Job ref: 421-MS-0975C Job title: LED Elderly Medicine (FY2 Equivalent)

Application for employment

Application for: LED Elderly Medicine (FY2 Equivalent) Job ref: 421-MS-0975C
Closing date: 6-Mar-2024 Application submitted: 22-Feb-2024 12:18
Application ID: 159081699 Applicant: Nurul Asyiqin Mohamed Haniffa

Personal details
Answers given in this part of the form are to help the Recruitment Centre to manage your application.
If you have any difficulty completing this form please ask someone to help you.
We would like to take this opportunity to thank you for applying.
Personal details

Title Dr
Forename Nurul Asyiqin
Middle name(s)
Surname Mohamed Haniffa
Address Apartment 513
Marco Island
Huntingdon Street
City / town Nottingham
County
Country United Kingdom
Postcode NG1 1AR
Email [email protected]
Work telephone
Mobile telephone 07818949522
Home telephone
UK National
Insurance number
Preferred
employment type
Full time

Relationships

If you are related to a director, or have a relationship with a director or employee of an appointing organisation, please state the relationship:

Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as amended)

The role you have applied for is exempt from the provisions normally afforded to individuals under the Rehabilitation of Offenders Act 1974. This means that the employer can
obtain a standard or enhanced disclosure through the Disclosure and Barring Service (DBS) under the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (as
amended) and, in certain circumstances, the Police Act 1997.

Enhanced disclosures may include other relevant non-conviction information held on police databases, at the discretion of the police or Chief Constable of the relevant police
force.

Before you complete this form, it is important for you to read the highlighted note in the section below.

If you have a criminal record and are unsure about what might be revealed about you as part of a DBS check, or the type of information you should consider declaring when
completing this form, the following links to guidance will help provide more clarity:

The simple guide to filtering (Unlock) at: http://hub.unlock.org.uk/knowledgebase/filtering-simple-guide/

Practical guidance on the DBS filtering rules (NACRO) at: http://www.nacro.org.uk/resettlement-advice-service/support-for-individuals/

Application: 159081699 [Vacancy: 6070578] Page 1 of 10

 Job ref: 421-MS-0975C Job title: LED Elderly Medicine (FY2 Equivalent)

Have you got any criminal convictions and/or cautions that are not protected?

This means they are not eligible for filtering under the Rehabilitation of Offenders Act 1974 (Exceptions) Order (as amended).

This is regardless of whether the conviction or caution has been issued in the UK or, in any other country where it would be considered an equivalent (or similar)
offence in England and Wales and it is not protected.

It also includes criminal convictions or relevant service discipline convictions received within the Armed Forces Justice System (e.g. through Summary Hearing or
Court Martial) where it would be considered an equivalent offence in England and Wales and is not protected.

It does not include parking offences. In such cases, you can select no.

No
You have two options
on how to disclose
this information.
Please provide details of the conviction, caution or Summary Hearing including the date and sentence administered in the space below
You can disclose your record separately together with any statement detailing your conviction,
caution or Summary Hearing. A member of the recruitment team will contact you and advise what
steps you need to take to submit your details separately.

Pre-screening: Internal/external

Before being given access to the online application form, the applicant was asked the following.

Are you currently an employee of Harrogate and District NHS Foundation Trust?
No
Are you currently an employee of any other NHS organisation?
Yes

Pre-screening: Immigration

Before being given access to the online application form, the applicant was asked the following.

Choose your immigration status

I have a 'Skilled Worker visa' that was sponsored for me by my current employer
If you wish to provide any additional information regarding your right to work/immigration status, please do so here

Page 2 of 10 Application: 159081699 [Vacancy: 6070578]

Job ref: 421-MS-0975C Job title: LED Elderly Medicine (FY2 Equivalent)

Application for: LED Elderly Medicine (FY2 Equivalent) Job ref: 421-MS-0975C
Closing date: 6-Mar-2024 Application submitted: 22-Feb-2024 12:18
Application ID: 159081699 Applicant: Nurul Asyiqin Mohamed Haniffa

Application questions
Details entered in this part of the form will be made available to the shortlisting panel. Please make sure that you have read the job description and person specification before
completing the application form, and ensure that your answers clearly and honestly demonstrate how your skills and experience are relevant to the post for which you are applying.
Education & professional qualifications

All the relevant qualifications. Please also indicate subjects currently being studied. All qualifications disclosed will be subject to a satisfactory check. Up
to 11 qualifications can be entered here.

Subject/Qualification Place of study Grade/Result Year obtained

MB BCh BAO Ireland Honours 2020

Relevant Training Courses Attended

Please provide details regarding training courses that you have attended or currently undertaking together with the date completed or to be completed by.
Up to 7 training course can be entered here.

