Application for Inclusion in the Northern Ireland Performers List

Please be advised you cannot proceed until you confirm you have read the Privacy Notice.

Please click on the link below to view the Privacy Notice:

Northern Ireland Performers List Privacy Notice
Declaration*
I have read and understand the Privacy Notice

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**Please be advised your form cannot be submitted or processed without a valid date of inclusion on the GP Register (Section D) **
A. PERSONAL DETAILS
Name*
First Last
Previous surname(s):
Date of Birth*
DD slash MM slash YYYY
Gender
- Male
- Female
Do you consent to your date of birth being included in the published list?*
- Yes
- No
National Insurance Number:*
Private address (include postcode):*
Street Address Town/City County Postcode
Do you have an alternative address for correspondance?
- Yes
- No
Correspondence address (include postcode):
(if different from the address given above/mobile service)

Street Address Town/City County Postcode
Preferred Contact Number*
Private email address*
** Please note this email address will be used for all correspondence relating to this application unless otherwise requested **
Do you, or have you, had any health concerns that would impact or have impacted, on your delivery of GMS?*
- Yes
- No
Please give details*

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B. PERFORMERS LIST – INTENDED ROLE
Please indicate what your role will be: (check as appropriate)*
- GP Principal (Contractor)
- Salaried GP
- Sessional GP
- Armed Forces GP
Will you be working solely or mainly in Out of Hours?*
- Yes
- No
Are you a director or one of the persons with corporate control of a corporate body?*
- Yes
- No
Please give the name and address of that body;*

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C. DETAILS OF WORK TO BE UNDERTAKEN
Do you have an offer of a contract or post?*
Is this offer from:*
- A practice in NI
- An Out of Hours provider
- Another organisation
When do you hope to start working?*
** Please Note - we cannot guarantee that your application will be approved before this date **
DD slash MM slash YYYY
Please confirm the average number of sessions per week*
How many sessions will be in Northern Ireland*

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D. PROFESSIONAL REGISTRATION AND QUALIFICATIONS
Please provide the following information about your professional registration:
GMC Number*
Date first registered:*
DD slash MM slash YYYY
Date of inclusion on the GP register:*
DD slash MM slash YYYY
Revalidation Date assigned by GMC:*
DD slash MM slash YYYY
Please provide the following information about your professional qualifications (including post-graduate and completion of vocational training if applicable).*
** To add additional rows please click on the + icon at the end of the row **
Title of Qualification Institution (name and location) Date Awarded

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E. PROFESSIONAL HISTORY AND EXPERIENCE

Please list, with the most recent first, your professional experience since obtaining your PRIMARY Medical Degree. Include experience as trainees or in hospital appointments. You must include any gaps between posts and give an explanation. Failure to do so may result in your application being delayed.*

Please note that a CV will not be accepted in lieu of completion of this section. ** To add additional rows please click on the + icon at the end of the row **

Employer/Practice (name and address)	Appointment position/job title and if a GP post whether salaried or partnership	From Date (dd/mm/yyyy)	To Date (dd/mm/yyyy)	Average of weekly sessions	Reason for leaving

Please give details of 'Other' reasons for leaving as above

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F. APPRAISAL AND PROFESSIONAL DEVELOPMENT
Please provide the following information for use by the SPPG Responsible Officer:
Please give the date of your most recent Appraisal
DD slash MM slash YYYY
If you have not undertaken appraisal in the last 12 months please provide reasons for this.*
(if this is not applicable please enter N/A)

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G. INCLUSION ON OTHER PERFORMERS LISTS
Please provide the following information regarding other performers’ lists for use by the SPPG Responsible Officer:
Are you currently on the Performers List of any Primary Care Organisation in England, Scotland or Wales?*
- Yes
- No
Name of the Responsible Officer*
First Last
Name of Primary Care Organisation*
Contact Name*
Email*
Telephone Number*
Address*
Street Address Town/City County Postcode
Dates of Inclusion on the Performers List*
Start Date
DD slash MM slash YYYY
Have you been refused admission, conditionally included in, suspended from, removed or conditionally removed from any Primary Care List or equivalent list?*
- Yes
- No
Please provide details and a supporting explanation*
Have you at any time during your career been subject to sanctions, conditions or suspensions imposed by your registration body, employer or other NHS body?*
- Yes
- No
Please provide details and a supporting explanation*
Please provide details of any outstanding applications (including deferred applications) for inclusion in the performers list or equivalent list of any Primary Care Organisation:*
(If not applicable please enter N/A)

