PERSONAL DETAILS
Surname		Must be completed
Forenames (Please ensure you use all middle names)		Must be completed
Date of Birth		Must be completed. Years must provide full 4 digits

CONTACT DETAILS (for the applicant only)
Address		Must be completed
City/Town		Must be completed
Post Code		Must be completed
Telephone	Day	Must be completed
	Evening	Must be completed
	Mobile	Must be completed
Email			Do you consent to contact via email	Yes No

ROLE AND LOCATION APPLIED FOR
Please detail which site and role you are applying for as well as your availability for volunteering. If you don't have a preference, please state this. Please refer to our website for volunteer roles that are available.
Must be completed

How did you hear about our volunteering opportunities in NHS Lothian?
Must be completed

Why do you want to volunteer with NHS Lothian and what do you hope to gain from volunteering with us? Min 100 / Max 200 words
0 words Must be completed

What could you bring as a volunteer to NHS Lothian? (Please tell us about previous study, volunteering, work, or other activities that you were involved in. Tell us about any characteristics or personal lived experience that you feel are relevant to the role. Please reference the role description when considering your answer.) Min 100 / Max 250 words
0 words Must be completed

Travel expectations
Due to very limited parking and our commitment to sustainable travel, volunteers must have a clear and realistic travel plan for getting to and from volunteering. Where possible, we recommend a journey time of no more than 50 minutes. Public transport and active travel (walking or cycling) are strongly encouraged. If your journey is likely to exceed this guideline, you are still welcome to apply, but we may discuss this with you before progressing your application. Applications without a clear travel plan may not be progressed. Please outline your intended travel arrangements, including, mode of transport and estimated journey time.

FOOTNOTES AND DECLARATIONS
Footnote (1) Criminal Convictions Having a criminal record will not necessarily stop you from volunteering with NHS Lothian. This will depend on the nature of the role, together with the circumstances and background of the offence(s). In September 2015 the Scottish Government made changes about what conviction information needs to be disclosed. [Some offences must always be disclosed, some offences do not need to be disclosed and some offences must be disclosed in specified circumstances.] The rules are complicated, so it is important you read the guidance below as part of making your application to volunteer. NHS Scotland is exempt from the 1974 Rehabilitation of Offenders Act (Exclusions & Exceptions) (Scotland) Order 2003. As part of any volunteering role applicants will be subject to one of the following: For regulated roles – Protection of Vulnerable Groups Scheme membership. For all other roles which are subject to a criminal conviction record check – A level 2 disclosure For roles not subject to a criminal conviction record check – A self-declaration For more information on the rules visit: Disclosing Criminal Convictions Rules For more information on offences which must always be disclosed: Always Disclose List For more information on offences which are to be disclosed subject to rules: Offences Subject to Rules

FOOTNOTES AND DECLARATIONS

Footnote (1) Criminal Convictions

Having a criminal record will not necessarily stop you from volunteering with NHS Lothian. This will depend on the nature of the role, together with the circumstances and background of the offence(s).

In September 2015 the Scottish Government made changes about what conviction information needs to be disclosed. [Some offences must always be disclosed, some offences do not need to be disclosed and some offences must be disclosed in specified circumstances.] The rules are complicated, so it is important you read the guidance below as part of making your application to volunteer. NHS Scotland is exempt from the 1974 Rehabilitation of Offenders Act (Exclusions & Exceptions) (Scotland) Order 2003.

As part of any volunteering role applicants will be subject to one of the following:

For regulated roles – Protection of Vulnerable Groups Scheme membership.
For all other roles which are subject to a criminal conviction record check – A level 2 disclosure
For roles not subject to a criminal conviction record check – A self-declaration

For more information on the rules visit: Disclosing Criminal Convictions Rules

For more information on offences which must always be disclosed: Always Disclose List

For more information on offences which are to be disclosed subject to rules: Offences Subject to Rules

Footnote (2) DATA PROTECTION LEGISLATION
In processing any personal information or data we hold about you we will comply with the requirements of Data Protection Legislation. In particular all reasonable steps will be taken to ensure data is processed fairly, kept secure, protected against loss or damage & only disclosed (unless required by law or legal process) on a need to know basis. Under the Legislation you are entitled to ask us to provide copies of certain data we hold about you.

Footnote (2) DATA PROTECTION LEGISLATION

In processing any personal information or data we hold about you we will comply with the requirements of Data Protection Legislation. In particular all reasonable steps will be taken to ensure data is processed fairly, kept secure, protected against loss or damage & only disclosed (unless required by law or legal process) on a need to know basis. Under the Legislation you are entitled to ask us to provide copies of certain data we hold about you.

