ࡱ> 7F456{ HbjbjBrBr ~  6]D4444.~"("""#$<$ -------$0O3-%##%%-""4y.2-)-)-)%d""--)%--)-) ,X,"00 [-&.$,-.H.,,,31&&3X,X,&3~,(%,%-):% F%Y%%%--W(%%%.%%%%3%%%%%%%%% : Research Passport Application Form  Version 3 01/09/2012 Please refer to the guidance notes before completing the form.Section 1 - Details of Researcher To be completed by Researcher1. Surname:  FORMTEXT      Prof FORMCHECKBOX  Dr FORMCHECKBOX  Mr FORMCHECKBOX  Mrs FORMCHECKBOX  Miss  FORMCHECKBOX  Ms FORMCHECKBOX  Other FORMCHECKBOX Forename(s):  FORMTEXT      Home Address:  FORMTEXT      Work Tel:  FORMTEXT       Mobile:  FORMTEXT       Email:  FORMTEXT      2.Date of birth:  FORMTEXT       Gender: Male  FORMCHECKBOX  Female  FORMCHECKBOX Ethnicity:  FORMTEXT       National Insurance number:  FORMTEXT       3.Professional registration details, if applicable (Doctors undertaking any form of medical practice should confirm they have a licence to practise). N/A  FORMCHECKBOX   FORMTEXT       4.Employer:  FORMTEXT       or place of study:  FORMTEXT      Work Address/Place of Study:  FORMTEXT      Post or status held:  FORMTEXT      Section 2 - Details of Research To be completed by Researcher5.What type of Research Passport do you need? Project-specific  FORMCHECKBOX  Multi-project  FORMCHECKBOX If you will be conducting one project only please complete the details below. If you anticipate that you will be undertaking more than one project at any one time, please give details in the Appendix.Project Title:  FORMTEXT      Project Start Date:  FORMTEXT       End Date:  FORMTEXT       Proposed start and end-date of 3-year Research Passport: Start Date:  FORMTEXT       End Date:  FORMTEXT      NHS organisation(s):Dept(s):Proposed research activities:Manager in NHS organisation: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Section 3  Declaration by Researcher To be completed by Researcher6.Have you ever been refused an honorary research contract?Yes  FORMCHECKBOX  No  FORMCHECKBOX Have you ever had an honorary research contract revoked?Yes  FORMCHECKBOX  No  FORMCHECKBOX If yes to either question, please give details:  FORMTEXT      I consent to the information provided as part of this Research Passport and attached documents being used, recorded and stored by authorised staff of the NHS organisations where I will be conducting research. Signed:Date:When Sections 1-3 have been completed, the researcher should forward the form to the appropriate person to complete Section 4. Section 4 - Suitability of Researcher To be completed by researchers substantive employer, e.g. line manager, or academic supervisor7.aWill this persons research activity mean that they may be undertaking regulated activity with children and/or adults as defined in the Safeguarding Vulnerable Groups Act 2006, as amended (in particular by the Protection of Freedoms Act 2012)? (please use the Research Passport algorithm to make this judgement) Yes  FORMCHECKBOX  No  FORMCHECKBOX  7. bI am satisfied that the above named individual is suitably trained and experienced to undertake the duties associated with the research activities outlined in this Research Passport form.Signed: Date: Name: Job Title: Department and Organisation: Address: Tel No:Email:Managerial responsibility for the applicant: When Section 4 has been completed, the researcher should forward the form to the appropriate person to complete Section 5. Section 5 - Pre-engagement checks To be completed by the HR department of the researchers substantive employer or registry at place of study8.Does the above named individuals research involve Regulated Activity with children and/or adults as defined in the Safeguarding Vulnerable Groups Act 2006, as amended (in particular by the Protection of Freedoms Act 2012)?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes to the above, has the above named individual been checked against ISA barred lists for adults and/or children, as appropriate and have you received confirmation via the criminal record disclosure that the person is not barred from working with adults and/or children? (NB individuals who are barred from working with adults or children must not undertake a regulated activity in the NHS with the vulnerable group from which they are barred, and you must not submit a Research Passport form in such cases).Checked against: ISA Adults List?Yes  FORMCHECKBOX  No  FORMCHECKBOX  N/A  FORMCHECKBOX ISA Childrens List?Yes  FORMCHECKBOX  No  FORMCHECKBOX  N/A  FORMCHECKBOX Can you confirm that a clear criminal record disclosure has been obtained for the above-named individual, with no subsequent reports from the individual of changes to this record? NB for Regulated Activity this must be an enhanced level criminal record check. For non-regulated activity, ensure the criminal record check is at the mandated level. Yes  FORMCHECKBOX  No  FORMCHECKBOX  N/A  FORMCHECKBOX If yes, please provide details of the clear disclosure:Date of disclosure:Type of disclosure: Disclosure No.:Organisation that requested disclosure: 9.Have the pre-engagement checks described below been carried out with regard to the above-named individual and is confirmation of the necessary checks, including any required satisfactory documentary evidence, available in the employing organisations/place of studys records?Employment/student screening: ID with photograph Yes  FORMCHECKBOX  No  FORMCHECKBOX two referencesYes  FORMCHECKBOX  No  FORMCHECKBOX verification of permission to work/study in the UKYes  FORMCHECKBOX  No  FORMCHECKBOX exploration of any gaps in employmentYes  FORMCHECKBOX  No  FORMCHECKBOX Evidence of current professional registrationYes  FORMCHECKBOX  No  FORMCHECKBOX  N/A  FORMCHECKBOX Evidence of qualificationsYes  FORMCHECKBOX  No  FORMCHECKBOX Occupational health screening / clearanceYes  FORMCHECKBOX  No  FORMCHECKBOX  Is the named individual on a fixed term contract or is the contract end imminent? