DepartmentTLA
Place of InterviewTelephone
Name of InterviewerDanny Miller
Interviewer Email AddressEmail hidden; Javascript is required.
Date of Interview09/05/2024
Personal Details
Applicant NameKHALIDA BEGUM
Date of Birth21/01/1989
Marital StatusSingle
Do you hold a driving license valid for use within the UK?Yes
National Insurance NumberJP220053B
Do you wish to register as a limited company?No
I confirm that I have received and read the Key Information DocumentYes
I confirm that The Locum Agency have my permission to request and obtain copies of payslips from my employer/ umbrella company/ personal service company and have my permission to make this available to third partiesI Agree
I confirm that I give my permission to The Locum Agency to share my data with Total Assist RecruitmentI Agree
Grade/Band8A
SpecialtyClinical Pharmacist
Next of Kin
NameAbdul Halim
RelationshipPartner
Contact Number07947192571
Address14 Bengal Road
Ilford
London, Essex IG1 2EH
United Kingdom
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Nationality
Do you hold a British Passport?Yes
Passport Number524732274
Passport Expiry Date16/05/2026
Should you hold any other Visa or residency permit, please provide the information below:

n/a

Current Address33 Tregaron Avenue
Drayton
Portsmouth, Hampshire PO6 2ND
United Kingdom
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Mobile Phone07515344743
Applicant Email AddressEmail hidden; Javascript is required.
Availability for Work
Availability to start work20/05/2024
Availability over the next 12 monthsOngoing
Which part of the UK do you prefer to work in?
  • London
Declarations

