Secondary Employment and Extra-Official Activities - Sydney South ...

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Attachment 2 Staff Specialist – Application Form for Secondary Employment/Participation in an Outside Business [for full-time staff specialists] I am employed as a full-time staff specialist and I am writing to seek approval to participate in an Outside Practice in terms of the provisions of Clause 15 of the Staff Specialists (State) Award (the “Award”). Surname: ____________________________________ First Name(s):______________________________ Facility Name: __________________________________________________________________________ Department:____________________________________________________________________________ Employee Number: _______________________Classification:___________________________________ 1) I certify that the Outside Practice: ……………………………………………………………………………………………………………… (Name of the Outside Practice) located at…… ………………………..……..………………………………………………………....… (the “Outside Practice”) will not conflict with my commitments in providing normal duties or on call requirements as a full time Staff Specialist / Medical Practitioner in the provision of services to public patients and / or to services provided by the Sydney South West Area Health Service at: …….…………………………………………………………………………………………………. …….…………………………………………………………………………………………………. (Please name all Sydney South West Area Health Service hospitals / services where you are employed to perform work) 2) I certify that my participation in the Outside Practice will not conflict with my obligations under the Code of Conduct issued by the NSW Department of Health, as varied from time to time. 3) I certify that I will only participate in the Outside Practice on the days and between the hours listed below and I will immediately notify my General Manager / Area Service Director of any change to this pattern. Day(s) Hours Monday From: To: Tuesday From: To: Wednesday From: To: Thursday From: To: Friday From: To: Saturday From: To: Sunday From: To:
Attachment 2 Staff Specialist – Application Form for Secondary Employment / Participation in an Outside Business [for full-time staff specialists] Please provide details of any on call arrangements with the Outside Practice: ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… 4) I certify that any referrals to me when undertaking my functions in the Outside Practice will be at ‘full arms length’ and in accordance with the provisions of the Health Insurance Act or its equivalent from time to time. 5) I accept that: (i) (ii) (iii) (iv) (v) The income generated whilst engaged in outside practice pursuant to Clause 15 of the Award will be retained exclusively by me and I am under no obligation to provide records regarding the income generated pursuant to Clause 15 of the Award (unless otherwise required by law); I will be/am liable for all expenses incurred whilst engaged in outside practice including professional indemnity insurance, administration, facility costs and any other expenses arising from the conduct of such practice; The use of any of the Sydney South West Area Health Service’s employees, equipment or other resources in conducting outside practice is not permitted unless approved by the Chief Executive; Sydney South West Area Health Service may terminate an approval to work in Outside Practice with reasonable notice. I will complete a new form at the time of my annual performance review, unless there are any changes in the interim. I will immediately notify my General Manager / Area Service Director of any changes. 6) A breach of this agreement or the provisions of Clause 15 of the Award will be dealt with pursuant to Clause 3 of the Award. Signed by the Applicant: ………………………………………… Date: ……………………………………… General Manager / Area Service Director Approved / Not approved If applicable, specify the date on which the approval expires: …………………….………………………………… Name: ……………….……………………………………………………Date: ……..……………………………….. cc: Applicant HR Department
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