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Please indicate current contract end-date Date:Signed: Date: Name: Job Title: Organisation: Department: Address:Tel No:Email:Please return the form to the researcher. Section 6 - Instructions to applicants To be completed by ResearcherPlease indicate which of the following documents are attached to this Research Passport:Current curriculum vitae, including details of qualifications, training and professional registration (please use the template C.V. at  HYPERLINK "http://www.rdforum.nhs.uk/docs/template_cv.doc" http://www.rdforum.nhs.uk/docs/template_cv.doc) Yes  FORMCHECKBOX  No  FORMCHECKBOX  Researchers copy of criminal record disclosure. NB where research involves regulated activity with children and/or adults as defined in the Safeguarding Vulnerable Groups Act 2006, as amended (in particular by the Protection of Freedoms Act 2012), the disclosure must include confirmation of a check against the appropriate ISA barred list(s). Yes  FORMCHECKBOX  No  FORMCHECKBOX  N/A  FORMCHECKBOX  Evidence of occupational health screening / clearanceYes  FORMCHECKBOX  No  FORMCHECKBOX  N/A  FORMCHECKBOX Appendix List of projects and amendmentsAppendix numbers: N/A  FORMCHECKBOX  Please send the completed form and original documents to the Lead R&D office. The completed form and original documents will be returned to you. This package of documents will be used to validate your completed Research Passport form. You may then, and where relevant, provide the Research Passport to other NHS organisations. You must inform all NHS organisations that have received this Research Passport of any changes to the information supplied above. Failure to do so may result in withdrawal of your honorary research contract or letter of access. As part of the quality control procedures for the Research Passport, random checks on the accuracy of the information held on this Research Passport may be made. Section 7 This section should be completed by HR in the Lead NHS organisation, only if additional checks are undertakenThe following additional checks have been completed: Having confirmed that the necessary additional pre-engagement checks have been completed, I am satisfied that the above named researcher is suitable to carry out the duties associated with their research activity outlined in this Research Passport. Signed: Date: Name: Job Title: Organisation: Department: Email: Section 8 - For Office Use OnlyThis section should be completed by the NHS R&D office that received the initial application. The NHS R&D office must countersign and date retained photocopies of the documents. The grey section must be completed before the form is returned to the applicant.CV reviewed?Yes  FORMCHECKBOX  No  FORMCHECKBOX Training?Yes  FORMCHECKBOX  No  FORMCHECKBOX Evidence of qualifications?Yes  FORMCHECKBOX  No  FORMCHECKBOX Appendix pages reviewed?Numbers: Professional registration details reviewed?Yes  FORMCHECKBOX  No  FORMCHECKBOX  N/A  FORMCHECKBOX Occupational health clearance reviewed?Yes  FORMCHECKBOX  No  FORMCHECKBOX  N/A  FORMCHECKBOX Criminal record disclosure reviewed?Yes  FORMCHECKBOX  No  FORMCHECKBOX  N/A  FORMCHECKBOX Date of disclosure: Disclosure No:For regulated activity as defined in the Safeguarding Vulnerable Groups Act 2006, as amended (in particular by the Protection of Freedoms Act 2012), did the criminal record disclosure confirm a satisfactory check against the appropriate ISA barred list(s)Yes  FORMCHECKBOX  No  FORMCHECKBOX  N/A  FORMCHECKBOX Enter Electronic Staff Record Number (if issued): Confirmation of valid Research Passport:Project specific  FORMCHECKBOX  Three-year  FORMCHECKBOX  Other End date  FORMCHECKBOX  Date: Signed: Date: Name: NHS Organisation Name and contact details Date Honorary Research Contract/letter of access issued (delete as appropriate) If required, this section should be added to the Research Passport Form and completed by each NHS R&D office receiving the valid Research Passport. The original Research Passport form and documents should be returned to the applicant.Has the Research Passport been validated by a Lead NHS organisation and is this validation acceptable to this NHS organisation? 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(delete as appropriate) Passport Appendix. List of projects and amendments Appendix Number: If you are applying for a three-year Research Passport, please use this section to enter details of projects and activities that will be covered by this Research Passport. Once you have a validated Research Passport, you may add details of subsequent projects during the three years that this Research Passport is valid. If you are applying for a project-specific Research Passport, but need to add further sites to the project, please enter the details below. Whenever you add further details, the full Research Passport and accompanying documents must be submitted to the relevant NHS organisations. Title: Start Date:End Date:NHS organisation(s):Dept(s):Proposed research activities:Manager in NHS organisation: Amendments to the Research Passport Please state what these are, e.g. they might be a change in name or employment details, or a change in research activities. Please check with the NHS organisation where you are undertaking your research if you are unsure whether you will need to submit new evidence of pre-engagement checks on a new Research Passport form, which will need to be validated by the NHS organisation(s) hosting your research. DateOld DetailsNew DetailsOffice use only NHS R&D contact details and signature    To add more projects please copy this page or download further blank pages. Each appendix page should be numbered. For office use only: A photocopy of the appendix should be retained whenever any amendments or additions to the appendix are made.     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