Thank you for your offer of help to support Trust caring for patient with COVOD-19 (Coronavirus) during the NHS Level 4 incident.  There are many opportunities for you to help the NHS respond to the COVID-19.  By completing the form below it will help the Trust to match you to a role based on your knowledge and skills.  

Once this questionnaire has has been completed and returned a member of the COVID-19 external placement team will respond within 72 hours.

Please note as a protective measure, if you meet any of the following criteria, we will be unable to deploy you in our hospitals due to an increased level of risk to your health:


·You are aged over 70+

·You are considered to be extremely vulnerable:

·Solid organ transplant recipients

·People with specific cancers:

·people with cancer who are undergoing active chemotherapy or radical radiotherapy for lung cancer

·people with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment

·people having immunotherapy or other continuing antibody treatments for cancer

· people having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors

·people who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs

·People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe COPD.

· People with rare diseases and inborn errors of metabolism that significantly increase the risk of infections (such as SCID, homozygous sickle cell).

· People on immunosuppression therapies sufficient to significantly increase risk of infection.

· Women who are pregnant with significant heart disease, congenital or acquired.

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* 1. Name:

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* 2. Contact telephone number:

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* 3. Contact email address:

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* 4. Date of Birth:

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* 5. National insurance number:

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* 6. Current status

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* 7. If applicable name of current employer / organisation:

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* 8. Contact phone number of employer

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* 9. Contact email address of employer

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* 10. Will you continue to be paid by your current employer? If you are unsure, please email rf-tr.hrbpadmin@nhs.net and we will talk you through options.

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* 11. Current role: (if applicable)

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* 12. Skills set:

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* 13. Have you worked at the Royal Free London NHS Foundation Trust within the last three years? 

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* 14. What placement type are you seeking?

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* 15. If a clinical placement, what is your professional registration number: ( i.e. GMC, NMC, HCPC or other) 

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* 16. Do you have an NHS Smartcard?

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* 17. Clinical roles only; will you require access to clinical applications?

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* 18. Do you have an in-date passport?

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* 19. Do you have a DBS certificate issued within the last three years ?

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* 20. What level is your current DBS check? 

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* 21. Do you have any known health condition(s)?

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* 22. What is your preferred site to work? Please tick all that apply

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* 23. Do you require accommodation? 

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* 24. Do you have any travel requirements including parking? 

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* 25. Which days of the week are you able to work?

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* 26. For clinical offers of help, please confirm if you have experience of working in the following areas:

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* 27. For clinical offers of help, are you willing to work in any other capacity other than your current clinical speciality?

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* 28. For non-clinical offers of help, which areas are you willing to work in?

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* 29. For non clinical voluntary offers of help only: 

Please note that in accordance with the General Data Protection Regulations,  the information which you provide will be shared with the Royal Free Charity who administer non clinical volunteers on behalf of the Royal Free London NHS Trust. 

Please confirm that you are happy with the Royal Free London NHS Foundation Trust sharing the information you have provided.  Please note If you click no we will no longer proceed with your offer of help.

 

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* 30. Are you happy to work in clinical areas where there are COVID positive patients including ICU (Intensive Care Unit)?

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