Fitness to Practice Form
NHS (Pharmaceutical Services) Amendment Regulations 2005
Corporate Governance Requirement
We request that all pharmacists and technicians complete the declarations below,
and that they provide Capital Locums Ltd. with a copy of proof of identity,
(copy of passport, photo driving license, birth certificate, etc,) and also provide
a National Insurance Number or other Government issued personal identifying
number, e.g. National Health Insurance Number, Visa details, etc. These details
may be passed to a future employer to comply with UK Government guidelines
Please read the following questions and answer in the form below:
Have you any criminal convictions in the UK?
Have you been bound over following a criminal conviction in the UK?
Have you accepted a police caution in the UK?
Have you in summary proceedings in Scotland in respect of an offence, been the subject of an order discharging you absolutely (without proceeding to conviction)?
Have you accepted a conditional offer under section 302 of the Criminal Procedure (Scotland) Act 1995 (fixed penalty: conditional offer by procurator fiscal) or agreed to pay a penalty under section 115A of the Social Security Administration act 1992 (penalty as alternative to prosecution)?
Have you been convicted elsewhere of an offence, or what would constitute a criminal offence if committed in England and Wales?
Are you currently the subject of any investigation into your professional conduct by any licensing, regulatory or other body?
Have you been the subject of any investigation into your professional conduct in respect to your current or previous employment, where the outcome was adverse?
Are you currently the subject of any investigation by another Primary Care Trust or equivalent body, which might lead to your removal from any list or equivalent list?
Are you to your knowledge, or have you been where the outcome was adverse, the subject of any investigation by the NHS Counter Fraud and Security Management Service in relation to fraud?
Have you ever been refused admission to, or conditionally included in, removed or contingently removed from, any list or equivalent list kept by any Primary Care Trust or equivalent body, are you currently suspended from such a list, on fitness to practice grounds?
Are you, or have you ever been, subject to a national disqualification?
If you answer YES to any of the above questions please give details in the message box below.
By completing this form:
1. I accept the terms and conditions of Capital Locums Ltd.
2. I Consent to a request being made by Capital Locums Ltd to any employer or former employer, licensing, regulatory or any other body in the United Kingdom or elsewhere for information relating to a current investigation, or an investigation where the outcome was adverse
3. I hereby declare that the information given here and on any continuation sheet is true and complete, and I give consent that Capital Locums Ltd may pass this information to a prospective employer.
4. I will notify Capital Locums Ltd within 7 days of any material changes to the information provided.