Declarations

In line with the Government legislation under the terms of the “Working Time Regulations” we recommend that your working hours should not exceed 48 hours per week (averaged over a 17 week period.)
Should you wish to waive this right, please confirm my ticking below:
  • I confirm that I wish to work more than 48 hours per week
I understand that information give on this form will be stored and handled by The Locum Agency in accordance with the Data Protection Act 1988, however, I agree that this information may be made available for audit by the relevant Government organisations e.g. CCS / CPP Framework.
Data Protection Act 1998 / The General Data Protection Regulations 2018
In relation to the Data Protection Act 1998 / The General Data Protection Regulations 2018, you agree to the processing of personal data for the purposes of the recruitment process as well as for future potential employment arrangements for the purposes of calculating your remuneration and maintaining records on attendance, health, discipline and grievances such as are necessary for the performance of your contract. For further information, please see the Information Commissioner's website ww.dataprotection.gov.uk, from which the above guidance is reproduced.
I acknowledge that I have been given a copy of the terms and conditions of service issued by The Locum Agency, which is mine to keep and further more that I have read those terms and conditions and agree to abide by them. I am not aware of any condition, medical or otherwise which would affect or limit my employment or performance, other than those declared in my Pre-employment Health Questionnaire From and I am fit for work.
I authorise The Locum Agency to disclose any convictions to any potential employers in accordance with the DBS Code of Practice and the Rehabilitation of Offenders. I declare that the details given by me on this application form are correct to the best of my knowledge and belief. I understand that if I have given any information which is false, or I withhold any relevant information, this may lead to my application being rejected, or if already appointed, to my dismissal, as well as a claim for recovery of any payments I have received, together with a claim for loss of profit to The Locum Agency.
I also give The Locum Agency Permission to apply and to check my DBS certificate on the UK DBS update service annually.
I give The Locum Agency Permission if required to conduct any relevant right to work checks Via the Government websites.
Signature
Consent I agree
Professional Details
Professional Registration Number2082503
Child Protection / Venerable Adults level 2/310/05/2024
Handling Complaints10/05/2024
Fire Procedures10/05/2024
Handling Violence & Aggression10/05/2024
COSHH & RIDDOR10/05/2024
Infection Control & Prevention10/05/2024
Lone Worker Training10/05/2024
Health & Safety10/05/2024
Risk Incident Reporting10/05/2024
Moving & Handling10/05/2024
The Caldicott Protocols10/05/2024
Basic Life Support14/05/2024
Have you been appraised within the last 12 months?No
Vaccine History
Have you received the influenza vaccine?No
Would you consider having the influenza vaccine, if offered to you?No
Have you received both doses of either a Pfizer BioNTech or Oxford/AstraZeneca COVID vaccine?Yes
If Yes please attach your COVID vaccine passportIf Yes please attach your COVID vaccine passport
Employment HistoryCan you please provide details in the boxes below of your last 3 years employment (most recent first). If there are any gaps of 3 month or more it is important that you explain the reason why in the box below.
Employer name (1)Mid and South Essex NHS Foundation Trust (Broomfield hospital, Chelmsford)
Position Held (Employer 1)Lead Clinical Pharmacist - Emergency Department (Band 8a)
Location (Employer 1)Chelmsford
Tel Number (Employer 1)01245 513516
Date From (Employer 1)01/04/2021
Date To (Employer 1)30/04/2024
Employer name (2)University Hospital Southampton NHS Foundation Trust
Position Held (Employer 2)Senior Specialist Pharmacist - Acute Medicine (Band 8a)
Location (Employer 2)Southampton
Date From (Employer 2)01/12/2019
Date To (Employer 2)31/03/2021
Employer name (3)University Hospital Southampton NHS Foundation Trust
Position Held (Employer 3)Specialist Pharmacist in Medicine (Band 7)
Location (Employer 3)Southampton
Date From (Employer 3)18/04/2016
Date To (Employer 3)30/11/2019
Professional RefereesYou are required to supply at least two work related professional referees. The 2 referees provided must be within the last 12 months and be concurrent. If you have worked at the same Hospital for the last 12 months then we require 2 referees from that Hospital. Both referees must be a Consultant or Clinical Director. (We have allocated space for additional referees to be included, should you wish to provide more than two referees you must follow the above same principle.)
Name of First RefereeMaria Richards
Email of First RefereeEmail hidden; Javascript is required.
Address of First RefereeBroomfield Hospital
Court Road
Chelmsford CM1 7ET
United Kingdom
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Phone of First Referee01245 513516
Known Capacity of First RefereePrincipal Clinical Pharmacist, Emergency Care at Mid and South Essex NHS Foundation Trust
Name of Second RefereeHelen Ellis
Email of Second RefereeEmail hidden; Javascript is required.
Address of Second RefereeBroomfield Hospital
Court Road
Chelmsford CM1 7ET
United Kingdom
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Phone of Second Referee01245 513516
Known Capacity of Second RefereePrincipal Pharmacist - Burns, Plastics and Dermatology at Mid and South Essex NHS Foundation Trust
Signature to apply for references
I give Total Assist Recruitment permission to forward my CV to agreed clients for the purpose of obtaining employment.
  • I agree
Equal Opportunities Policy

Equal Opportunities Policy

As an Equal Opportunities employer the organisation welcomes applications from suitably qualified persons from all sections of the community. The organisation is committed to achieving a working environment which provides equality of opportunity and freedom from discrimination on the grounds of race, nationality, religion, gender, class, family responsibilities, marital status, sexual orientation, age, disability or special need. The Directors believe in best practice in Equal Opportunities on the grounds of morality, good business practice and awareness that certain kinds of discrimination are unlawful. This is a key employment value to which all employees and candidates are expected to give their support. To ensure that the policy is effective it is essential that detailed monitoring is carried out, which necessitates the collection of information. The information on this form will be kept confidential and will not be used by those involved in the selection procedure and is for statistical purposes only and will not form part of any job application. *
Please SelectAsian
Criminal Record DeclarationNo
Have you ever had an Enhanced Disclosure Barring Service Check (previously DBS check) ?No
Disclosure Number001873021386
Date of Disclosure27/03/2024
Consent I agree
Applicants NameKhalida Begum
Applicant's Signature
For Office Purposes OnlyTHE F2F OFFICER MUST COMPLETE THE BELOW BEFORE LEAVING THE MEETING.