additional forms to be completed by locums wanting to work in … · 2015. 2. 24. · antipodean...

Antipodean Medical Recruitment Locum Pack 8 January 2010 Version 1.1 Date printed - 18 January 2010 Australia Tollfree – 800 070 339 NZ Tollfree – 0800 633 000 ABN – 19 416 942 761 Fax - +64 3 328 9979 www.antipodeanmedical.com Unit 3, 4 Ficus Ave, Avoca Beach 2251

Dear Doctor Thank you for your interest in working as a locum doctor through Antipodean Medical Recruitment Pty Ltd. We look forward to working with you to ensure you get the best locum opportunities to suit your needs, qualifications and experience. To assist you we have compiled this Locum Application Pack. Please ensure you read through it carefully, complete the required forms and return them to our office. A CD can be provided, if preferred, with the relevant forms and New South Wales Health guidelines – please request this by calling or emailing our office. If you have any questions, please do not hesitate to ask. Forms to be completed by all Locums:

1. Antipodean Medical Recruitment Pty Ltd Locum Registration Form 2. Criminal Record Statutory Declaration – Australia 3. Working With Children Clearance Form 4. Vaccination Records 5. Prohibited Employment Declaration 6. Antipodean Medical Recruitment Pty Ltd Consent Form

Additional forms to be completed by Locums wanting to work in New South Wales:

1. Clinical Skills Self Assessment – Non Specialist 2. Referee Check – Clinical Skills Assessment – Non Specialist 3. Locum Medical Officer Referee Check – Professional Behaviour (3 forms to be completed by your referees) 4. Policy Sign Off Sheet (All NSW Health policies can be found on www.antipodeanmedical.com) 5. Clinical Skills Assessment – Specialist or GP Procedural Qualifications 6. Skills Order Form 7. 100 Point Identification List 8. Employment Declaration

Documents to be provided by Locum:

1. Current CV with names and phone numbers of three clinical referees (one being a current or recent supervisor 2. Medical Registration 3. Medical Indemnity 4. Certified Proof of 100 Point ID i.e. passport, licence 5. Certified copies of qualifications or transcripts and specialist qualifications if applicable 6. E-Orientation Certificate of Completion (http://nswhealth.moodle.com.au/login/index.php) (NSW only)

Please ensure that you or your referees have completed all of the above forms and included all of the above documents before returning this package to Antipodean Medical Recruitment Pty Ltd.

http://nswhealth.moodle.com.au/login/index.php


Employment Registration Form General Information

Surname: ____________________________________________________________________________________

Given Names: ________________________________________________________________________________

Address: _____________________________________________________________________________________

Postal Address: _______________________________________________________________________________

Contact Details: (Home) _________________________ (Work) ________________________________________

(Mobile) ______________________________________ (Fax) _________________________________________

(Email) _______________________________________ (2nd

Email) _____________________________________

Date of Birth: __________________________________ Country of Birth: ________________________________

Nationality: ___________________________________ Languages Spoken: _____________________________

Tax File Number: _______________________________ Drivers Licence No.: _____________________________

Provider No: __________________________________ Vocationaly Reg: ________________________________

Medical Defence: ______________________________ Medical Defence No.: __________ Expiry Date: _______

Qualifications

Qualifying Degree: ______________________ University: _______________________________ Year: ________

Post Graduate Degree/s: __________________ Obtained at: ______________________________ Year: ________

______________________________________ Obtained at: ______________________________ Year: _______

Date of Registration in NSW: _______________ Reg. No.: _________________________________

Registration in Other States: _____________________________________________________________________

Present Post: _________________________________________________________________________________

Experience

Experience in Internship: ________________________________________________________________________

Experience Overseas: __________________________________________________________________________

Experience in any of the following: (Please circle)

Emergency Medicine Anaesthetics ICU CCU Paediatrics

General Surgery Psychiatry General Medicine Obs/Gynae Rehabilitation

General Practice Sports Med

Other:

Experience in any of the following procedures: (Please circle)

Et Intubation/Ventilation IV Cannulation Central Line Insertion

Long Line Insertion Tracheostomy Insertion Urethral Catheterisation

Other: _______________________________________________________________________________________


Locum Employment Information

Locum Experience: ____________________________________________________________________________

Date Available From: _________________ For Work In: (Please circle) Hospital / G.P / Metropolitan / Rural

Days and Hours Available: ______________________________________________________________________

Position Type: (Please circle) Permanent Full Time Permanent Part Time Other

Reason for Seeking Locum Work

Future Professional Plans: _______________________________________________________________________

Will you work in rural areas as a short term locum? ___________________________________________________

Do you have a preferred location? ________________________________________________________________

Preferred Payment Bank Details: _________________________________________________________________

Superannuation Fund Details: ____________________________________________________________________

Have you ever had any action taken against you by a) Medical Board or b) Medical Defence?

