Job Application: Te Tai Tokerau Research fellow and Clinical Senior House Officer General Surgery – Supernumerary for Learning/Research position (non-SET) (SGHO2022)

Northland District Health Board has established a set of values by which the organisation will respond, in part, to achieving its goals and objectives through their workforce. The following Values are expected behaviours of each individual employed with NDHB:

Values	Supporting Statement
People First Tangata i the tuatahi	People are central to all we do
Respect Whakaute (tuku mana)	We treat others as we would like to be treated
Caring Manaaki	We nurture those around us, and treat all with dignity and compassion
Communication Whakawhitiwhiti korero	We communicate safely, openly and with respect to promote clear understanding
Excellence Taumata teitei (hirangi)	Our attitude of excellence inspires success, competence, confidence and innovation

APPLICATION FOR EMPLOYMENT ~ TE TONO KIA WHIWHI MAHI
The completion of this form does not indicate there is an obligation on Northland District Health Board to engage the applicant. This information is collected for the purpose of assessing your suitability for employment at Northland District Health Board, which may include subsequent changes in your employment with Northland District Health Board. Required fields are indicated with an asterisk (*).

Please note, if short-listed for an interview, evidence of entitlement to work in New Zealand will be required from both New Zealand citizens and non-New Zealanders in accordance with the Immigration Act (2009).

Northland DHB has a responsibility to minimise the risk of harm to patients, clients and staff from preventable diseases. Potential new employees are subject to occupational health clearance, which includes being able to prove or obtain immunity from preventable diseases. Any offer of employment will be subject to satisfactory occupational health clearance.

Personal details

Title*

Given names*

Surname*

Address*

Please select an address from the drop down after you start typing, or alternatively click on enter address manually.

Enter address manually

My postal address is different to this address

Email Address*

Work Number

Home Number

Mobile Number

Please fill in at least 1 contact number field.

Do you have New Zealand citizenship or permanent residency?*

Yes No

Do you currently work for Northland District Health Board?*

Yes No

Have you previously worked for Northland District Health Board, Northland Health Ltd, Northland Area Health Board or the Northland Hospital Board?*

Yes No

What is your gender?

Covid-19 vaccination status*

For statistical reporting purposes we are asking you to answer the following question. This information is NOT used in the evaluation of your application, it is for statistical purposes only.

Please would you state which ethnic group you best identify with? (You must answer this question but you may choose not to reveal your ethnicity if you wish)
Note: An ethnic group or ethnicity is a category of people who identify with each other based on common language, ancestral, social, cultural, or national experiences.

What is your ethnicity?*

Have you ever been convicted in court for an offence? *
Note: All successful candidates will be required to undergo New Zealand Police clearance. This clearance is subject to the Criminal Records (Clean Slate) Act 2004 and may be subject to the exception contained in section 19(3)(e) of the Criminal Records (Clean Slate) Act 2004.

Yes No

Are you awaiting court charges? *

Yes No

Have you lived in an overseas country for more than 12 months in the past 10 years? *

Yes No

Do you have any demerit points? *

Yes No

Do you have a current driver's licence?*

Yes No

Do you smoke?*

Yes No

Do you have secondary employment?*

Yes No

Professional Qualifications: Doctor/Medical Officer/Specialist

Are you registered with the Medical Council of New Zealand?*

Yes No

Do you have a current Practicing Certificate?*

Yes No

Are you currently enrolled in a New Zealand Vocational Training Programme?*

Yes No

Are there any limitations or pending charges to your scope of practice?*

Yes No

Have you ever had a complaint lodged with a previous or current registering body with regard to your practice?*

Yes No

Are you currently under investigation by a previous or current registering body?*

Yes No

Education Qualifications

Country of primary qualification

Qualification

Year of completion of primary qualification

Add further qualifications

Current Employer

Organisation

City

Country

Position Held

Reason for leaving

Previous Employment

Organisation

City

Country

Position Held

Reason for leaving

Add further work experience

Other Relevant Details

Do you speak / write any language other than English, which could help you in your job?*

Yes No

List any other voluntary or unpaid work that may be relevant to the position you are applying for.

Do you have any relatives, members of your household or friends already employed by Northland District Health Board with whom you maybe working in close association with if you are appointed to the position applied for?*

Yes No

Have you had any injury or medical condition caused by gradual process, disease or infection (for example, hearing loss, sensitivity to chemicals, occupational overuse syndrome (repetitive strain injury), or back injuries) that may be aggravated or further contributed to by the tasks of this job, or which may otherwise affect your ability to carry out the duties you will be required to perform?*

Yes No

Is there any other information or facts which will be relevant to the organisation's decision whether to employ you?*

Yes No

Have you been represented by an agency in the last 12 months?*

Yes No

Send me an email to confirm that this application has been submitted

Yes No

Where did you see this position advertised?*

Curriculum Vitae & other Supporting Documents

'Select Files' from your computer to accompany your application.
Once finished selecting files (you can remove files before uploading) click the 'Upload Files' link below to attach the files to your application.

Allowed formats: .pdf .doc .docx & .txt.
Maximum filesize of 2MB each.

Select files Upload files

Disclosure

Do you consent to the disclosure to Northland District Health Board of whether you have been subject to a serious misconduct investigation, either concluded and upheld or currently under investigation, from all previous Public Service and statutory Crown entity employers for the last three years?
Should you be selected as the preferred candidate, your response will be checked with your previous employer(s) at that stage. We will not conduct this check prior to you being selected as the preferred candidate.

References

I consent to Northland District Health Board seeking verbal or written information on a confidential basis about me from representatives of my previous/current employers and or referees, and authorise the information sought to be released by them to Northland District Health Board for the purposes of ascertaining my suitability for the position I am applying for.*

Senior Medical Officers: Please note, three references are required and at least two should be within the past two years and from the same scope of practice*

Resident Medical Officers: Please note references should be from present or previous employers in a supervisory role within the last year*

First Name*

Surname*

Position held at time of working with applicant*

Organisation*

City*

Country*

E-mail*

Contact Phone

Contact Mobile

Please fill in at least 1 contact number field.

First Name*

Surname*

Position held at time of working with applicant*

Organisation*

City*

Country*

E-mail*

Contact Phone

Contact Mobile

Please fill in at least 1 contact number field.

First Name*

Surname*

Position held at time of working with applicant*

Organisation*

City*

Country*

E-mail*

Contact Phone

Contact Mobile

Please fill in at least 1 contact number field.

Declaration

I declare that to the best of my knowledge the answers provided in this application form and any other information provided to Northland District Health Board in support of my application is correct and I understand that if any false or deliberate misleading information is given, or any material suppressed, I will not be accepted, or if I am employed, my employment may be terminated. I also understand that any false information given in relation to my medical history with regard to gradual process, disease or infection can result in my loss of entitlement to any accident compensation.*

Date of application 18/05/2022 03:13, submitted by IP address: 34.231.147.28

Data Retention Declaration

The information that you provide to Northland District Health Board (NDHB) is used for recruitment purposes. Northland DHB staff involved in the recruitment process will be given access to this information.

Data retention
We keep your information for the time period required to complete the purposes for which it is processed or satisfy legal retention requirements. The length of time for which we retain information depends on the purposes for which we collected and use it or the requirements of the applicable laws.
If our processing of your data is covered by European data protection law (GDPR - General Data Protection Regulation), you have certain rights including:

You can request access and review information your information at any time
You have a right to correct your personal data
You can ask that we stop using your information
You have the right to request that your information is erased
You have the right to withdraw consent

We undertake to keep your information safe to the best of our ability by maintaining the integrity/security of systems on which your data is kept.
If you have any questions about our dealings regarding your Personal Information including any breaches by us of any privacy laws or any questions regarding this Privacy Statement you are able to submit that complaint or query by contacting us at jobs@northlanddhb.org.nz

Any complaints received by us will be referred to Human Resources and a response will be provided to you as soon as possible.

For more information about privacy issues in New Zealand and protecting your privacy, visit the New Zealand Privacy Commissioner's website.

By my Accepting below, I certify that I have read, fully understand and accept all terms of the foregoing statement.

I Accept.*