DECLARATION
I have completed this application form and the details I have supplied are, to the best of my knowledge, true and complete; I understand that if appointed to this post the information on this form will be kept as part of my personal file record; I authorise NHS Lothian to obtain references in support of this application. I understand that NHS Lothian require the details included in this form which will only be used for specific and lawful purposes as stated in Data Protection Legislation. This information will be held in accordance with the board's policies regarding confidentiality and data security. I agree to complete a criminal convictions check or a criminal convictions declaration form, if I am identified as a suitable volunteer.
I declare that I have no previous convictions, or have identified any I have above. Read, agreed and understood Must be completed

DECLARATION

I have completed this application form and the details I have supplied are, to the best of my knowledge, true and complete;

I understand that if appointed to this post the information on this form will be kept as part of my personal file record;

I authorise NHS Lothian to obtain references in support of this application.

I understand that NHS Lothian require the details included in this form which will only be used for specific and lawful purposes as stated in Data Protection Legislation. This information will be held in accordance with the board's policies regarding confidentiality and data security.

I agree to complete a criminal convictions check or a criminal convictions declaration form, if I am identified as a suitable volunteer.

I declare that I have no previous convictions, or have identified any I have above.
Read, agreed and understood

Must be completed

REFERENCES

Please supply details of two referees who have known you for over one year, and who can comment on your background and suitability for the post.

It is a requirement to supply two professional references, or one professional reference and one character reference. As an example, a professional reference can be a previous/current employer, colleague, volunteering manager, teacher, support worker, doctor/healthcare professional, minister of religion, or club official. A character reference can be provided by a previous/current neighbour or family friend. You should NOT use family members.

If you have lived outside of the UK for 12 consecutive months or more in the last 5 years, please make sure your referees are from the country(s) you have lived during this time.

Referees will normally be contacted by email in the first instance, so please provide an email address for each referee. They will be asked to complete a short questionnaire and the information they give will be used to help us make a decision regarding your suitability for the post.

Please note references will not routinely be requested, however NHS Lothian reserves the right to contact references as/when needed. We will inform you before contacting your referees, if we decide to take up references.

Referee (1)
Name:	Must be completed
Relationship to you:	Must be completed
Address:	Must be completed
Postcode:	Must be completed
Telephone:	Must be completed
Email:	Must be completed

Referee (2)
Name:	Must be completed
Relationship to you:	Must be completed
Address:	Must be completed
Postcode:	Must be completed
Telephone:	Must be completed
Email:	Must be completed

EMERGENCY CONTACT
Emergency Contact Information We ask volunteers to provide us with an emergency contact so that we can get in touch with someone on your behalf if, for example: You become unwell during your time volunteering with us You injure yourself during your volunteering session We need to contact someone in cases of medical or other emergency your involved in We have been unable to get in touch with you via phone and email, and need to check that you are ok Your emergency contact should be someone you would not mind us contacting should you need assistance, or should we have concerns about your welfare if we are unable to reach you. Ideally, your emergency contact should be a person who can physically come to your assistance or who would be able to contact someone who can. We’d advise you to seek permission from your emergency contact before sharing their details with us. We will only ever contact them in cases of emergency, or if we have tried to get in touch with you through all other available avenues and have not had a response. Please provide us with the following information:
Emergency Contact Name		Must be completed
Emergency Contact Phone Number		Must be completed
Relationship to you		Must be completed

DISABILITY
The Disability Discrimination Act 1995 and Amended Regulations 2005 define disability as follows: "any physical or mental impairment which has a substantial adverse effect on a person's ability to carry out normal day to day activities". NHS Scotland is "Positive about disabled people", and as such we provide job opportunities for disabled people. NHS Scotland operates an Interview Guarantee scheme, which means that if you have a disability, and meet the minimum criteria outlined within the role description, you will be guaranteed a volunteer interview. However, some disabled people prefer not to take this option, so please tick your preference if you are a disabled candidate. Do you want to participate in the Guarantee Scheme? Yes No

DISABILITY

The Disability Discrimination Act 1995 and Amended Regulations 2005 define disability as follows: "any physical or mental impairment which has a substantial adverse effect on a person's ability to carry out normal day to day activities". NHS Scotland is "Positive about disabled people", and as such we provide job opportunities for disabled people.

NHS Scotland operates an Interview Guarantee scheme, which means that if you have a disability, and meet the minimum criteria outlined within the role description, you will be guaranteed a volunteer interview. However, some disabled people prefer not to take this option, so please tick your preference if you are a disabled candidate.

Do you want to participate in the Guarantee Scheme?

Yes
No

Guidance on completing the Occupational Health Self-Declaration form

Why is self declaration important?

The purpose of the self-declaration form is to ensure that NHS Lothian fulfils its obligation to protect the health and safety of its patients, visitors, staff and volunteers.

The information you provide on the self declaration form will enable NHS Lothian to make decisions about any risks for patients and for volunteers. Any information you provide on the form will be treated in the strictest confidence and will not be shared outside the Volunteer Service without your consent.

