C KENDRICKmalcolm kendrick2162006-02-26T11:46:00Z2008-02-04T16:47:00Z2008-02-04T16:47:00Z16443677PRIVATE308431311.8125M&K Healthcare Locums Ltd9 Blue Anchor Road Penclawdd Swansea SA4 3JQwww.mkhealthcare.com Tel:01792 851 121 Fax 01792 851 868 LOCUM DOCTOR APPLICATION FORMGENERAL PRACTICE DIVISION Personal Information – where necessary please circleTitle/Surname:……………………………………………………………………………………………Forename(s):……………………………………………………………………………………………..Sex: Male / FemaleAddress:-………………………………………………………………………………………………….……………………………………………………………………………………………………………..Postcode:-……………….Home telephone number:-……………………….Fax:-……………………………………Mobile telephone number:-………………………Email:-………………………………….Date of birth:-……………………………………Marital Status:-…………………………Nationality:-……………………………………..N.I.number:-……………………………Banking DetailsBank Name and Address:………………………………………………………………………………….……………………………………………………………………………………………………………..Account Name:-…………………………………………………………………………………………...Account number:-……………………………….Sort code:-……………………………...Note:- Any payment made to you shall be made directly into your bank account through the Bank Automated Crediting System on a weekly basisYou shall, for the purposes of any placements made through M & K Healthcare Locums Ltd, be deemed to be self employed and we shall presume that by signing this application form, you confirm you r self-employed status to us.P.1M&K Healthcare Locums LtdPre-employment health questionnaireIn keeping with the recommended codes of practice of the industry and other guidelines, we shall require you to give us information about your state of health and your immunisations. All information given herein shall be treated in the strictest of confidence and shall not be disclosed to any other party without obtaining prior to your approval.Working in conjunction with the NHS code of practice, are you aware of any circumstances that may affect your performance as a Locum Doctor? YES /NOIf yes – Details:-…………………………………………………………………………………………...……………………………………………………………………………………………………………..(Please complete questionnaire 1 below)Questionnaire 1- Health QuestionnairePlease circle yes or no where applicable:-Tuberculosis, asthma, bronchitis or chest complaints?………………………………………….Yes / NoChest pains, heart condition or raised blood pressure?………………………………………….Yes / NoBlackouts, fits or attacks of giddiness?…………………………………………………….…….Yes / NoDepression, mental illness or nervous breakdown?……………………………………………...Yes / NoAny other accident, operation, or illness?………………………………………………………..Yes / NoHave you any reason to believe you may be infected by………………………………………...Yes / NoAny communicable disease?Any other current or recent medical condition or……………………………………………...Yes / NoTreatment which might affect your attendance orPerformance at work?Any physical disabilities including defect of sight and hearing?………………………………..Yes / NoP2M&K Healthcare Locums LtdPlease give dates of immunisation or vaccination for:- (please circle if copies are enclosed)DateDateTetanus………………………………..Hepatitis B……………………………………….Poliomyelitis…………………………..Diphtheria……………………………………….Rubella (German Measles)……………Tuberculosis BCG……………………………….Last chest X-ray………………………Other……………………………………………..Best practice ChecksPlease enclose a copy of your CRB check.The DOH Circular (88,19), Protection of children, requires that any professional with access to children must not be/have been a named person on the Protection Of Children Act list 99 Register.Do you confirm that you are not/have been / are not in the process of being on the POCAL99 Register.Yes / NoBy signing below, you confirm that the information given above is true.Your Signature…………………………………..Date:-…………………………………...Declaration:-In addition to this, please attach an up to date CV in order that we may find you placements best suited to your experience, work pattern and circumstance.You now need to sign this form in order that we may know that all the information provided above is correct to the best of your knowledge.I declare that all the information provided above and the attached CV is correct and accurate to the best of my knowledge. I am aware this information shall be relied upon to find placement opportunities for me.Signature:………………………………………….Date:-………………………………….. P3