If yes please provide details: _____________________________________________________________________

____________________________________________________________________________________________

Are there any conditions on your registration? _______________________________________________________

Is there any procedure you would not do? __________________________________________________________

Other Information

Hobbies and Interests: __________________________________________________________________________

Do you have a motor vehicle? ____________________________________________________________________

How did you hear of Antipodean Medical Recruitment Pty Ltd? (Please circle)

Classifieds Friends Word of Mouth Internet Search Other __________________

References

Please list three references and their relationship to you.

1) _________________________________________________ Contact Details: ____________________________

2) _________________________________________________ Contact Details: ____________________________

3) _________________________________________________ Contact Details: ____________________________

Signed: _____________________________________________________________________________________

Name: ______________________________________________________________________________________

Date: _______________________________________________________________________________________


CONSENT FORM & DECLARATION

I, acknowledge that I am a locum doctor registered with Antipodean Medical Recruitment Pty Ltd. I declare that:

1) I have full (unconditional) registration to practise medicine in the state of NSW Number MPO Renewal date • I am not aware of any investigation into my registration that would compromise my ability to accept work. • I have/have not been investigated by any medical board/council or suspended from duty. • I have not had my registration cancelled for any reason and am not subject to any restrictions If yes, details are: • I do not have any serious or chronic health problems that will affect my ability to carry out my work as a

doctor.

2) I am an Australian citizen or I am legally able to work in Australia (please supply copy of your work/residency visa).

3) I have current Medical Indemnity insurance with Category . Renewal date:_________________. The insurance effected by me is adequate to cover any liability I may incur in the course of my locum work as a medical practitioner. I am not aware of any outstanding medical negligence claims against me. If yes, give details .

4) My prescriber number is . I am eligible to apply for provider number YES / NO.

My provider number is .

5) In consideration of Antipodean Medical Recruitment Pty Ltd agreeing to try and place me in a position, I agree to indemnify Antipodean Medical Recruitment Pty Ltd and its directors, employees and representatives, against any claim made against any of them relating to medical negligence, dishonesty or otherwise which may arise in connection with any engagement or employment I may accept which is arranged by Antipodean Medical Recruitment Pty Ltd.

6) I understand Antipodean Medical Recruitment Pty Ltd has no responsibility to employ or pay me. I will either be

employed by an Area Health Service or will work as an independent contractor, issuing a tax invoice to the employer/host client through my own ABN or entity.

7) I undertake to work to the best of my ability, with due diligence, punctuality, honesty, courtesy and care.

• I undertake to dress and behave appropriately. • I undertake not to attend work impaired by the effects of alcohol or drugs. • I undertake to notify Antipodean Medical Recruitment Pty Ltd as soon as possible if an adverse event or

situation occurs, which could result in any disciplinary or legal action or compromise the status of my medical registration.

• I have no objection to Antipodean Medical Recruitment Pty Ltd obtaining regular feedback reports from the employing organisation for reasons of quality control.

• I understand my employment could be terminated if my work or attitude is deemed to be unsatisfactory by the employer or if my Medical Registration is altered or compromised in any way.


8) I am prepared to undergo annual criminal record checking and sign a PED (Prohibited Employment

Declaration). I consent to Antipodean Medical Recruitment Pty Ltd providing copies of Criminal Record Consent and PED to prospective employers for the purposes of obtaining work. I have not been convicted of a crime that may affect my application to work as a doctor.

9) I consent to Antipodean Medical Recruitment Pty Ltd undertaking reference checks with my referees as nominated.

10)I consent to Antipodean Medical Recruitment Pty Ltd providing copies of my CV, Medical Registration, Medical Indemnity, references & proof of identification and any other documentation required to any prospective employer for the purposes of obtaining work.

