WESTERN SUSSEX HOSPITALS NHS FOUNDATION TRUST
ORGANISATION NAME
EMPLOYEE NUMBER
PART ONE – FOR COMPLETION BY EMPLOYEE
Section 1 – PERSONAL DETAILS
Surname
Title
Forename
Marital Status
Middle Name
Gender
Preferred Name
Date of Birth
Previous Surname
Place of Birth
Country of Birth
Nationality
National Ins Number
Home Address
Post Code
Email Address
Home
Telephone Number
Home
Work
Work
Mobile
Section 2 - PREVIOUS NHS EMPLOYMENT
EMPLOYER
POST TITLE
GRADE/BAND
WT/PT
FROM
TO
NHS PENSION?
Section 3 - PROFESSIONAL REGISTRATION
AWARDING BODY
REGISTRATION NO.
LEVEL
EXPIRY DATE
MEDICAL STAFF ONLY
(FULL/PROV/TEMP)
Section 4 - QUALIFICATIONS
QUALIFICATION
AWARDING BODY
AWARDED DATE
Section 5 - EMERGENCY CONTACT DETAILS
Surname
Forename(s)
Address
Title
Relationship
Post Code
Telephone Numbers
Home
Work
Mobile
Section 6 - BANK DETAILS
Bank / Building Society Name
Sort Code
Building Society Account No.
Account No
Section 7 – PENSION DETAILS
Are you already a member of the NHS Pension
Scheme?
YES
Please complete
remainder of
Section 7
NO
You will be automatically
enrolled into the NHS Pension
Scheme. Proceed to Section 8
Tick all that apply:
Are you already employed elsewhere in full time
capacity in the NHS Pension Scheme?
You will automatically be enrolled into NEST
(National Employment Savings Trust) unless you:
Are you in receipt of an ill health NHS Pension?






Are you a re-employed 1995 scheme pensioner?
Are you a re-employed 2008 Scheme pensioner?
Do you have an Added Years Contract?
If yes, what is the contribution percentage?
(to be verified with the NHS Pensions Agency)
earn less than £9,000 per annum,
are under the age of 22,
are a Non-Executive Director or Officer holder
are a volunteer in receipt of expenses only
are a widow/widower
are a GP Solo or Member of GP section of
scheme
…….%
Section 8 - DISABILITY DISCRIMINATION ACT
The Disability Discrimination Act states: a person has a disability – ‘if they have a physical or mental impairment which has
a substantial long term adverse effect on their ability to carry our normal day to day activities’
Do you suffer from a recognised disability?
YES
NO
Section 9 – THE EQUALITY ACT
Please indicate how you would describe your ethnic origin
A = White British
B = White Irish
C = White Other
D = Mixed – White/Black Caribbean
E = Mixed - White/Black African
F = Mixed – White/Asian
G = Mixed – Other
H = Asian or Asian British – Indian
J = Asian or Asian British - Pakistani
K = Asian or Asian British Bangladeshi
L = Any other Asian background
M = Black or Black British – Caribbean
N = Black or Black British – African
P = any other Black background
R = Chinese
S = Any other ethnic group
Z = Not stated
Section 10 – EMPLOYMENT EQUALITY REGULATIONS
Please indicate which term would best describe your sexuality
Bisexual
Lesbian
Gay
I do not wish to disclose
Heterosexual
Please indicate your religion or belief
Atheism
Buddhism
Christianity
Hinduism
Islam
Jainism
Judaism
Sikhism
Other
I do not wish to disclose my religion/belief
Section 11 – SALARY DEDUCTIONS
Doctors Mess Subscription
Mess membership is an opt-out scheme and the current subscription is £20 per month (Chichester) or £15 per month
(Worthing). Do you wish to pay this subscription?
Yes / No / Not Applicable
Section 12 – MEDICAL BANK
*Doctors contracted to the 2016 Terms and Conditions of Service
If you intend to undertake hours of paid work as a locum, additional to the hours set out in your work schedule,
you must initially offer such additional hours of work exclusively to the service of the NHS via our internal NHS
staff locum bank.
The requirement to offer such service is limited to work commensurate to your grade and competencies, rather
than work at a lower grade than you are currently employed to work at.
You must inform us as your employer of your intention to undertake additional hours of locum work. You can
carry out additional activity over and above the standard commitment set out in your work schedule up to a
maximum average of 48 hours per week (or up to 56 hours per week if you have opted out of the Working
Time Regulations).
You have a professional responsibility for ensuring your total hours of work, including any work undertaken for
any other employer, comply with the contractual and regulatory limits set out in Schedule 3 of the Terms and
Conditions of Service for NHS Doctors and Dentists in Training (England) 2016.
*Have you read and understood your responsibilities as outlined above regarding additional working under the 2016 Terms
and Conditions of Service?
Yes / No / Not Applicable
All medical staff will automatically be added to the Western Sussex Hospitals NHS Foundation Trust Locum Bank.
Do you wish to opt out?
Yes / No / Not Applicable
Note: You should opt out if you do NOT wish to conduct locum work in addition to your substantive position of employment.
Section 13 – EMPLOYEE CERTIFICATION
I certify the above information is true and correct, and I understand the information from this form will be held in a manual
filing system and on the NHS electronic staff record database
I authorise that my previous employers can be contacted in order to verify my salary and continuous service.
Employee Signature
Date