FODMS38 Application for appointment as an appointed doctor

under regulations

This form is for use by doctors applying for appointment for the first time (complete parts 1, 2 and 3) or by established appointed doctors applying to have their appointment extended to cover additional regulations (complete parts 1 and 3 only).

*Are you currently an Appointed Doctor?	Yes	No

Part 1 – Appointment details *Full name of doctor
Title	Forename	Family Name
PIN Number (current appointed doctors only)	*GMC Number

* Regulation(s) under which you require appointment and the number of medicals you expect to perform in the first 12 months of your appointment for each regulation
If you are applying for an appointment under the Control of Lead at Work Regulations, do you intend undertaking medical surveillance of lead workers at more than one company during the first year of appointment?	Yes	No
If 'Yes', you should provide evidence with your application that you can meet at least one of the following criteria (select as appropriate)

You have undertaken training for appointed doctors on lead (Please provide a copy of training certificate)
You have previously been appointed under the Control of Lead at Work Regulations and have conducted medical surveillance on lead workers (Please provide previous PIN number and copy of Certificate of Appointment)
If appointed, your work will initially be supervised by an experienced appointed doctor who has conducted medical surveillance under the Control of Lead at Work Regulations (Please provide Name and PIN number of appointed doctor)

Part 2 – Doctor's details if applying for appointment for the first time *Address for official correspondence
Address Line 1	(eg building name)
Address Line 2	(eg street)
Address Line 3	(eg district)
*Town
County
*Postcode	Phone Number
*Email Address

*Do you consent to having your name, address, email and telephone number included in a list of appointed doctors published on HSE's website?	Yes	No

*Professional qualifications
*Qualifications in Occupational Medicine
*Details of any relevant training undertaken in Occupational Health
*Details of any relevant practical experience in Occupational Health
*Details of current posts held

Part 3 – Submitting your application

To apply, sign the declaration below and send this document, plus scanned copies of the information requested in the checklist, to: appointed.doctor@hse.gov.uk - incomplete applications will not be considered.

Declaration

If appointed, I agree to accept the conditions of appointment below. I will:

a) carry out medical examinations in accordance with guidance issued by HSE for appointed doctors specific to the regulations under which I am appointed;

b) comply with any administrative procedures for appointed doctors as required by HSE;

c) ensure I have suitable facilities and equipment for carrying out medical examinations;

d) keep appropriate records and provide information that HSE reasonably requests;

e) undertake suitable refresher training as required by HSE, and provide evidence of this training;

f) notify HSE of any changes to my contact details or GMC registration/licensing; and

g) ensure my practice as an appointed doctor meets the standards expected by HSE and the general standards of medical practice required by the General Medical Council.

Failure to observe any of these conditions may result in revocation of your appointment.

Name	Date
Signature

Checklist

This completed and signed document.
Documentary evidence of satisfactory completion of your last annual appraisal, containing your name as appraisee, name of appraiser, signature of appraiser (or electronic confirmation) and date of appraisal.
A copy of the certificate of your highest qualification in Occupational Medicine.
For an appointment under the Ionising Radiations Regulations, a copy of your ionising radiation training certificate.
For an appointment under the Work in Compressed Air Regulations, evidence of specialist knowledge in hyperbaric medicine.