FODMS38R - Renewal of appointment as an appointed doctor

Doctor’s details
Title	Forename	Family Name
PIN Number	*GMC Number
Medicals *How many medicals have you undertaken, for each set of regulations under which you are appointed, in the last 12 months?

Submitting your application

Declaration

To apply for renewal of appointment, sign the declaration below and send this document, plus scanned copies of the information requested in the checklist (see page 2) to: appointed.doctor@hse.gov.uk – incomplete information will not be considered.

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

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

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

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

keep appropriate records and provide information that HSE reasonably requests;

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

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

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.
Audit form.
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.
For an appointment under the Ionising Radiations Regulations, a copy of your current ionising radiation training certificate.
For an appointment under the Work in Compressed Air Regulations, evidence of up to date specialist knowledge in hyperbaric medicine.