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I. CLINICAL REFEREES
Please provide details of two referees. Referees should normally be clinical representatives of your current and most recent clinical posts where you were in post for a continuous period of at least three months. If you are a locum, referees should be from the two practices where you have worked the most time in the last twelve months. If this is not possible, a full explanation and alternative referees must be given. See more detailed notes on requirements for referee reports by clicking HERE
Referee 1 - Name*
Prefix First Last
Job Title*
Address*
Street Address Town/City County Postcode
Telephone Number*
Email*
If available
How does this person know you?*
e.g. current/last employer, current/last business partner, clinical supervisor etc
What date did you start work with this person?*
Enter the date you started this employment.
DD slash MM slash YYYY
Is this your present employment?*
- Yes
- No
Date ended employment with this person*
DD slash MM slash YYYY
Referee 2 - Name*
Prefix First Last
Job Title*
Address*
Street Address Town/City County Postcode
Telephone Number*
Email*
If available
How does this person know you?*
e.g. current/last employer, current/last business partner, clinical supervisor etc
What date did you start work with this person?*
Enter the date you started this employment
DD slash MM slash YYYY
Is this your present employment?*
- Yes
- No
Date ended employment with this person*
DD slash MM slash YYYY

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J. INFORMATION FOR APPLICANTS
This application should be read in conjunction with the Performers Lists regulations at the following links:

Govt Legislation
Performers List Regulations
Documents Required to Support Your Application to the NI Primary Medical Performers List:
The following documents should be submitted at the time of your application. (See also the requirements of the Disclosure and Barring Service – appendix 4)
All Documents must be ORIGINALS (photocopies cannot be accepted). The documents will be photocopied and returned to you.

Your graduation certificate.
Note: Graduation certificates are not required for ST2 doctors who undertook training with NIMDTA
Graduation certificates are required for ST3 Trainees who are undergoing training outside of Northern Ireland

Your certificate of completion of training in General Practice
Or
Certificate of Prescribed/Equivalent Experience e.g. JCPTGP, PMETB or Evidence of Equivalency. (Note JCPTGP only applies to doctors who qualified after 15th February 1981. If you qualified before this date you should have been sent a certificate confirming your inclusion on the medical list.
Relevant details on health (eg GP letter) where appropriate.

Language Knowledge Certificate, or alternative – if applicable
Evidence of identity:
Please note only certain documents in certain combinations are acceptable as evidence of identity for an Enhanced Criminal Records check as listed on the Access NI website Guides for form completion

Documents in languages other than English.

Where a document is not in English, you may need to provide a translation of that document into English along with the original
• Translations of overseas police records checks should be sworn translations.
• Translations of overseas professional qualifications can be certified or sworn translations.
A sworn translation is one carried out by a translator who has been accredited by the government of the country in question to translate and authenticate a document. A document provided by a sworn translator is an official document in its own right. The translation will be provided with a stamped declaration which is written in the relevant language, as well as English.
A certified translation is one carried out by a translator and which is accompanied by a signed statement from the translator that it is an accurate translation. However the translation is not an official document in its own right.
Safeguarding of Vulnerable Groups:

It is a requirement that a doctor applying for inclusion on the NI Primary Medical Performers’ Lists (NIPMPL) has an Enhanced Disclosure Certificate. This certificate provides details of spent and unspent convictions in addition to other relevant information held in police records.

Applications for Enhanced Disclosures must be made by individuals and countersigned by the Registered Body, the Business Services Organisation (BSO). On receipt of the NIPMPL application form you will be contacted with the AccessNI PIN number which you will require to create an account and complete the AccessNI application on line. The BS0 will then submit the completed Disclosure Application form to Access NI.

There is a charge of £33 to the doctor which may be paid by cheque and made out to BSO or, alternatively, a payment can be made over the phone by contacting Finance on 028 95362182 and asking for the Receipting Team.

Please note that an identity check, as described in the Disclosure Application Form, must be completed at BSO before the application can be processed. This identity check must be done in person at BSO offices in Belfast and must be confirmed by production of the relevant documents (which must include photographic ID) as listed on the ACCESSNI website under “Guides for form completion”. You may wish to telephone 028 90535516 to arrange an appointment or to discuss any queries.

