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Honorary Staff Record

University College London
RECORD FORM: HONORARY APPOINTMENTS

Person ID No.: ______________

PLEASE USE BLOCK CAPITALS

Family Name (Surname):


Known Name(s) (Forename):


Preferred Forename:


Title: Professor/Dr/Mr/Mrs/Miss/Ms

Honours/Qualifications

Nature of Qualifications
(please tick)
Degrees Both
Professional or other degree level
 
No formal qualification
 
DETAILS
OF
DEGREES
HELD
Letters of Degree Awarding University Class Subject
 
 
 

 

Male  Female 
Date of Birth:

Date Commenced:


Home Address:


 


Home Telephone Number:


Department:




Have you ever been a student at UCL YES/NO If YES please can you supply the following information:

Department:


Dates attended:




Name:


Address:


Telephone Number:



FOR MEDICALLY QUALIFIED MEMBERS OF

Name:


Department:


In common with all universities in the United Kingdom his College provides to agencies various information on an annual basis relating to all and students. The data provided to these agencies is subject to strict confidentiality safeguards and material is drawn from the record only in the form of statistical tabulations.

In order to enable me to complete your record, could you please provide us with the following information:

State Registration No.:



(Nurses/MLSO's etc.)

Medical Registration No.:



(GMC/GDC Registration No.)

Medical Insurance No.:


Medical Speciality - (please tick appropriate box) 

Subject Code
Number
Alternative titles
and sub-specialties
Accident and emergency 030
Administration 097
Anaesthetics 091
Basic medical sciences 095 Anatomy, Physiology, Pharmacology
Blood transfusion 092
Cardiology 007 Paediatric cardiology
Cardio-thoracic surgery 029 Cardiac surgery, Thoracic surgery 
Chemical pathology (clinical biochemistry) 072 Biochemical endocrinology,
Chemical toxicology 
Child and adolescent psychiatry 053
Clinical cytogenetics and molecular genetics 079
Clinical genetics 020 Genetics, Medical genetics 
Clinical immunology and allergy 085
Clinical neurological physiology 014 Applied-electro-physiology,
Electro- encephalography,
Neurological physiology 
Clinical pharmacology and therapeutics 010
Clinical physiology 013 Clinical measurement, Clinical rheology,
Medical engineering, Medical physics,
Physiology
Subject
Code
Alternative titles/sub-specialties
Community medicine 090 Epidemiology, Human ecology,
Industrial health, Public health and hygiene,
Social and industrial medicine
Dental medicine specialties 065 Oral microbiology, Oral pharmacology,
Oral pathology, Oral medicine,
Dental radiology, Dental anaesthesia
Dermatology 005 Leptrology
Diabetes and Endocrinology 017
Family planning session work (anaesthetics) 041
Family planning session work (surgery) 042
Forensic medicine 081
Forensic psychiatry 054
Gastroenterology 018 Liver disease
General medicine 001 Chemotherapy, Experimental medicine,
Homoepathy, Human metabolism,
Medical care of chronic sick and
epileptics, Sterile unit, Toxicology
General pathology 071
General Practice 082
General Surgery 021 Hand surgery, Rectal surgery,
Vascular surgery
Genito-urinary medicine 009
Geriatric medicine 011
Haematology 073
Histopathology 074 Cancer research, Cytology
Immunopathology 077 Clinical immuno-pathology
Infectious diseases 003 Tropical diseases, Tropical medicine
Medical microbiology 075 Bacteriology, Parasitology
(microbial genetics)
Medical oncology 012
Mental handicap 051
Mental illness 052 Psychiatry, Psychogeriatrics
Nephrology 015 Artificial Kidney, Haemodialysis
Renal Research
Neurology 006 Cerebral palsy, Epilepsy,
Paraplegia, Spinal injuries
Neuropathology 076
Nuclear medicine 016 Physicians with a special interest
in nuclear medicine, 
Radioactive isotope clinical
investigation, radio-biology
Subject Code Alternative titles/sub-specialties
Obstetrics and gynaecology 040 Family planning, Fertility,
Gynaecology (not practising obstetrics),
Gynaecological endocrinology,
Obstetrics, Parenthood clinic
Occupational health 093
Old age psychiatry 056
Opthalmology 025 Contact lenses
Oral surgery 061 Maxillo-facial surgery
Orthodontics 062
Other 099 Audio-visual aids including
medical illustration, Medical 
photography, General duties
to which no subject is appropriate
Otolaryngology 023 Ear, nose and throat, Audiology, Otology
Paediatrics 002
Paediatric dentistry 064
Paediatric neurology 049
Paediatric surgery 022 Neonatal surgery
Plastic surgery 028
Palliative medicine 094
Psychotherapy 055
Radiology 080 Mass radiography, Neuro-radiology,
Dental radiology
Radiotherapy 026
Rehabilitation 084
Research 096 Research to which no subject
listed is appropriate
Restorative dentistry 063 Conservative dentistry,
Periodontology, Prosthetics
Rheumatology 008 Physical medicine, Physiotherapy,
Rheumatism
Student health 098
Thoracic medicine 004 Diseases of the chest, 
Pneumoconiosis, Research in acute
respiratory failure, Tuberculosis
Traumatic and orthopaedic surgery 024 Orthopaedics
Urology 027
Virology 078

 
 
 

No:


 

 
 
 

CONFIDENTIAL

EQUAL OPPORTUNITIES CLASSIFICATION FORM

Name Date of Birth Dept

 

University College London has a commitment to ensuring that are appointed, retained and promoted on the basis of merit, regardless of ethnic origin, sex or disability.

Monitoring enables us to see what is happening in practice, to assess the impact of our equal opportunities policy and its implementation, and to set any targets for improvements, and measure and publish progress. To enable us to do this, and to make the exercise successful, we rely on all to supply the following details, which will be treated in the strictest confidence.

Thank you for your co-operation.

Choose one section from A-F, and then tick the appropriate box to indicate your cultural background.

Ethnic Group

  • A White
    British Irish
    Any other White background, please specify ________________________
  • B Mixed Race
    White and Black Caribbean White and Black African White and Asian
    Any other Mixed Race background, please specify ________________________
  • C Asian or Asian British
    Indian Pakistani Bangladeshi
    Any other Asian background, please specify ________________________
  • D Black or Black British
    Caribbean African
    Any other Black background, please specify ________________________
  • E Chinese
    Chinese
  • F Other ethnic group
    Any other background, please specify ________________________

sex

Male Female

Nationality


Are you disabled or do you have any condition that may require adjustments to your work or working environment? ( Examples of a 'condition' may include impairment of senses, co-ordination, memory, mobility, learning, health or wellbeing. )

 

Yes

No

(If you have ticked yes, you will be contacted by UCL's Occupational Health Service to assess your requirements and to advise your manager of any reasonable adjustments that are needed)

I do consider myself to have a disability, but I do not wish this information to be shared with anyone else.

 

Yes

No

(If you have ticked yes, but require reasonable adjustments in the future, it is your responsibility to inform UCL through your manager)