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Annex H
Declarations Required from All Doctors Joining the Medical/Supplementary List
and from existing GP Principals.
NHS (GMS) Regulations (Schedule 2 paragraph 36A (1&2), Part III of
Schedule 3 paragraph 6A (a&b)
NHS (GMS Supplementary List Regulations (Reg 4(4&5))
i. Details of whether or not he:-
· has any criminal convictions1 in the United Kingdom ;
· has been bound over following a criminal conviction in the United Kingdom;
· has accepted a police caution in the United Kingdom ;
· has been convicted elsewhere of an offence, or what would constitute a
criminal offence if committed in England and Wales, or is subject to a penalty
which would be the equivalent of being bound over or cautioned;
· is currently the subject of any proceedings which might lead to such a
conviction, which has not yet been notified to the Health Authority;
· has been subject to any investigation2 into his professional conduct by any
licensing, regulatory or other body anywhere in the world, where the outcome was
adverse2;
· is currently subject to any investigation2 into his professional conduct by
any licensing, regulatory or other body anywhere in the world;
· is the subject of any investigation by another Health Authority or equivalent
body, which might lead to the removal from any of that Health Authority's lists
or equivalent lists;
· is, or has been where the outcome was adverse2, the subject of an
investigation into his professional conduct in respect of any current or
previous employment;
· is to his knowledge, or has been where the outcome was adverse2 the subject
of any investigation by National Health Service Counter Fraud Service in
relation to a fraud case;
· has been removed, contingently removed, refused admission to, or
conditionally included in any list kept by another Health Authority or
equivalent body, or is currently suspended from such a list;
and if so, give details, including approximate dates, of where any
investigation2 or proceedings were or are to be brought, the nature of that
investigation or proceedings, and any outcome.";
ii. If he is, has in the preceding six months been, or was to his knowledge
at the time of the originating events, a director of a body corporate, whether
it -
· has any criminal convictions1 in the United Kingdom ;
· has been convicted elsewhere of an offence, or what would constitute a
criminal offence if committed in England and Wales, or is subject to a penalty
which would be the equivalent of being bound over or cautioned;
· is currently the subject of any proceedings which might lead to such a
conviction, which has not yet been notified to the Health Authority;
· has been subject to any investigation2 into its provision of professional
services by any licensing, regulatory or other body anywhere in the world, where
the outcome was adverse2;
· is currently subject to any investigation into its provision of professional
services by any licensing, regulatory or other body anywhere in the world;
· is to his knowledge, or has been where the outcome was adverse2, the subject
of any investigation by National Health Service Counter Fraud Service in
relation to a fraud case;
· is the subject of any investigation by another Health Authority or equivalent
body, which might lead to its removal from that Health Authority's lists or
equivalent lists;
· has been removed, contingently removed, refused admission to, or
conditionally included in any list or equivalent list kept by another Health
Authority or equivalent body, or is currently suspended from such a list,
and if so, give the name and registered office of the body corporate, and
details, including approximate dates, of where any investigation or proceedings
were or are to be brought, the nature of that investigation or proceedings, and
any outcome.".
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