hta-application - Department of Health, Social Services and Public

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PUBLIC APPOINTMENTS - APPLICATION FORM
Department of Health, Social Services and Public Safety (DHSPSS)
BOARD OF THE HUMAN TISSUE AUTHORITY NORTHERN IRELAND MEMBER
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Applications must be made using this form - CVs will not be accepted.
Please write legibly and use black ink or typescript (minimum font size 12).
If completing this electronically, please do not alter the formatting/layout.
This application form can be made available in other formats upon request. Please contact
(028) 9052 8372 for details.
Please complete all parts of this form, and return your application to the postal or e-mail
address below.
The closing date for this appointment opportunity is 5p.m. on 28 January 2015.
Forms received after the closing time and date will not be accepted.
DHSSPS Secondary Care Directorate
Room 1
Annexe 1
Castle Buildings
Stormont Estate
Belfast BT4 3SQ
For official use only
Application Form Received:
Official’s Name & Date:
E-mail: secondary.care@dhsspsni.gov.uk
If e-mailing your application, to facilitate processing, please put the following as the
e-mail subject line:
CONFIDENTIAL - Public Appointment - HTA NI Member
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1.
PERSONAL DETAILS
Title:
Surname:
Forename(s):
Postal Address:
Postcode:
Telephone:
Mobile:
E-mail:
National Insurance Number:
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2.
SUITABILITY FOR APPOINTMENTSUITABILITY FOR APPOINTMENT
Complete each box below using the space provided. Additional sheets will not be
accepted. If typing, use minimum font size 12.
(i)
Corporate Governance and Scrutiny
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Experience of working at or close to Board level, demonstrating application of the Principles
of Corporate Governance and risk management, including the role of non-executive directors
in holding executive directors to account.
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(ii)
Strategic Thinking
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Experience of adding value to an organisation at a senior level by understanding its
business, thinking strategically and determining the organisation’s strategic direction, and
exercising sound judgment on complex and sensitive issues.
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(iii) Financial Accountability and Management
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Experience at a senior level of applying principles of financial accountability and
management within an organisational setting.
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(iv) Public Service Principles
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Experience of understanding of, and commitment to, the principles of public service, and a
broad understanding of the social, political and economic influences on the Health and
Social Care sector.
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Please note that the following sections 3 - 5 regarding current employment/voluntary
work and public appointments play no part of the selection process. This information is
used to identify any potential disqualifications and/or conflicts of interests only.
3.
CURRENT EMPLOYMENT
Are you currently employed?
YES
NO
If YES, please give details below.
Organisation:
Start date:
DD/MM/YYYY (Complete as appropriate)
Position:
Main Responsibilities:
4.
CURRENT VOLUNTARY WORK
Are you currently involved in voluntary work?
YES
NO
If YES, please give details below.
Organisation:
Start date:
DD/MM/YYYY (Complete as appropriate)
Position:
Main Responsibilities:
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5.
CURRENT PUBLIC APPOINTMENTS
Do you currently hold any public appointments?
YES
NO
If NO, please go to Section 6.
If YES, please give details below for all public appointments currently held (use additional
pages as needed).
Organisation:
Start date:
DD/MM/YYYY (Complete as appropriate)
Position:
Main Responsibilities:
Remuneration Fees Paid:
Organisation:
Start date:
DD/MM/YYYY (Complete as appropriate)
Position:
Main Responsibilities:
Remuneration Fees Paid:
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Organisation:
Start date:
DD/MM/YYYY (Complete as appropriate)
Position:
Main Responsibilities:
Remuneration Fees Paid:
Organisation:
Start date:
DD/MM/YYYY (Complete as appropriate)
Position:
Main Responsibilities:
Remuneration Fees Paid:
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6.
PREVIOUS RELEVANT EMPLOYMENT AND/OR VOLUNTARY WORK
EXPERIENCE
Please provide details of your pervious employment and/or voluntary work experience that you
consider relevant to this application.
Organisation:
Start date:
DD/MM/YYYY
End date:
DD/MM/YYYY
Position:
Main Responsibilities:
Organisation:
Start date:
DD/MM/YYYY
End date:
DD/MM/YYYY
Position:
Main Responsibilities:
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Organisation:
Start date:
DD/MM/YYYY
End date:
DD/MM/YYYY
Position:
Main Responsibilities:
Organisation:
Start date:
DD/MM/YYYY
End date:
DD/MM/YYYY
Position:
Main Responsibilities:
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7.
INTEGRITY/PROBITY AND CONFLICTS OF INTEREST
Before you complete this section, it is important that you read section 4 of the Commissioner
for Public Appointments’ Code of Practice for Ministerial Appointments to Public Bodies
(2012), available at http://publicappointmentscommissioner.independent.gov.uk/wpcontent/uploads/2012/02/Code-of-Practice-20121.pdf
NOTE:
Conflicts of interest will be explored at interview.
Are there any real, perceived or potential conflicts of interest between your circumstances and
the appointment for which you have applied?
YES
NO
If YES, please provide details below.
Have you been involved in activities that could call into question your own reputation and/or
damage the reputation of this organisation?
YES
NO
If YES, please provide details below.
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8.
DECLARATION
I declare that the information I have given in support of my application is true and complete to
the best of my knowledge, is an accurate reflection of my own individual experience, personal
achievements and undertakings and all statements contained therein relate to me personally.
I have read the candidate information pack and understand my responsibilities in relation to
statutory disqualifications and public appointments. I understand that, if I am appointed and the
information I have provided is incorrect, or any of the statements made in this declaration are
untrue, or subsequently circumstances arise at any time before the end of my term of office
which would render any such statements untrue, then my tenure of office may be terminated.
In addition, I undertake that, if appointed, I must raise with the Chief Executive of the HTA any
probity or conflict of interest issues that might arise during my term of appointment, and that
my failure to do so could lead to my appointment being terminated.
I understand and accept that the information I have provided in this form will be processed by
the Department of Health, Social Services & Public Safety, in accordance with its Data
Protection Registration, for the purposes of making public appointments. This may involve
disclosing information to other Government Departments, the Commissioner for Public
Appointments for Great Britain, and anonymously in response to Assembly/Parliamentary
Questions and other enquiries. I also understand and accept that, if appointed, my name will
be published in the Public Appointments Report. In addition, if appointed some of the
information contained in my application will be used for a Press Release.
I have read section 4 of the Commissioner for Public Appointments’ Code of Practice for
Ministerial Appointments to Public Bodies (2012), and completed Section 7of this application
form accordingly.
Signature:
Date:
The closing date for this appointment opportunity is 5p.m. on 28 January 2015.
Forms received after the closing time and date will not be accepted.
If submitting by post, send to:
DHSSPS Secondary Care Directorate
Room 1
Annexe 1
Castle Buildings
Stormont Estate
Belfast BT4 3SQ
If submitting by e-mail, please save in PDF format and submit to
secondary.care@dhsspsni.gov.uk with the subject line as: CONFIDENTIAL - Public
Appointment - HTA NI Member
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