Please Refer to Guidance Overleaf Before Completing This Form

HONORARY

CONTRACT REQUEST

** Please refer to guidance overleaf before completing this form **

SECTION 1: Reason for HONORARY CONTRACT Request (please tick the appropriate boxes)
Data Protection Act 1998 compliance as work involves access to patient identifiable data / Work involves direct patient contact / Extension of existing honorary contract
SECTION 2: PERSONAL DETAILS (please complete in block capitals)
Title: Mr / Mrs / Miss / Ms / Dr / Prof. / Surname:
Forename(s): / Date of Birth:
Address:
Post Code:
(if applicable)
Employing Organisation:
Professional Registration Body:
Professional Registration No: / Expiry Date:
SECTION 3: POST DETAILS (please complete in block capitals)
Job Title: / Hospital Site:
Dept: / Care Group: / Division:
Contract Start Date: / Contract End Date:
Is the above named individual authorised to claim expenses? / YES * / NO
* If you have answered ‘yes’ to the above question, then you must provide costcode details below:
Occupation code:
Three digits / Cost Centre:
Six digits / Account Code:
Four digits
Please provide brief details of the work the honorary contract holder will be undertaking during their placement:
(If appropriate, please attach the relevant job description to this form)
SECTION 4: AUTHORISATION (to be completed by the SUHT Supervisor)
As the named SUHT Supervisor, I agree to take full responsibility for the day-to-day supervision of the above named individual and their work. I confirm the work they will be undertaking is appropriately approved and will ensure that they are fully informed of the following SUHT policies (a) Data Protection, (b) Health & Safety, (c) Email / Internet, and (d) R&D. These policies are available on the SUHTranet.
Manager’s Signature:...... / Job Title:......
Print Name:...... / Dept/Care Group/Division:......
Tel / bleep no:...... / Date:......
ACTIONED BY : HR / Date: / Initials:
Position Number

COMPLETING A HONORARY CONTRACT REQUEST FORM – GUIDELINES TO MANAGERS

Please ensure that you complete ALL sections of this form, in clear and legible handwriting.

Incomplete forms will not be actioned, but will be returned to the relevant manager for completion. This will result in a delay in issuing the new contract, and may also delay the individuals start date.

Completed forms should be returned to the Main HR Office, at least 2 weeks prior to the contract commencement date. Contracts will only be issued once Occupational Health clearance has been received, and if applicable, the individual has submitted a fully completed CRB form and relevant identification to the Main HR Office. Individuals MUST NOT commence their placement with the Trust until their honorary contract has been issued.

SECTION 1: Reason for Honorary Contract Request

·  Please tick the relevant box(es) to indicate the reason for the contract request.

·  Those individual’s who will be undertaking work that involves direct patient contact, will be subject to CRB clearance. (NB. If the contract period is less than 3 months, CRB clearance will not be required).

SECTION 2: Personal Details

·  Please complete ALL sections.

·  In cases where the work being undertaken is through joint agreement between SUHT and the individual’s permanent employer, please provide the organisation’s full name.

·  Where professional registration is required in order to undertake the work, please provide the individuals registration details for verification.

SECTION 3: Post Details

·  Please complete ALL sections.

·  All honorary contracts must have an end date (maximum contract length is ? years). Honorary contracts can be extended at a future date by submitting a duplicate form to the Main HR Office.

·  If the honorary contract holder will be entitled to claim expenses, please indicate this on the form. The Main HR Office will then contact the individual to request their bank details. Individuals will be required to submit appropriately authorised expenses claim forms, as per current claim procedures. Expenses will be paid to the individual via a direct bank credit transfer on a monthly basis.

·  You must provide cost centre and account code information in ALL cases.

SECTION 4: Authorisation

·  The contract request must be signed and authorised by an appropriately qualified supervisor who holds a Southampton University Hospitals NHS Trust (SUHT) contract and will be responsible for the honorary contract holder in their research/work placement.

HR/ ESR/ Honorary Contract Request Form/ Aug 2006

Issue 1