FOR NEW SOUTH WALES HOSPITAL DOCTORS ONLY (Doctors undertaking only GP work OR work in other States can strike this section out)

11) Please initial each point below to acknowledge awareness and agreement of these requirements from NSW Health

a. PD2005_626 NSW Health Code of Conduct

http://www.health.nsw.gov.au/policies/pd/2005/pdf/PD2005_626.pdf

b. PD2005_469 NSW Health Conflicts of Interest in the Public Health System http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_469.pdf

c. PD2005_409 Workplace Health and Safety: Policy and Better Practice Guide http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_409.pdf

d. PD2005_593 Privacy Manual http://www.health.nsw.gov.au/policies/pd/2005/pdf/PD2005_593.pdf

e. PD2005_231 Records Management Policy http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_231.pdf

f. PD2005_186 Employment Health Assessment Policy & Guidelines http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_186.pdf

g. PD2005_162 HIV, Hepatitis B or Hepatitis C – Health Care Workers Infected http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_162.pdf

h. PD2007_006 Occupational Screening & Vaccination of Health Care Workers Against Infectious Diseases http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_006.pdf

i. PD2007_036 Infection Control http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_006.pdf

j. PD2007_061 Incident Management http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_061.pdf


http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_469.pdf










k. GL2007_023 NSW Fatigue – Preventing and Managing Work Related Fatigue: Guidelines http://www.health.nsw.gov.au/policies/gl/2007/pdf/GL2007_023.pdf

l. PD2008_029 Employment Screening Policy http://www.health.nsw.gov.au/policies/pd/2008/pdf/PD2008_029.pdf

m. PD2009_001 Special Remuneration Rates Payable to Non-Specialist Staff – Short Term / Casual (locum) PE 30 June 2012 http://www.health.nsw.gov.au/policies/pd/2009/pdf/PD2009_001.pdf

n. PD2009_004 Service Check Register for NSW Health Services http://www.health.nsw.gov.au/policies/pd/2009/pdf/PD2009_004.pdf

• I have been supplied with a copy of the NSW Health Code of Conduct (PD2005-626) and agree to act according to its terms

• I have been supplied with a copy of NSW Health Conflicts of Interest in the Public Hospital System (PD2005-469) and agree to abide by it

• I will read a copy of the NSW Secondary Employment Policy and agree to abide by it (currently under development and to be supplied in the future)

• I have been supplied with a position description

• I have already undertaken or am prepared to undergo i) Electronic Records management (EMR) training, Place/date of training ii) Mandatory child notification training Place and date of training iii) Mandatory annual theoretical component of fire training as part of hospital orientation/induction. Place and

date of training

• I am aware of and agree to abide by OH & S legislation on manual handling

• I am aware of Occupational Screening and vaccination of Health Care Workers Against Infectious Diseases

• I have received and completed the Employment Screening Questionnaire and Declaration. Locum medical officers who decline immunisation must sign a Statutory Declaration to this effect

• I am aware of Infection Control policies

• I am aware of Workplace health and Safety: Policy and Better Practice Guide and agree to abide by it

• OH& S Act (NSW) 2000

• OH&S Regulation (NSW) 2001

• I am aware of Incident Management protocol and agree to abide by it

http://www.health.nsw.gov.au/policies/gl/2007/pdf/GL2007_023.pdf





• I am aware of Privacy policy and agree to abide by it

• I am aware I may be required to supervise junior medical officers

• I am aware I am required to perform my engagement in accordance with the direction of the customer

• The Area Health Service where I am employed is aware of my intention to do locum work. They have no objection to this provided that it does not raise any work performance issues. I am not aware of any reason that would disqualify me from accepting locum work for NSW Health.

• I am mentally, physically and professionally able to perform my duties as a medical officer.

• I am aware of the need to comply with safe working hours guidelines and preventing and managing work related fatigue(GL2007_023) and the need to take minimum break periods, including taking a break before commencing an engagement in any NSW public hospital.

• I am aware that prior to commencing work for NSW Health, an internal service check will be conducted

• I will/have provided 3 recent references to confirm my competency for the positions applied for

SIGNED in on 20 NAME Please email or fax this back to Antipodean Medical Recruitment Pty Ltd with the required documents:- Email – [email protected] Fax - +64 3 328 9979 If you have any questions, please phone our office:- Australia Tollfree – 1800 070 339 NZ Tollfree – 0800 633 000

mailto:[email protected]

CGRM_WCC_HS 7.2 Last Updated March 2010

APPLICANT DECLARATION AND EMPLOYMENT SCREENING

CONSENT FOR CHILD RELATED EMPLOYMENT

Provide your full name as well as any other names / aliases by which you have been known. Employers are required to sight applicant’s original identifying documents as per 100 point ID check and retain copies of identification documents

Family Name First Given Name Given Name 2 Given Name 3

Primary Name

Maiden Name (if applicable)

Complete Previous / Alias Name if any and circle the appropriate name type

Previous/Alias Name 1




Gender � Male � Female

Date of Birth / / (dd/mm/yyyy)