If the applicant is joining the list as an ST2 trainee and is in possession of an Enhanced Criminal Record Check (ECRC) completed via NIMDTA, a copy of this will suffice and a further check will not be required.

HSC BSO adheres to the ACCESSNI Code of Practice, this can be viewed HERE

Please note that a criminal conviction will not necessarily be a barrier to joining the Primary Medical Performers List; if you wish to see our policy with regard to this, please contact GPrevalidation@hscni.net.
.
Declaration*
- I have read and understand the documentary requirements for this application

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UNDERTAKINGS AND CONSENT
ALL applicants must complete this section.
Schedule 1(3) to the Health and Personal Social Services (Primary Medical Performers Lists) Regulations (Northern Ireland) 2004 requires an applicant to the Primary Medical Performers List to make the undertakings listed below.

- I consent to a request being made by the Board to any employer or former employer, licensing, regulatory or other body in the United Kingdom or elsewhere, for information relating to a current investigation, or an investigation where the outcome was adverse, into me or a body corporate referred to in this paragraph and, for the purposes of this sub-paragraph, “employer” includes any partnership of which I am or was a member.

- I agree that should the Health and Social Care Board consider it necessary to request further information, documentation or references from me in order to make a decision on my application, I will provide such further information, documentation or references within 28 days (or such longer period that the Health and Social Care Board may agree).

- I understand that failure to provide any information requested within the specified time frame may lead to my application being discontinued.

I undertake that:
1. (a) I will participate in appropriate and relevant appraisal procedures.
2. (b) I will co-operate with the NPSA, when requested to do so by the Board.
3. (c) I will provide the Board with an enhanced criminal record certificate issued under section 113B of the Police Act 1997.
4. (d) I will notify the Board if I am included or apply to be included, in any other primary medical services performers list held by a Board or equivalent body.
5. (e) I will notify the Board in writing within 7 days of its occurrence if I –
1. (i) am charged in the United Kingdom with a criminal offence, or am charged elsewhere with an offence which, if committed in Northern Ireland, would constitute a criminal offence
2. (ii) am convicted of a criminal offence in the United Kingdom;
3. (iii) am convicted elsewhere of an offence which would constitute a criminal offence if committed in Northern Ireland;
4. (iv) have, in summary proceedings in Scotland in respect of an offence, been the subject of an order discharging me absolutely (without proceeding to conviction);
5. (v) have accepted and agreed to pay a penalty under Section 109A of the Social Security Administration (Northern Ireland) Act 1992, a penalty under Section 115A of the Social Security Administration Act (Northern Ireland) 1992 or a procurator fiscal fine under section 302 of the Criminal Procedure (Scotland) Act 1995;
6. (vi) have accepted a police caution in the United Kingdom;
7. (vii) am bound over following a criminal conviction in the United Kingdom;
8. (viii) become the subject of any investigation into my professional conduct by any licensing, regulatory or other body;
9. (ix) am informed by any licensing, regulatory or other body of the outcome of any investigation into my professional conduct, and there is a finding against me;
10. (x) become the subject of any investigation or proceedings by another Board or equivalent body, which might result in me being disqualified, conditionally disqualified, removed or suspended from a list, or equivalent list;
11. (xi) am disqualified, conditionally disqualified, removed or suspended from or refused admission to any list or equivalent list;
12. (xii) am, was in the preceding 6 months, or was at the time of the events that gave rise to the charge, conviction or investigation, a director or one of the persons with control of a body corporate and that body corporate–
1. (a) is charged in the United Kingdom with a criminal offence, or is charged elsewhere with an offence which, if committed in Northern Ireland, would constitute a criminal offence;
2. (b) is convicted of a criminal offence in the United Kingdom;
3. (c) is convicted elsewhere of an offence which, if committed in Northern Ireland, would constitute a criminal offence;
4. (d) becomes the subject of any investigation into its provision of professional services by any licensing, regulatory or other body; or
5. (e) is informed by any licensing, regulatory or other body of the outcome of any investigation into its provision of professional services, and there is a finding against it, together with details of the occurrence, including approximate dates, and where any investigation or proceedings were or are to be brought, the nature of that investigation or proceedings, and any outcome;
6. (f) If I am a provider of primary medical services under a general medical services contract, I will comply with the requirements of paragraph 116 (gifts) of Schedule 5 (other contractual terms) to the General Medical Services Contracts Regulations;
7. (g) If I am not a provider of primary medical services but perform primary medical services in accordance with a general medical services contract, I will comply with the requirements of paragraph 116 (gifts) of Schedule 5 to the General Medical Services Contracts regulations as though I were a provider of primary medical services.
Declaration to be made by ST2 Trainee GP’s only where the performer is an ST2 Trainee, unless the performer has an acquired right under regulation 5(1)(d) of the Vocational Training for General Medical Practice (European Requirements) Regulations 1994