Year
Course title Training provider Duration completed

Advanced Life Support (ALS) Resuscitation Council UK 2 days 2023

Conversations in End of Life and Palliative Care Health Education England 6 hours 2023

Psychiatric Sinulation Training Health Education England 6 hours 2023

University Hospitals of Derby and

Acute Simulation Training 4 hours 2023
Burton

End of Life Care Chesterfield Royal Hospital 6 hours 2022

Palliative Care SIMS Chesterfield Royal Hospital 1 day 2022

Systematic Training in Acute Illness Recognition and Treatment

Chesterfield Royal Hospital 1 day 2022
(START)

Membership of Professional Bodies

Please provide details regarding any relevant professional registrations or memberships. This information will be subject to a satisfactory check.

Please indicate your professional registration status

I have current UK professional registration relevant for this post
Professional body
General Medical Council ~ Registered with Licence
Please provide details below
Membership / Registration number
7936619
Expiry / renewal date
31/07/2028

NHS Service

Start date of August 2022

continuous NHS
service (if applicable)

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 Job ref: 421-MS-0975C Job title: LED Elderly Medicine (FY2 Equivalent)

Months since most

recent employment
ended (if applicable)

Employer/activity history

Please record below the details of your full employment history beginning with your current or most recent first. Up to 10 previous employments can be
entered here. If required, please provide additional information regarding your employment history within the 'Supporting Information' section.

Page 4 of 10 Application: 159081699 [Vacancy: 6070578]

Job ref: 421-MS-0975C Job title: LED Elderly Medicine (FY2 Equivalent)

Employer name Ministry of Health Malaysia

Employer address Penang General Hospital
Jalan Residensi, 10990 George Town, Pulau Pinang, Malaysia
Type of business
Reporting to (job -
title)
Telephone
Your job title
Start date April 2021
End date May 2022
Grade FY1/House officer
Salary
Period of notice
Reason for leaving (if applicable)
Brief description of your duties & responsibilities
Managing patients and reviewing acutely ill patients by rotating in different departments and gain hands on experience in the diagnosis
treatment and management of patients under the guidance of senior doctors

Employer name Chesterfield Royal Hospital

Employer address Chesterfield Rd, Calow, Chesterfield S44 5BL
Type of business
Reporting to (job
title)
Telephone
Your job title FY1 Doctor
Start date August 2022
End date August 2023
Grade FY1
Salary
Period of notice
Reason for leaving (if applicable)
Brief description of your duties & responsibilities
Attend to the day to day management of day case, out-patient and in-patients, attend and participate in ward rounds, attend general and
specialist out-patient, diagnostic and pre-assessment clinics if there is, with guidance of senior doctors and consultants

Employer name Royal Derby Hospital

Employer address Uttoxeter Rd, Derby DE22 3NE
Type of business
Reporting to (job
title)
Telephone
Your job title FY2 Doctor
Start date August 2023
End date August 2024
Grade FY2 doctor
Salary
Period of notice
Reason for leaving (if applicable)
Brief description of your duties & responsibilities
Similar to roles of a FY1 doctor however with more responsibility and independence when managing patients, be involved in patients
management plan and guiding more junior doctors and teaching medical students who were on the current same rotation

Gaps in employment

If you have any gaps within your employment history, please state the reasons for the gaps below.
May 2022-August 2022: period after resignation as a house officer in Malaysian hospital to prepare for moving to the UK to start FY1 job in
Chesterfield in 2022 - necessary for visa sorting purposes and settling into accommodation in UK.

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 Job ref: 421-MS-0975C Job title: LED Elderly Medicine (FY2 Equivalent)

Supporting information

Supporting Information Fields marked with an asterisk are mandatory

In this section you need to demonstrate that you have read the published person specification and how you meet the essential and (where relevant) desirable criteria for this particular
post, if this has not been fully covered in the previous sections.

Please include your reasons for applying and take the opportunity to highlight your particular talents and strengths, (what you feel you can personally offer - what is unique to you -
what sets you apart from your peers).

Please DO NOT include personal details or duplicate information already provided elsewhere in your application.

Supporting information
I have worked in the NHS since 2022 now due to finish my F2 year in August. I have had experience working in medical field and in geriatrics ward in
my F1 and F2 year. I have previous experience working in acute medicine where it involves me working with various age range of patients and doing
oncalls on geriatric ward. While I have been working in Trauma and Orthopaedic, I work closely with an orthogeriatrician to co-manage patient from
both ortho and medical point of view to best optimize patients for surgery and help facilitate safe discharge (as a lot of the patients that get admitted
to the wards are elderly and frail with neck of femur fracture.)

