Staff Record Form
Human Resources, University of Dundee, Dundee, DD1 4HN

  
Please provide the following details :
    

Name :	

Post :	

College / School / Directorate / Unit :	



Dear Colleague 

It is likely that you have already provided the University with personal information in your Curriculum Vitae / Application Form / A Previous Staff Record Form. However by completing this form, the information is set out in a format suitable for entry into our computerised staff records system. It is therefore important that this form is completed, printed, and returned to us as soon as possible. 

For new Staff, it would be appreciated if you could return the completed form with your signed contract. 

Access to this record is strictly controlled, and the only extracts from it which are published, are those required for the compilation of University electoral and mailing lists, and for the staff list in the University Calendar. 

Completion of this form will also allow for the University to comply with its legal obligation to gather and monitor data on the current Equality Duties, thus allowing for us to gauge the effectiveness of our Equal Opportunity policies and practices.

The computerised staff record is also used to provide information to the Higher Education Statistics Agency (HESA), however this is extracted in such a way that the data is not associated with named individuals, and it is used only for the production of aggregate statistics. This includes the information gathered on the Equality Duties. (Please note that the Ethnic Origin categories are those used in the 2001 Census of Population within the UK. Also, existing staff will notice a difference in the section focusing on Disability Details. Following the introduction of the Disability Equality Duty, we are now required to gather information on the nature of staff disability. On the recommendation of the Equality Challenge Unit (ECU), HESA, has adopted a version of the coding framework developed by the Disability Rights Commission (DRC) to facilitate gathering of staff disability data.)


Yours sincerely



Mrs Pamela Milne
Director of Human Resources




YOUR PERSONAL DETAILS

SURNAME :	

FORENAMES :	

TITLE  (please write yes at the end of the appropriate line from the options below) :

Professor	
Mrs	
Miss
Ms	
Mr	
Other			
           
If selecting Other, please state :

NATIONAL INSURANCE NUMBER :

DATE OF BIRTH :				

MAIDEN NAME :

HOME ADDRESS :




PREFERRED MAILING ADDRESS 
(If different from standard University Department / Unit address.) :





EMERGENCY CONTACT :	  

Person to Contact in an Emergency :	
				
Relationship to you :		
				
Their Contact Address:





Their Telephone Number :
           



YOUR EQUAL OPPORTUNITIES INFORMATION

NATIONALITY (please state) :


ETHNICITY (please write yes at the end of the appropriate line from the options below) :	

11 White-British 
12 White-Irish
13 White-Scottish
14 Irish Traveller
19 Other White Background
21 Black or Black British-Caribbean
22 Black or Black British-African
29 Other Black Background
31 Asian or Asian British-Indian
32 Asian or Asian British-Pakistani		
33 Asian or Asian British-Bangladeshi
34 Chinese
39 Other Asian Background
41 Mixed-White and Black Caribbean
42 Mixed-White and Black African
43 Mixed-White and Asian 
49 Other Mixed Background
80 Other Ethnic Background
90 Not Known
98 Information Refused (Please select this option if you would prefer not to provide us with this information)


DISABILITY :	

If you have no disability please write no disability at the end of this line :  


If you have a disability or disabilities, please identify on the list below, up to a maximum of 2, those that have the most impact on your ability to undertake day-to-day activities (please write yes at the end of the appropriate lines from the options below) :

51   Specific learning disability (such as dyslexia or dyspraxia)
52   General learning disability (such as Down’s syndrome)
53   Cognitive impairment (such as autistic spectrum disorder or resulting from head injury)
54   Long standing illness or health condition (such as cancer, HIV, diabetes, chronic heart disease or epilepsy)
55   Mental health condition (such as depression or schizophrenia)
56   Physical impairment or mobility issues (such as difficulty using arms or require to use a wheelchair or crutches)
57   Deaf or serious hearing impairment
58   Blind or serious visual impairment
96   Other type of disability


If you have selected ‘Other type of disability’, please provide some addition information at the end of this line about your disability / disabilities : (You can also use this section to provide us with any other additional / relevant information.)






The University encourages disclosure of a disability so that all reasonable adjustments can be put in place to meet any work-related needs. Please contact Disability Services http://www.dundee.ac.uk/disabilityservices or Occupational Health http://www.dundee.ac.uk/safety/Occ_Health.htm in confidence, if you feel you need any adjustments to be made, or if you would like to find out more about the support available to disabled staff.



YOUR PREVIOUS EMPLOYMENT DETAILS

Please state where you were employed, prior to starting your current period of employment with the University of Dundee (please write yes at the end of the appropriate line from the options below) :	

01 Another HEI in UK 				
02 HEI in an overseas country 
03 Other education institution in UK 		
04 Other education institution in an overseas country 
05 Research institution in the UK 			
06 Research institution overseas 
07 Student in UK 					
08 Student in an overseas country 
09 NHS/General medical or general dental practice in UK	
10 Health service in an overseas country 
11 Other public sector in UK 				
12 Private industry/commerce in UK 
13 Self-employed in UK 				
14 Other employment in UK 
15 Other employment in an overseas country 		
21 Not in regular employment 


For staff who are new to the University of Dundee :

Have you ever been employed by a UK Higher Education Institution? If so, please advise of the following :

