For further information about pension auto enrolment, including how eligibility is assessed, please visit the government website.

      Please sign below to confirm that the above regulations have been discussed with you as part of your application to join the UCLH bank.  

    • Date
       - -
      2 digit day, 2 digit month, 4 digit year
    • HMRC Starter Checklist 
    • Employee statement - You need to select only one of the following statements A, B or C*
    • Do you have one of the Student Loan Plans described below which is not fully repaid?*

    • For further guidance about repaying Student Loans go to https://www.gov.uk/repaying-your-student-loan

    • Student Loan Plans

      You’ll have a Plan 1 Student Loan if:
      • you lived in Scotland or Northern Ireland when you started your course (undergraduate or postgraduate)
      • you lived in England or Wales and started your undergraduate course before 1 September 2012

      You’ll have a Plan 2 Student Loan if:
      • you lived in England or Wales and started your undergraduate course on or after 1 September 2012
      • your loan is a Part Time Maintenance Loan
      • your loan is an Advanced Learner Loan
      • your loan is a Postgraduate Healthcare Loan

    • Did you complete or leave your studies before the last 6th April?*
    • Are you repaying your Student Loan direct to the Student Loans Company by direct debit?*
    • What type of Student Loan do you have?*
    • Do you have a Postgraduate Loan which is not fully repaid?*

    • You'll have a Postgraduate Loan if:

      - you lived in England and started your Postgraduate Master's course on or after 1 August 2016

      - you lived in England or Wales and started your Postgraduate Master's course on or after 1 August 2017

      - you lived in Wales and started your Postgraduate Master's course on or after 1 August 2018

      For further guidance about funding and repaying Postgraduate Loans go to https://www.gov.uk/funding-for-postgraduate-study

    • Did you complete or leave your Postgraduate studies before 6th April?*
    • Are you repaying your Postgraduate Loan direct to the Student Loans Company by direct debit?*
    • Data Protection 

    • Barts Data Consent:

      Bank Partners are processing your data on behalf of Barts Health Trust. You confirm that by submitting your personal data that you have read and understood Barts Health Trust’s privacy notice. 

      We’ll occasionally send you information about our exclusive promotions. We’d hate for you to miss out, but if you’d rather not receive this information, you can opt-out by emailing: dpo@acaciumgroup.com

      You can find more information about managing your marketing preferences here:

      Please note that job opportunities, legal and service updates relating to you working with us are not direct marketing and cannot not be opted out of.

    • UCLH Data Consent:

      Bank Partners are processing your data on behalf of University College London Hospitals NHS Foundation Trust. You confirm that by submitting your personal data that you have read and understood the University College London Hospitals NHS Foundation Trust privacy notice.

      We’ll occasionally send you information about our exclusive promotions. We’d hate for you to miss out, but if you’d rather not receive this information, you can opt-out by emailing: dpo@acaciumgroup.com

      You can find more information about managing your marketing preferences here:

      Please note that job opportunities, legal and service updates relating to you working with us are not direct marketing and cannot not be opted out of.

    • Whittington Data Consent:

      Bank Partners are processing your data on behalf of Whittington Health NHS Trust. You confirm that by submitting your personal data that you have read and understood the Whittington Health NHS Trust privacy notice.

      We’ll occasionally send you information about our exclusive promotions. We’d hate for you to miss out, but if you’d rather not receive this information, you can opt-out by emailing: dpo@acaciumgroup.com

      You can find more information about managing your marketing preferences here:

      Please note that job opportunities, legal and service updates relating to you working with us are not direct marketing and cannot not be opted out of.

    • North Mid Data Consent:

      Bank Partners are processing your data on behalf of North Middlesex University Hospital NHS Trust. You confirm that by submitting your personal data that you have read and understood the North Middlesex University Hospital NHS Trust privacy notice.

      We’ll occasionally send you information about our exclusive promotions. We’d hate for you to miss out, but if you’d rather not receive this information, you can opt-out by emailing: dpo@acaciumgroup.com

      You can find more information about managing your marketing preferences here:

      Please note that job opportunities, legal and service updates relating to you working with us are not direct marketing and cannot not be opted out of.

    • Moorfields Data Consent:

      Bank Partners are processing your data on behalf of Moorfields Eye Hospital NHS Foundation Trust. You confirm that by submitting your personal data that you have read and understood the Moorfields Eye Hospital NHS Foundation Trust privacy notice. 

      We’ll occasionally send you information about our exclusive promotions. We’d hate for you to miss out, but if you’d rather not receive this information, you can opt-out by emailing: dpo@acaciumgroup.com

      You can find more information about managing your marketing preferences here:

      Please note that job opportunities, legal and service updates relating to you working with us are not direct marketing and cannot not be opted out of.

    • GOSH Data Consent:

      Bank Partners are processing your data on behalf of Great Ormond Street Hospital for Children NHS Foundation Trust. You confirm that by submitting your personal data that you have read and understood the Great Ormond Street Hospital for Children NHS Foundation Trust privacy notice.

      We’ll occasionally send you information about our exclusive promotions. We’d hate for you to miss out, but if you’d rather not receive this information, you can opt-out by emailing: dpo@acaciumgroup.com

      You can find more information about managing your marketing preferences here:

      Please note that job opportunities, legal and service updates relating to you working with us are not direct marketing and cannot not be opted out of.

    • Portsmouth Data Consent:

      Bank Partners are processing your data on behalf of Portsmouth Hospitals University NHS Trust. You confirm that by submitting your personal data that you have read and understood Portsmouth Hospitals University NHS Trust’s privacy notice.

      We’ll occasionally send you information about our exclusive promotions. We’d hate for you to miss out, but if you’d rather not receive this information, you can opt-out by emailing: dpo@acaciumgroup.com

      You can find more information about managing your marketing preferences here:

      Please note that job opportunities, legal and service updates relating to you working with us are not direct marketing and cannot not be opted out of.

    • Data Protection

      Bank Partners are processing your data on behalf of Barking, Havering and Redbridge University Trust. You confirm that by submitting your personal data that you have read and understood Barking, Havering and Redbridge University Trust privacy notice.


      We’ll occasionally send you information about our exclusive promotions. We’d hate for you to miss out, but if you’d rather not receive this information, you can opt-out by emailing: click here.

      You can find more information about managing your marketing preferences here:

      Please note that job opportunities, legal and service updates relating to you working with us are not direct marketing and cannot not be opted out of.

       
       
       

    • Bank Partners are processing your data on behalf of the BSW Trust(s) you selected. You confirm that by submitting your personal data that you have read and understood the privacy notice for each BSW Trust you selected. 

      We’ll occasionally send you information about our exclusive promotions. We’d hate for you to miss out, but if you’d rather not receive this information, you can opt-out by emailing: dpo@acaciumgroup.com

      You can find more information about managing your marketing preferences in the Bank Partners privacy policy.

      Please read the privacy notice for each BSW Trust you selected:

      • Salisbury NHS Foundation Trust — employee privacy notice
      • Great Western Hospitals NHS Foundation Trust — staff privacy notice
      • Royal United Hospitals NHS Foundation Trust — staff privacy notice

      Please note that job opportunities, legal and service updates relating to you working with us are not direct marketing and cannot be opted out of.

    • Occupational Health 
    • I am writing to confirm that (please tick the box that is appropriate)*
    • Date*
       / /
      2 digit day, 2 digit month, 4 digit year

    • Click the link to complete your Occupational Health Assessment: Occupational Health Assessment

    • Isle of Wight Data Consent:

      Bank Partners are processing your data on behalf of Isle of Wight NHS Trust. You confirm that by submitting your personal data that you have read and understood Isle of Wight NHS Trust’s privacy notice.

      We’ll occasionally send you information about our exclusive promotions. We’d hate for you to miss out, but if you’d rather not receive this information, you can opt-out by emailing: dpo@acaciumgroup.com

      You can find more information about managing your marketing preferences here:

      Please note that job opportunities, legal and service updates relating to you working with us are not direct marketing and cannot not be opted out of.

    • Isle of Wight Information Governance Agreement 

    • Bank Temporary Staffing - Information Governance Agreement

      Information Governance facilities and governs the management of information within the Trust. Working in conjunction with other governance initiatives such as clinical governance, research governance etc it ensures that the NHS is fully compliant with Legislation and Department of Health guidelines, whilst safeguarding high standards of patient care.

      All staff are required to take personal responsibility to safeguard the confidentiality of personal information of patients or employees, or the business relating to the Trust. This is in accordance with the NHS Caldicott principles on patient data and the Data Protection Acts 2018. Confidentiality is also referred to in Codes of Professional Conduct for professional staff.

      It is a condition, therefore, that under no circumstances will information of a confidential nature be discussed with, or passed on to any unauthorised persons during the course of your work, or after termination of employment. Any known breach of confidentially will be investigated and may cause disciplinary or legal action to be taken against you.

    • Information governance agreement date*
       - -
      2 digit day, 2 digit month, 4 digit year
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