I believe this post is suitable for me as I like managing patients as a whole especially in elderly populations where the issues when coming into
hospital aren't usually the only ones that needs optimizing. I believe I can offer support to the ward with guide from more senior colleague to better
manage patients acutely and safely.

This would be a good opportunity for me to expand my experience in participating in research, audits and teaching opportunities in the post as this
would be a good way for me to expand my knowledge and strengthen them by applying what have I learnt.

I am strongly passionate on building good rapport with my patients and believe having the necessary skills to work with patients in the age range from
my previous experience working in Derby A&E for example, elderly patients will not always able to express their concerns (due to dementia/frailty)
thus requiring a more extensive examination and workup to not miss any probably diagnosis.

Pre-screening questions

Questions asked before the application form was opened.

I understand that I will need to provide evidence either at interview or before commencement of the role that I possess the qualifications (or a higher relevant
qualification) that are designated as essential requirements for the position applied for.

Yes

Page 6 of 10 Application: 159081699 [Vacancy: 6070578]

Job ref: 421-MS-0975C Job title: LED Elderly Medicine (FY2 Equivalent)

Application for: LED Elderly Medicine (FY2 Equivalent) Job ref: 421-MS-0975C
Closing date: 6-Mar-2024 Application submitted: 22-Feb-2024 12:18
Application ID: 159081699 Applicant: Nurul Asyiqin Mohamed Haniffa

References
References

If you are successful, prior to appointment, we will take up as many references as needed to cover all activities, including periods of employment and full time education,
that you have undertaken over the past three years. Any offer will be subject to these being satisfactory. Please ensure that you provide full contact details for your Employer/Line
Managers or Course Tutors for each activity. Please include their work email address where possible to avoid any unnecessary delays.

If during the last three years you have any periods in which you have not been in either employment or full-time education please provide details of someone who can provide a
character reference for you to cover this period. Character references should be provided by a person of standing in the community such as a Teacher, Health Care Professional (i.e.
Doctor, Physiotherapist, Registered Nurse), Minister of Religion, Police Officer or Solicitor. Character references should only be used in EXCEPTIONAL circumstances to cover
periods of time when you have not been in either employment or education.

Please use the "Add another" button below to add as many referees as required to meet the above requirements. Periods that referees cover may overlap but there should
not be any gaps over the past three years.

Referee's title Dr
Referee's first Richard
name(s)
Referee's surname Hopkins
Referee's Chesterfield Royal Hospital
organisation name
Job title Consultant Acute Physician
How do they know Employer / Line Manager
you?
Address 1 Chesterfield & North Derbyshire Royal Hospital
Address 2 Chesterfield Road
Address 3 Calow
City / Town Chesterfield
County / State
Postcode S44 5BL
Country United Kingdom
Telephone no.
Mobile no.
Email address [email protected]
Can the referee be Yes
approached prior
to the interview?
Period this August 2022
reference covers
from:
Period this December 2023
reference covers
to:
What name will the
referee know you
by if different from
your current
name?
Why has your
name changed?

Referee's title Dr
Referee's first Lindsay
name(s)
Referee's surname Lewis
Referee's Chesterfield Royal Hospital
organisation name
Job title Consultant Paediatrician
How do they know Employer / Line Manager
you?

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 Job ref: 421-MS-0975C Job title: LED Elderly Medicine (FY2 Equivalent)

Address 1 Chesterfield & North Derbyshire Royal Hospital

Address 2 Chesterfield Road
Address 3 Calow
City / Town Chesterfield
County / State
Postcode S44 5BL
Country United Kingdom
Telephone no.
Mobile no.
Email address [email protected]
Can the referee be Yes
approached prior
to the interview?
Period this December 2022
reference covers
from:
Period this April 2023
reference covers
to:
What name will the
referee know you
by if different from
your current
name?
Why has your
name changed?

Referee's title Dr
Referee's first Gauri
name(s)
Referee's surname Sankhe
Referee's Royal Derby Hospital
organisation name
Job title Consultant Anaesthesist
How do they know Employer / Line Manager
you?
Address 1 Royal Derby Hospital
Address 2 Uttoxeter Road
Address 3
City / Town Derby
County / State
Postcode DE22 3NE
Country United Kingdom
Telephone no.
Mobile no.
Email address [email protected]
Can the referee be Yes
approached prior
to the interview?
Period this August 2023
reference covers
from:
Period this August 2024
reference covers
to:
What name will the
referee know you
by if different from
your current
name?
Why has your
name changed?