I will:-
1. (i) not perform primary medical services except when acting for, and under the supervision of, my GP Trainer;
2. (ii) withdraw from the primary medical services performers list if any of the events in paragraph 4 takes place;
3. (iii) until the coming into force of Article 10 of the 2003 Order apply for a certificate of prescribed experience under regulation 10 of the Vocational Training Regulations or a certificate of equivalent experience under regulation 12 of those Regulations as soon as the I am eligible to do so, and provide the Board with a copy of any such certificate; and
4. (iv) after the coming into force of Article 10 of the 2003 Order, provide the Health Board with evidence of my inclusion in the GP Register;
The events to which the above applies are–
1. (a) the conclusion of any period of training prescribed by regulation 6(3) of the Vocational Training Regulations or after the coming into operation of Articles 4 and 5 of the 2003 Order, any period of general practice training required pursuant to those Articles, unless–
1. (i) it forms part of a vocational training scheme which has not yet been concluded, or
2. (ii) the ST3 Trainee provides the Board with–
1. (a) a certificate of prescribed experience under regulation 10 of the Vocational Training Regulations,
2. (b) a certificate of equivalent experience under regulation 12 of those Regulations, or
3. (c) after the coming into operation of Article 10 of the 2003 Order, evidence of the applicant’s inclusion in the GP Register;
the failure satisfactorily to complete any period of training within the meaning of regulation 9 of the Vocational Training Regulations or after the coming into operation of Articles 4 and 5 of the 2003 Order, of general practice training within the meaning of those Articles; and

the completion of a vocational training scheme, unless the ST3 Trainee provides the Board with–
1. (i) a certificate of prescribed experience under regulation 10 of the Vocational Training Regulations,
2. (ii) a certificate of equivalent experience under regulation 12 of those Regulations, or
3. (iii) after the coming into operation of Article 10 of the 2003 Order, evidence of the GP Registrar’s inclusion in the GP Register.
Terms and Conditions
I have read the undertakings and consents set out above. I understand that I am required to give these undertakings as a condition of being included in the NI Primary Medical Performers List and I agree to be bound by them.
Applicant declaration*
- By ticking this box I confirm that I have read and agree to the above terms and conditions
I declare that the information included above, on any separate sheets, and in step 13 (Declarations), is true and accurate and that I have not withheld any information that the Health and Social Care Board could reasonably wish to know which would affect my application. I have read and agree to all undertakings and consents set out in step 14. I apply for inclusion in Northern Ireland Primary Medical Performers List.*
By ticking this box I confirm that I have read and agree to the terms.
Full Name*
You are advised that entering your name and the date is considered an electronic signature and acceptance of the undertakings.
Date*
DD slash MM slash YYYY
Email
This field is for validation purposes and should be left unchanged.

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Application for Inclusion in the Northern Ireland Performers List

Step 1 of 13

A. PERSONAL DETAILS

B. PERFORMERS LIST – INTENDED ROLE

C. DETAILS OF WORK TO BE UNDERTAKEN

D. PROFESSIONAL REGISTRATION AND QUALIFICATIONS

E. PROFESSIONAL HISTORY AND EXPERIENCE

F. APPRAISAL AND PROFESSIONAL DEVELOPMENT

G. INCLUSION ON OTHER PERFORMERS LISTS

H. ENGLISH LANGUAGE COMPETENCY

I. CLINICAL REFEREES

J. INFORMATION FOR APPLICANTS

K. APPLICANT DISCLOSURE

Criminal Convictions

Investigations into professional Conduct and / or Fraud

Corporate Body Declaration

Applicant Declaration

UNDERTAKINGS AND CONSENT

Title of Qualification	Institution (name and location)	Date Awarded