Next steps

When the self-declaration form is returned it will be reviewed by the Volunteer Services Managers Team who will decide if you are able to progress to the next stage of the application process straight away or if we require more information or if some additional steps need to be taken to ensure everyone's safety.
If you have any conditions listed under 'issues of concern' you will need to discuss this with the Occupational Health Service, whose knowledge of the work environment will ensure that the potential for additional support or adjustments is not overlooked. If this is the case the Volunteer Service Manager will provide you with a link to allow you to complete an electronic pre-placement questionnaire. You may be contacted by Occupational Health to discuss your concerns over the phone or asked to attend an appointment with a nurse or doctor.
Following an Occupational Health appointment the Volunteer Service Manager will receive information to confirm your fitness and any requirement for adjustments or support you may require when we are looking at appropriate placements.

NB: Please note it is exceptionally rare that we are unable to find a suitable placement due to your health. However, it is on some occasions not possible.

Vaccinations

It is recommended that volunteers who are in close contact with patients should have confirmed immunity to key workplace-acquired infections, namely:

Measles
Varicella (Chickenpox)
Tuberculosis (TB)

Most people registered with the NHS from birth will have received vaccinations for these infections when they were younger or acquired immunity through infection (e.g. they had a chickenpox infection as a child and are now immune). Having immunity to these infections protects you, your family and friends, NHS staff, and patients and visitors. As part of our volunteer recruitment process, you will have the option to be vaccinated against these infections if you do not currently have confirmed immunity.

If you would like to access Hepatitis B vaccination or to explore the vaccinations you have had to date please call 0131 536 1135 option 1 then option 2 and request a “Volunteers immunisation update”.

Issue of Concern	Why are we concerned	What we can potentially do about it - Adjustments/Support/Restrictions
Physical Health: Any disability or illness that requires help or assistance with mobility, normal daily activities and social interactions.	You will be asked not to participate in manual handling of patients. However in an emergency you may need to be able to remove yourself and others from any immediate risk of injury. This means you need to be able to negotiate safely around the hospital and have no difficulties using emergency escape routes.	Occupational Health will be able to advise on any specific recommendation or adjustments to ensure your safety.
Mental Health: Any mental health condition that has required support (including medication), from a counsellor, GP, psychologist etc. in the last 2 years, or any problems coping with difficult or stressful situations	Working around patients who are unwell can be very psychologically demanding and some areas of work are recognised as being more of a challenge than others. It is sometimes hard to imagine the impact of this if you have not done this before.	If appropriate Occupational Health may recommend that you are initially situated in areas that we know have less psychological demand and can access support from others easily. This can be re-evaluated after a period of time if your health status changes.
Sensory Problems: Issues with your speech, hearing, or vision that are not corrected by glasses, lenses or hearing aids	Hospitals are busy places and it needs to be clear where people may have difficulties negotiating around the physical environment or who may struggle with standard communication tools.	Again Occupational Health can provide specific guidance. The Volunteer Service Manager will need to undertake a risk assessment to ensure that you are not put in any danger e.g. if you are unable to hear the fire alarm or are visually impaired
Health issues which may cause sudden incapacitation or require emergency attention: E.g. Cardiac conditions, epilepsy or poorly controlled diabetes or asthma	We need to know if you have a condition that may require emergency assistance to ensure your safety at all times.	Again Occupational Health can provide specific guidance regards working alone. With your consent, key colleagues can be informed of any risks or likely emergency assistance you may need.
Suppressed Immunity: Any health condition, which impacts your immunity e.g. removal of spleen, steroid treatment, cancer treatment, HIV etc.	There are a lot of opportunistic infections in a hospital which may put you at risk. Also some conditions prevent individuals from retaining immunity to childhood diseases which may then pose a risk to the patients.	Again Occupational Health can provide specific guidance to allow a suitable role and environment to be identified.

Occupational Health Self Declaration

Please provide honest and accurate information and return this form to a Volunteer Service Manager. Once the Volunteer Service Manager has reviewed the information provided they will be in touch to discuss next steps in the recruitment pathway.

I have read and understood the guidance on self-declaration					Yes No
Must be completed
I am aware of the health conditions or disabilities which may impact on someone’s ability to volunteer with NHS Lothian and I am aware that volunteers are recommended to have confirmed immunity for key workplace-acquired infections.					Yes No
Must be completed
I have a health condition or disability for which I may require support, adjustments, or restrictions in order to volunteer with NHS Lothian. Please note: If you answer yes to this you will be provided with a link to allow you to complete an electronic pre-placement questionnaire or if you would prefer this questionnaire can be provided hard copy. Both of these options will mean all information is returned directly to Occupational Health. All confidential medical data will be stored securely within Occupational Health in line with the General Data Protection Regulations (GDPR 2018)					Yes No
Must be completed
I understand that it is my responsibility to inform NHS Lothian of any changes to my health during the period I am a volunteer which may impair my ability to volunteer with NHS Lothian					Yes No
Must be completed

FAIR TREATMENT STATEMENT

Emergency Contact Information

Guidance on completing the Occupational Health Self-Declaration form

Occupational Health Self Declaration