FULL NAME AND POSTAL ADDRESS OF PREVIOUS INSTITUTION :	

DEPARTMENT(S) EMPLOYED WITHIN :	

TITLE(S) OF POSITION(S) HELD :	

Date(s) From :	
Date(s) To :	

HESA ID NUMBER (Obtainable from your previous HEI’s HR / Personnel / Payroll / Planning Department) :







YOUR QUALIFICATIONS

What is your highest Academic Qualification? (please write yes at the end of the appropriate line from the options below) :	

01 Doctorate 						
02 Other Higher Degree 
03 PGCE 		
09 Other Postgraduate Qualification (Including Professional) 
11 First Degree 					
12 First Degree with Qualified Teacher Status (QTS)
19 Other qualifications at first-degree level (Including Professional) 
21 Diploma of HE					
22 HND/HNC 	
29 Other undergraduate qualification (Including Professional) 
31 ‘A’ level, Scottish Higher or equivalent (NVQ/SVQ Level 3) 		 
32 ‘O’ level/GCSE or equivalent (NVQ/SVQ Level 2) 
97 Other qualification 				
98 No qualifications 


Please list the details of ALL your Academic Qualifications below :


Doctorate	
Letters of Degree / Qualification :
Main Subject Area :
Awarding Institution :

Masters
Letters of Degree / Qualification :
Main Subject Area :
Awarding Institution :

First
Letters of Degree / Qualification :
Main Subject Area :
Awarding Institution :

Other (Diplomas, Certificates, School, etc.) 
Letters of Qualification :
Main Subject Area :
Awarding Institution :


Should you need additional space to advise of your academic qualifications, ie: you have more than one First Degree, please provide this information at the end of this line :




Pease list the details of ALL your Professional Qualifications below :


Name of Professional Qualification :
Main Subject Area :
Awarding Institution :

Name of Professional Qualification :
Main Subject Area :
Awarding Institution :

Name of Professional Qualification :
Main Subject Area :
Awarding Institution :


Should you need additional space to advise of your professional qualifications, please provide this information at the end of this line :




ADDITIONAL INFORMATION


Please complete the following if they are relevant to you :


Teaching Staff 

GTC Registration Number :	
Expiry Date :	

Clinical Staff 

GMC Registration Number :	
Expiry Date :	

GDC Registration Number :	
Expiry Date :

Nursing Staff 

NMC Pin Number :		
Expiry Date :	


Regulatory Body :

Please select your regulatory body. (Please write yes at the end of the appropriate line from the options below) If the Regulatory Body with whom you are registered is not listed, please write yes after the list item 00  Not currently registered to practice.

00 Not currently registered to practice 		
01 General Medical Council (GMC) 
02 General Dental Council (GDC) 			
03 General Optical Council (GOC) 
05 The Pharmaceutical Society of Northern Ireland (PSNI)
06 The Nursing and Midwifery Council (NMC) 		
07 Health Professions Council (HPC) 
08 General Social Care Council (GSCC) 		
09 Scottish Social Services Council (SSSC) 
10 Care Council for Wales (CCW) 			
11 Northern Ireland Social Care Council (NISCC) 
12 General Osteopathic Council (GOsC) 		
13 General Chiropractic Council (GCC) 
14 Royal College of Veterinary Surgeons (RCVS) 
15 The General Pharmaceutical Council (GPhC)


Healthcare Professional Speciality. (Please write yes at the end of the appropriate line from the options below) (To be completed by Clinical Staff only) :	

01 Anaesthetics 				
02 Obstetrics & Gynaecology 
03 Ophthalmology 				
04 Paediatrics and Child Health 
05 Pathology 					
06 Psychiatry 
07 Radiology 					
08 Surgery 
09 Physicians/Medicine 			
10 Public Health Medicine 
11 Occupational Medicine 			
12 Dentistry 
13 General Practice 				
14 Additional Dental Specialities
15 Infection / Microbiology			
16 Oncology
17 Medical Education				
21 Others in Medicine or Dentistry 
31 Nursing 					
32 Midwifery 
33 Health Visiting 				
34 Physiotherapy 
35 Radiography 				
36 Occupational Therapy 
37 Podiatry 					
38 Speech and Language Therapy 
39 Art therapy 				
40 Paramedic 
41 Orthoptics 					
42 Prosthetics and orthotics 
43 Dietetics 					
44 Healthcare Scientists 
45 Pharmacy 					
46 Clinical Psychology 
51 Others 

If you have selected 51  Others, please provide some addition information at the end of this line :







Thank you for taking the time to complete this form. 

Please print it off, then sign and date in the space below as confirmation that the details within this form are a true account of your current personal details. The completed form should be returned to Human Resources, 7th Floor, Tower Building, University of Dundee, Dundee, DD1 4HN


Signature :

Date :



Or, to return electronically, please type your name at the end of this line :

Enter today's date at the end of this line.

Both will be taken by Human Resources as as confirmation that the details within this form are a true account of your current personal details.

You should now email the form to Human Resources using the email address  personnel@dundee.ac.uk   from your official University email account.



Should you have any questions, or require additional information to allow for you to complete this form, please contact Human Resources by email at   personnel@dundee.ac.uk   or by telephone on    +44(0)1382384015