Health and social care board / business services organisation



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HEALTH AND SOCIAL CARE BOARD / BUSINESS SERVICES ORGANISATION
APPLICATION FOR INCLUSION ON THE OPHTHALMIC LIST

AS AN OPTOMETRIST

15A Form



APPLICATION FOR INCLUSION ON THE OPHTHALMIC LIST

AS AN OPTOMETRIST

To apply to be included in the Ophthalmic List of the Health and Social Care Board (HSCB) please complete all relevant sections of this form. Please return the completed form to: Mrs Karen Lee, Ophthalmic Directorate, Business Services Organisation, 2 Franklin Street, Belfast BT2 8DQ.


If you have any queries regarding the application form please contact Karen Lee on 028 9053 5631 or email Karen.Lee@hscni.net
Once the completed form has been received an interview with an Optometric Adviser will be arranged.

You must include: (original copies only, photocopies are not acceptable and certificates will be returned).


1. A current Certificate of registration with the General Optical Council.


  1. Certificate of Professional Qualification.

3. Photographic Identification. This is required on the day of the interview.




  1. Equal Opportunities Form. Please bring this, in a sealed envelope, to your interview.


You may be requested to provide:

1. Health Clearance information.

PART 1




PERSONAL DETAILS




PLEASE PRINT DETAILS BELOW

SURNAME: ________________________________________



FORENAME(S): ________________________________________

MAIDEN/PREVIOUS

SURNAMES: ________________________________________
PRIVATE ADDRESS: ________________________________________

________________________________________

POSTCODE: _________________________

TELEPHONE NO(s): ________________________________________
EMAIL ADDRESS: …………………………………………………………..

(Please remember to use upper and lower case as appropriate for email)



PART 2


OPHTHALMIC QUALIFICATION(S)/REGISTRATION AS AN OPTOMETRIST IN THE U.K.


Qualifications: ______________________________________________________

Date qualification was gained: Day_______Month_______Year_______

Date of U.K registration as an Optometrist: Day_______Month_______Year_______

Details of further qualifications held

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

General Optical Council Number: ____--____________




PART 3

EMPLOYMENT/PRACTICE INFORMATION


I ______________________________________________________(name)


Hereby undertake to test sight and supply spectacles/contact lenses on the terms of services for the time being in force (General Ophthalmic Service Regulations (Northern Ireland) 2007), and apply to have my name included in the Ophthalmic List for the Health and Social Care Board of Northern Ireland.
I am a self-employed Locum Optometrist Yes / No *

*Please delete whichever is not applicable.


I am employed by ____________________________________________and the Practice(s) has/have been approved for the provision of General Ophthalmic Services. My usual hours of service are as stated* below:-


Address(es) of Consulting Rooms or Optometric Practice

Days and Hours of Service


Premises Code

1.








2.








The registered Optometrist(s) in charge of this/these Practice(s) is/are as follows:




Name of Optometrist

General Optical Council Number

1.





2.






I do/do not conduct other business at the above premises*.
If another business is carried out please state nature of the business:-

_____________________________________________________________________

_____________________________________________________________________

PART 4
DECLARATIONS

A) DISQUALIFICATION


I ___________________________________________________ (name)


am not disqualified from undertaking service by reason of exclusion from the Ophthalmic List or from any corresponding list in Great Britain and now apply to have my name included in the Ophthalmic List. I understand that I have a responsibility to adhere to the essential criteria of General Optical Council registration in order that I may conduct sight testing. Should any of these details alter in any way I undertake to inform the Health and Social Care Board of Northern Ireland.

B) HEALTH CLEARANCE


In line with DHSSPS guidance on Health Clearance for Health Care workers in relation to Tuberculosis (TB) please answer the following questions. The information provided will be treated in strict confidence. Applicants who are concerned about health clearance in regard to TB may contact a HSCB optometric adviser to discuss their application in advance of submitting their application.
Do you have any of the following? - :
A cough which has lasted more than 3 weeks Yes No*

Unexplained weight loss Yes No*

Unexplained fever Yes No*

Have you had Tuberculosis (TB) or



been in recent contact with open TB Yes No*
*Please delete whichever is not applicable.

N.B If the answer to any of the above questions is ‘Yes’ an optometric adviser will contact the applicant to discuss the application.


PART 4 cont.
DECLARATIONS
C) PREVIOUSLY/PRESENTLY PROVIDING GOS WORK

Have you previously or are you presently providing GOS in another part of the UK

Yes No* *Please delete whichever is not applicable.
If you have answered yes to the question above please provide details of the Health Authority /Board/PCT(s) for which you have provided GOS





Name of Health Authority / PCT


Address & Contact Number of Health Authority / PCT

Date Employed

1.








2.








3.








D) CONSENT


I declare that I am a fully registered ophthalmic practitioner, currently included in the General Optical Council’s Ophthalmic Register/a fully registered Ophthalmic Medical Practitioner, currently included in the General Medical Council’s register/ a fully registered Dispensing Optician, currently included in the General Optical Council’s Ophthalmic Register, in the name shown at the beginning of this form.  I give the above undertakings, declarations and consent and I HEREBY DECLARE that the information given here and on any continuation sheet is true and complete.
I consent to the HSCB/BSO making contact with any organisation it deems necessary to verify or validate any of the information I have provided in this application.

Signed: _____________________________________


Print Name: _____________________________________
Date: _____________________________________

PART 5




FOR HSCB/BSO use only




The above individual (name) _____________________________________ has / has not* been admitted to the Ophthalmic List on this day (date) ____________________ and has been assigned the personal code of __________ which must be used when conducting General Ophthalmic Services.

*Please delete whichever is not applicable.


Signed: __________________________________________
Position: __________________________________________
Date: __________________________________________

OPHTHALMIC SERVICES, BUSINESS SERVICES ORGANISATION, 2 Franklin Street, Belfast BT2 8DQ


Tel: 028 9032 4431 ext 5893 • Textphone: 028 90535575

EMAIL:- Karen.Lee@hscni.net


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