FAIR TREATMENT STATEMENT

No applicant will be unfairly discriminated against on account of their age, cultural/religious/political belief, disability, ethnicity, gender, race, relationship status, and sexual orientation and/or Trade Union membership/stewardship.

PERSONAL DETAILS
Surname		Must be completed
Forename(s)		Must be completed
Date of Birth		Must be completed. Years must provide full 4 digits

CONTACT DETAILS
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

EMERGENCY CONTACT
Name		Must be completed
Address		Must be completed
Phone number		Must be completed
Relationship		Must be completed

ROLE APPLIED FOR
Please see https://www.nhslothian.scot/GetInvolved/Volunteering/Pages/Volunteering-opportunities.aspx for details on roles and locations Please detail which role, site and time.
Must be completed

Why do you want to volunteer with NHS Lothian? Approx.100 words
Must be completed

What could you bring as a volunteer to NHS Lothian? (skills, knowledge, experience, characteristics) Approx.100 words
Must be completed

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 roles in regulated activity – Protection of Vulnerable Groups Scheme membership. For all other roles which are subject to a criminal conviction record check – A Police Act check. 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 roles in regulated activity – Protection of Vulnerable Groups Scheme membership.
For all other roles which are subject to a criminal conviction record check – A Police Act check.
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 of 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 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.

DECLARATION

I have completed of 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 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.

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

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

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

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 Occupation 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 important that you have immunity to various infectious diseases, such as Measles, Mumps, Rubella, Hepatitis B, Chicken Pox, and Tuberculosis. Many British citizens will have received vaccinations for these when they were younger or have immunity. Having these vaccinations protects you, your family and friends, other staff, patients and visitors and it is a requirement that you are compliant with NHS Lothian's Infection Control Policy.

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 5 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 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.

See Guidance on the following pages.

I have read and understood the guidance on self-declaration					Yes
Must be completed
I am aware of the health conditions or disabilities which may impair someone's ability to volunteer with NHS Lothian					Yes
Must be completed
I have a health condition or disability which may impair my ability 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
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
Must be completed