Version 2.3 (Last Update: Sep 2015)

Version 2.3 (Last Update: Sep 2015)

FORM A
NHS HONORARY CLINICAL COVER
NHS HONORARY CLINICAL[1] CONTRACT REQUEST FORM
FOR STAFF EMPLOYED BY UNIVERSITY OF EDINBURGH

PART A - To be completed for all new appointments and extensions

Name:
Type of Employee: / Below Consultant / Consultant / Nurse / Other (please specify)
University Job Title:
University Grade:
New Appointment or Extension: / New Appointment / Extension
Staff Request / Vacancy Reference Number:
Deanery/Department:
Medical Specialty/Department: (if applicable)
Honorary Cover Start Date:
Contract End/Review Date:
Current Home Address:
GMC/GDC/NMC/HPC Registration Number:
National Insurance Number:
University Manager’s Name:
NHS Supervising Consultant - Name & Contact Details (needs to be NHS employee):
Sites Within NHS Lothian Where Clinical Work /Research Undertaken:
Any NHS Boards Outwith NHS Lothian Where Clinical Work / Research Undertaken:
Reason For Clinical Contract: / Clinical Academic undertaking clinical sessions within the NHS / Nurse providing clinical care to NHS Patients / Other (please specify)

Part B – For Doctors/Dentists Below Consultant Level (new appointments only)

National Training Number (if applicable)
Expected CCT Date (if applicable)

Part C - Documentation Required (new appointments only)

3 x Verified Forms of ID (at least 1 of which must be photographic & 1 address based)
Copy of CV (signed and dated by the individual)
1 x Protecting Vulnerable Groups (PVG) form
1 x Signed Disclosure Permission Form
1 x Completed Occupational Health Questionnaire (if applicable)[2]
1 x Signed IT Declaration Form
2 x References (for consultant posts only)

NHS sign off (electronic signature or email confirmation acceptable)

NHS Supervising Consultant
(must be an NHS employee;
named on Honorary contract) / Full Name:
Date:
Signature:
Appointment approved by
NHS CD / AMD*
(must be an NHS employee -
if not, AMD to sign) / Full Name:
Contact Email:
Date:
Signature:

* CD/AMD can delegate this approval to the supervising consultant for all Honorary requests in their Department if they see fit – this must be confirmed by the CD/AMD in an email sent to the University and Medical & Dental Recruitment..

Part D – For University HR Use ONLY (new appointments only)

Level of PVG Required: / PVG (Both Lists) / PVG (Adults) / PVG (Children)
Has PVG registration/update been completed?
PVG Membership Number:
Date of Issue of Disclosure:
Level of Occupational Health Check Required: / Additional (including EPP) / Standard (excl EPP) / Not required as transferring from NHS Lothian (see note 2 below)
Has Occupational Health Clearance been received? / Yes / Not Required as transferring from NHS Lothian
Date of Issue of Occupational Health Clearance:
Contact Person in University HR:
Contact Person in NHS:
Date request sent to NHS

Part E – For NHS Lothian Recruitment Administrator Use ONLY (new appointments only)

DS/PVG Confirmed / Yes/No
OHS Check Confirmed / Yes/No
NHS Lothian Recruitment Administrator Name
Date Honorary Clinical Contract Issued
Date Copy of Contract Sent to University HR

[1] Clinical – the primary purpose of working within NHS Lothian is to carry out a clinical/service role, which includes seeing & treating patients (e.g. Clinical Academic, Nurses or Allied Health Care Professionals

[2] Not required for Medical Staff transferring to UoE from NHS Lothian in a role which requires the same level of check and they have been previously occupational health checked by NHS Lothian