Suburb/Town:

Place of Birth

State: Country:

No/Street:

Suburb/Town: Current Residential Address

State: Postcode: Country:

Postal Address (if same as Residential Address, write

“As Above”)

No/Street:

Suburb/Town: Previous Address (if any)

State: Postcode: Country:

Email

Telephone No Mobile: Business: Private:

Title of Child Related Position

(specify its child-related nature eg ‘child care assistant’, not ‘assistant’)

Type of Position

(Please tick)

� Paid Employee � Contractor � Volunteer providing intimate personal care to disabled children � Volunteer providing mentoring to disadvantaged children � Minister, priest, rabbi, mufti or other like religious leader or spiritual officer of a religion or other member of a religious organisation � Licensee for prescribed children’s services

If you have used one of these documents to verify your identity, please fill in these details:

Driver’s Licence Number: Issuing State:

Firearms Licence Number: Issuing Agency:

Passport details

Number: Type:

� Private � Government � UN Refugee

Issuing Country:

It is an offence for a prohibited person to apply for, attempt to obtain, undertake or remain in child-related employment, or to sign this declaration. A prohibited person is a person who is convicted of the following (whether in NSW or elsewhere): � murder of a child � serious sex offence, including carnal knowledge � child-related personal violence offence (an offence committed by an adult involving intentionally wounding or causing

grievous bodily harm to a child) � indecency offences punishable by imprisonment of 12 months or more � kidnapping (unless the offender is or has been the child’s parent or carer) � offences connected with child prostitution � possession, distribution or publication of child pornography; or � attempt, conspiracy or incitement to commit the above offences.

A prohibited person includes a Registrable person under the Child Protection (Offenders Registration) Act 2000. A conviction includes a finding that the charge for an offence is proven, or that a person is guilty of an offence, even though the court does not proceed to a conviction.

Details of these offences and Employer Guidelines can be found online at http://kids.nsw.gov.au/ Guidelines/FactSheet 1]

CGRM_WCC_HS 7.2 Last Updated March 2010

Applicant Declaration and Employment Screening Consent Form for Child Related Employment (page 2)

DECLARATION

I am the applicant named in this form. All information in this form, and identification documents provided for this application, are true and correct. I understand that if I have provided false or misleading information it may result in a decision not to employ me, or, if already employed, may lead to my dismissal. I have not omitted any names or aliases that I use or used in the past.

I have read and understood the contents of this form and the relevant information in the Working With Children Guidelines. I declare that I am not a prohibited person under the Commission for Children and Young People Act 1998 and I understand that it is an offence for a prohibited person to seek child-related employment.

I am aware that if considered for child-related employment with NSW Health, several checks will be undertaken to ascertain my suitability, including checks directly related to child related employment and checks related to more general suitability for employment in the public sector.

1. In relation to checking for general public sector employment national criminal record check for all charges which have not been heard or finalised by the court and for all convictions vetted in accordance with the Criminal Records Act 1991 or, if a Commonwealth offence, the Commonwealth Crimes Act 1914.

2. In relation to undertaking a Working With Children Check:

� National criminal record check for charges and/or convictions (including spent convictions, convictions or charges that may have not been heard or finalised by a court; or are proven but have not led to a conviction; or have been dismissed, withdrawn or discharged by a court) for:

• any sexual offence (including but not limited to, sexual assault, acts of indecency, child pornography, child prostitution and carnal knowledge);

• any child-related personal violence offence;

• any assault, ill treatment or neglect of, or psychological harm to a child and any registrable offence; punishable by imprisonment for 12 months or more.

In addition:

• Check for relevant Apprehended Violence Orders taken out by a police officer or other public official for the protection of a child or children; and

• Check for relevant employment proceedings notified to the Commission for Children and Young People under the Commission for Children and Young People Act 1998.

I understand that both checks will be undertaken by the Department of Health who is also an Approved Screening Agency.

CONSENT I consent to these checks being conducted and consent to the Commission for Children and Young People or an Approved Screening Agency obtaining any relevant record identified by these checks and any additional information relating to that record from sources such as courts, police, prosecutors and past employers to enable a full and informed estimate of risk and/or Employment Risk Assessment. I consent to these sources disclosing information relating to the Working With Children Check relevant records to the Commission for Children and Young People and/or Approved Screening Agency.

