HEALTH AND SOCIAL CARE BOARD / BUSINESS SERVICES ORGANISATION
APPLICATION FOR INCLUSION ON THE OPHTHALMIC LIST
AS AN OPHTHALMIC MEDICAL PRACTITIONER
15B Form
To apply to be included in the Ophthalmic List of the Health and Social Care Board (HSCB) please complete all relevant sections of this form. Please return the completed form to: Mrs Karen Lee, Ophthalmic Directorate, Business Services Organisation, 2 Franklin Street, BelfastBT2 8DQ. Once the completed form is received the BSO will contact the DHSSPSto enable your application to be passed to the Ophthalmic Qualifications Committee.
If you have any queries regarding the application form please contact Karen Lee on 028 90535631 or email
Once the DHSSPS have completed their part of the process the BSO will then arrange an interview with an Optometric Adviser.
You must include:(original copies only, photocopies are not acceptable and certificates will be returned).
- A current Certificate of registration with the General Medical Council.
- Certificate of Professional Qualification.
- Photographic Identification. This is required on the day of the interview.
- Equal Opportunities Form. Please bring this, in a sealed envelope, to your interview.
You may also be requested to provide:
1.Health Clearance information.
PART 1
PERSONAL DETAILS
PLEASE PRINT DETAILS BELOW
SURNAME:______
FORENAME(S):______
MAIDEN/PREVIOUS
SURNAMES:______
PRIVATE ADDRESS:______
______
______
Postcode:______
TELEPHONE NO:______
EMAIL ADDRESS:………………………………………………………….
(Please remember to use upper and lower case as appropriate for email)
PART 2
MEDICAL QUALIFICATION(S)/REGISTRATION AS
A MEDICAL PRACTITIONER IN THE U.K.
Qualifications: ______
Date qualification was gained: Day_____Month_____Year______
Date of U.K registration as a Medical Practitioner: Day____Month______Year____
Details of further qualifications held: ______
______
______
General Medical Council Number___--______
PART 3
EMPLOYMENT/PRACTICE INFORMATION
I ______(name)
being a registered Medical Practitioner having the qualifications prescribed for the purposes of Article 62 of the Health and Personal Social Services (Northern Ireland) Order 1972, undertake under the arrangements for General Ophthalmic Services to test sight and supply spectacles/contact lenses on the terms of services for the time being in force (General Ophthalmic Services Regulations (Northern Ireland) 2007) and apply to have my name included in the Ophthalmic List for the Health and Social Care Board of Northern Ireland.
The particulars of my work are as follows:
Address(es) of surgery or consulting room(s). / Days and hours of attendance1.
2.
I am practising in partnership with/I am acting as an assistant to*:
*Please delete whichever is not applicable.
Name and address of Medical Practitioner / General Medical Council Number1.
2.
Department of Health and Social Services Serial Number:______
I do/do not conduct other business at the above premises*.
If another business is carried out please state nature of the business
______
PART 4
DECLARATIONS
I ______(name)
am not disqualified from undertaking service by reason of exclusion from the Ophthalmic List or from any corresponding list in Great Britain and now apply to have my name included in the Ophthalmic List. I understand that I have a responsibility to adhere to the essential criteria of General Medical Council registration in order that I may conduct sight testing. Should any of these details alter in any way I undertake to inform the Health and Social Care Board of Northern Ireland.
B)HEALTH CLEARANCE
In line with DHSSPS guidance on Health Clearance for Health Care workers in relation to Tuberculosis (TB) please answer the following questions. The information provided will be treated in strict confidence. Applicants who are concerned about health clearance in regard to TB may contact an optometric adviser of the Health and Social Care Board to discuss their application in advance of submitting their application.
Do you have any of the following? - :
A cough which has lasted more than 3 weeksYesNo*
Unexplained weight lossYesNo*
Unexplained feverYesNo*
Have you had Tuberculosis (TB) or
been in recent contact with open TBYesNo*
*Please delete whichever is not applicable.
N.B If the answer to any of the above questions is ‘Yes’ an optometric adviser will contact the applicant to discuss the application.
PART 4 cont.
DECLARATIONS
C)PREVIOUSLY/PRESENTLY PROVIDING GOS WORK
Have you previously or are you presently providing GOS in another part of the UK
YesNo**Please delete whichever is not applicable.
If you have answered yes to the question above please provide details of the Health Authority/ Board/PCT(s) for which you have provided GOS
Name of Health Authority / PCT / Address & Contact Number of Health Authority / PCT / Date Employed1.
2.
3.
D)CONSENT
I declare that I am a fully registered ophthalmic practitioner, currently included in the General Optical Council’s Ophthalmic Register/a fully registered Ophthalmic Medical Practitioner, currently included in the General Medical Council’s register / a fully registered Dispensing Optician, currently included in the General Optical Council’s Ophthalmic Register, in the name shown at the beginning of this form. I give the above undertakings, declarations and consent and I HEREBY DECLARE that the information given here and on any continuation sheet is true and complete.
I consent to the HSCB/BSO making contact with any organisation it deems necessary to verify or validate any of the information I have provided in this application.
Signed:______
Print Name:______
Date:______
PART 5
FOR HSCB/BSO use only
The above individual (name) ______has / has not* been admitted to the Ophthalmic List on this day (date) ______and has been assigned the personal code of ______which must be used when conducting General Ophthalmic Services.
*Please delete whichever is not applicable.
Signed:______
Position:______
Date:______
OPHTHALMIC SERVICES, BUSINESS SERVICES ORGANISATION,
2 Franklin Street, BelfastBT2 8DQ
Tel: (028) 90535527/90535631 • Textphone: (028) 90535575