Page 8 of 10 Application: 159081699 [Vacancy: 6070578]

Job ref: 421-MS-0975C Job title: LED Elderly Medicine (FY2 Equivalent)

Application for: LED Elderly Medicine (FY2 Equivalent) Job ref: 421-MS-0975C
Closing date: 6-Mar-2024 Application submitted: 22-Feb-2024 12:18
Application ID: 159081699 Applicant: Nurul Asyiqin Mohamed Haniffa

Equal opportunities
Equal opportunities

NHS organisations recognise the benefits of having a diverse workforce and therefore welcome applications from all sections of the community. In addition to this, under the
provisions of the Equality Act 2010, all NHS organisations are required to demonstrate that their recruitment processes are fair and that they are not discriminating against or
disadvantaging anyone because of their age, disability, gender reassignment status, marriage or civil partnership status, pregnancy or maternity, race, religion or belief, sex or
sexual orientation. Therefore a series of questions need to be raised in order to ascertain who is applying for each position and to ensure that no one is being unfairly
discriminated against or disadvantaged.

This section of the application form will be detached from your application form and will not be used as part of the selection process nor will it be seen by anybody who is
interviewing you. The information collected is only used for monitoring purposes in an anonymised format to assist the organisation in analysing the profile and make up of
individuals who apply, are shortlisted for and appointed to each vacancy. In this way, they can check that they are complying with the Equality Act 2010.

The Equality Act 2010 protects people against discrimination on the grounds of:

• their age and sex.

• their race which includes colour, nationality, ethnic or national origin.
• their religion or belief, including a lack of any belief.
• their sexual orientation, be it bisexual, gay, heterosexual and lesbian.

The Equality Act 2010 also protects people who are married or in a civil partnership.

Equality and Diversity Monitoring

Please state your date of birth

23/09/1996
Please indicate your gender
Female
Please indicate the option which best describes your marital status:
Single
Please indicate your ethnic origin
ASIAN or ASIAN BRITISH - Indian
Which of the following options best describes how you think of yourself?
Heterosexual or Straight
Please indicate your religion or belief
Islam

Disability

The Equality Act 2010 protects disabled people - including those with long term health conditions, learning disabilities and so called "hidden" disabilities
such as dyslexia. If you tell us that you have a disability we can make reasonable adjustments to ensure that any selection processes - including the
interview - are fair and equitable.

According to the definition of disability do you consider yourself to have a disability?

No
Please identify the category which applies to you or other type of disability. People may experience more than one type of impairment, in
which case you may indicate more than one. If none of the categories apply, please mark 'Other'.
If you have a disability, do you wish to be considered under the Guaranteed Interview Scheme if you meet the minimum criteria as specified in
the Personal Specification?
No

Reasonable adjustments will be made available should you be invited to interview.

How did you learn of this vacancy?

Please state where you first saw this post advertised

NHS Jobs - nhsjobs.com or nhsjobs.net

Declaration

The information in this application form is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting
this application or subsequent dismissal if employed by the organisation. Where applicable, I consent that the organisation can seek clarification regarding professional registration
details.

I agree to the above declaration Yes

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 Job ref: 421-MS-0975C Job title: LED Elderly Medicine (FY2 Equivalent)

Next Steps
Once you submit the form your application will be available to the Employer. However, you will be able to update your "Personal Information" should any of your contact details
change.

All your application forms (submitted or not) can be viewed under "Applications" when you are signed in.

Privacy notice

Application for: LED Elderly Medicine (FY2 Equivalent) Job ref: 421-MS-0975C
Closing date: 6-Mar-2024 Application submitted: 22-Feb-2024 12:18
Application ID: 159081699 Applicant: Nurul Asyiqin Mohamed Haniffa

Privacy notice
Your data is being collected by Harrogate and District NHS Foundation Trust, whose privacy notice can be found here.

The data controller for this information is Harrogate and District NHS Foundation Trust. This application tracking system is provided by Civica UK Ltd
(https://www.civica.com/en-gb/product-pages/trac/) as a data processor.

To make an enquiry, a request for your personal information held as part of this process, or to arrange for any mistakes to be corrected, you may
contact either the team who are handling your application or the Data Protection Officer ([email protected]).

Your data is being collected by Harrogate and District NHS Foundation Trust, whose privacy notice can be found here: https://www.hdft.nhs.uk/privacy-notices/

The data controller for this information is Harrogate and District NHS Foundation Trust. This application tracking system is provided by Civica UK Ltd (
https://www.civica.com/en-gb/product-pages/trac/) as a data processor.

To make an enquiry, a request for your personal information held as part of this process, or to arrange for any mistakes to be corrected, you may contact the team who are
handling your application via email at [email protected]

Page 10 of 10 Application: 159081699 [Vacancy: 6070578]