I acknowledge that:

1. In relation to a Working With Children Check:

• the information obtained during the Working With Children Check, including this consent, may be collected and used by and/or disclosed to the Commission for Children and Young People or an Approved Screening Agency for relevant purposes of the Working With Children Check;

• the Commission for Children and Young People and Approved Screening Agencies may share the information obtained during the Working with Children Check for the purposes of the Working with Children Check;

• the outcome of an estimate of risk will be provided to my prospective employer or their employer-related body;

• the information provided may be referred to the Commission for Children and Young People and/or to NSW Police for law enforcement purposes and for monitoring and auditing compliance with the procedures and standards for the Working With Children Check in accordance with Section 36 (1)(f) of the Commission for Children and Young People Act 1998.

• my relevant records under the Commission for Children and Young People Act 1998 will not be released to the Health agency through which I am seeking employment;

2. In relation to a National Criminal Record Check:

• the information provided will be used and/or disclosed by the Department of Health for the purposes of undertaking the check and in this context, the information obtained as part of the National Criminal Record Check may be provided to the Health agency through which I am seeking employment to ascertain my suitability;

3. Generally

• any information obtained as part of this process may be used by Australian Police Services for law enforcement purposes, including the investigation of any outstanding criminal offences.

Name: _________________________________________________________________________________________

Signature: ______________________________________________ Date: __________________________________

NOTE: This form is to be kept by the employer.

100 Point Identification Check

Instructions:

1. The 100 point identification check must be completed prior to lodgement of a National Criminal Record Check or Working With Children Check or Aged Care Check.

2. Employers are required to sight original identifying documents, certify a photocopy which is to be retained on the applicant’s personnel file, and ensure that an appropriately delegated officer completes the record of identifying documents below.

3. Identification must be current and should include at least one type of photographic ID and identification that contains a signature and date of birth.

4. The point score of documents produced must total at least 100 points.

Applicant’s Name: ______________________________________________________

DOCUMENTS POINTS

Verify the name of the preferred applicant using one of:

- Birth Certificate

- Birth Card issued by the NSW Registry of Births, Deaths and Marriages

- Citizenship Certificate

- Current Australian passport

- Expired Australian passport which has not been cancelled and was current within the

preceding 2 years

- Current passport from another country or diplomatic documents

70

Verify the name and photograph/signature of preferred applicant from one or more of these

(the first item used from this list is worth 40 points. Any additional items used are worth

only 25 points each):

- Current driver photo licence issued by an Australian state or territory

- Identification card issued to a public employee

- Identification card issued by the Australian or any state government as evidence of a person’s

entitlement to a financial benefit

- Identification card issued to a student at a tertiary education institution. - Name of preferred applicant verified in writing, signed by both the person giving it and the

applicant, from one of the following:

- A financial body certifying that the applicant is a known customer.

- An acceptable referee under AUSTRAC Guideline No. 3

(www.austrac.gov.au/files/guideline_3.pdf)

40

Verify name and address of preferred applicant from one or more of these:

- Document held by a cash dealer giving security over property

- A mortgage or other instrument of security held by a financial body

- Council rates notice

- Document from current employer or previous employer within the last two years

- Land Titles Office record

- Document from the Credit Reference Association of Australia.

35

NOTE: This 100 point identification is adapted to accord with the Commonwealth Financial Transaction Reports Act 1988 as required by the CrimTrac Agency and NSW Commission for Children and Young People – Working with Children Check Guidelines February 2010

CGRM_100Check 7.11 last Updated March 2010

DOCUMENTS POINTS

Verify name of preferred applicant from one or more of these:

- Current credit card or account card from a bank, building society or credit union

- Current telephone, water, gas or electricity bill

- Foreign driver’s licence

- Medicare Card

- Electoral roll compiled by the Australian Electoral Commission

- Lease/rent agreement

- Current rent receipt from a licensed real estate agent

- Records of a primary, secondary, or tertiary educational institution attended by the applicant

within the last 10 years

- Records of a professional or trade association of which the applicant is a member.

25

Verify name of preferred applicant using:

- one document from the 70 point list above or

- a student card or a letter signed by the principal, deputy principal, head teacher, deputy head

teacher or enrolment officer, confirming that the applicant currently attends the institution.

Applicants under 18

Employers to note: if an applicant is unable to provide documents to meet the identification requirements due to their personal circumstances or special needs, the employer should contact his or her Approved Screening Agency for assistance.

Record of identifying documents: Please record relevant details in the table below:

Description of document

Date of Issue

Place/ Office of issue/ issuing organisation

Expiry date

Ref. or doc. number

Points

Total points

Name and position title of officer sighting documents

Date: