1. Surname/Family name
Your surname/family name.
2. Previous Surname/Family name
Your previous surname/family name, e.g. your maiden name
3. First Forename/First name
Your actual first forename. This is your first name.
4. Other Forenames /Middle name(s):
Any other forenames. This is your middle name(s).
The title by which you are known e.g. MR, MRS, DR, PROFESSOR
6. Known As
The forename/first name by which you wish to be known.
7. UK National Insurance Number
Your National Insurance Number
8. Date of Birth
Your date of birth in format [dd/mm/yyyy]
10. Ethnic Background
Your ethnic background. Please select from the options listed on the pro-forma.
Your religion. Please select from the options listed on the pro-forma.
13. Do you have a disability?
The Disability Discrimination Act defines disability as a physical or mental impairment which has a substantial and long-term adverse effect on a person’s ability to carry out normal day to day activities. This definition now includes progressive conditions, e.g. cancer, HIV, MS, which are likely to produce a substantial adverse effect in the future.
14. Nature of any Disability
Please select from the options listed on the pro-forma.
15. (15 – 21) Home addresses Line 1 –4 & phone numbers.
Line 1 - 4 of your home address and your home and mobile phone numbers.
22. Emergency contact surname/family name
The surname or family name of your emergency contact.
23. Emergency contact first forename/first name
The forename or first name of your emergency contact.
24. Emergency contact known as
Your emergency contact known as.
25. Emergency contact title
Your emergency contact’s title e.g. MR, MRS, DR etc
26. Relationship to you
The relationship of your emergency contact to you e.g. mother, father etc
27. (27-34) Emergency contact address and phone numbers
Emergency contact address, home, work and mobile phone numbers.
35. Start Date at Queen Mary.
The first date of your current period of employment at Queen Mary, the Medical School, QMW, QMC, Westfield College, LHMC or SBHMC.
36. Continuous service date
Unless otherwise specified in your contract, your continuous employment with the College is taken to begin with the first day of your appointment to a post in the College. In most instances this will be the same as your start date.
37. Previous Employment
Please select your type of employment immediately prior to Queen Mary from the options listed. If you were previously employed by QMW, QMC, Westfield College, LHMC or SBHMC then please enter  in this field.
38. Previous UK Higher Education Institute (HEI)
If your previous employment (see above) was within a UK Higher Education Institution, please complete this field with the name of your previous HEI (most recent).
39. Highest Qualification Held
Please select your highest academic qualification from the options listed.
40. Academic Discipline 1
Please indicate the major academic discipline of your highest academic qualification (see above).
41. Academic Discipline 2
If your highest academic qualification has a second, or secondary, academic discipline, please indicate.
42. Date you became an academic in the UK
Please give the date of the first day of your first academic post on the payroll of a UK Higher Education Institute under a contract of employment that listed research and/or teaching as the primary purpose of your employment.
43. Regulatory Body
This relates to the registration of employees with statutory health or social care regulatory bodies.
44. Regulatory Body Registration No
If you have indicated a Regulatory Body (see above), please provide your registration number here.
45. Regulatory Body Type
If you have indicated a Regulatory Body (see above), please provide your registration type here. Valid entries are; Full, Temporary or Provisional
46. Regulatory Body Registration Expiry Date
If you have indicated a Regulatory Body (see above), please provide your registration expiry date.
47. National Training Number (Applies to medical professions only) Example = WMD/006/012/N
Each doctor who is accepted for a specialist registrar training programme and who holds a substantive appointment in the specialist registrar grade requires a Training Number. This number is unique to the doctor and, other than by exception, is held until training is completed and the doctor has left the grade.
48. Are you a current student at Queen Mary including the Medical School?
Are you a current student at Queen Mary including Barts and the London Medical School? Please provide effective date.
49. Have you ever been a student at Queen Mary, the Medical School, QMW, QMC, Westfield College, LHMC or SBHMC?
Have you ever been a student at Queen Mary, Medical School, Queen Mary and Westfield College, Queen Mary College, Westfield College, London Hospital Medical College or St Barts Hospital Medical College? Please provide effective dates.
50. Please provide your student ID number?
If applicable, enter your student ID number(s) here
51. Central College username provided by IT Services (formerly Computing Services):
The username used for example to access email on the central imap mail service. This username will consist of either three or four letters, followed by three numbers e.g.abc123 or ugye000. This is the account you use to access College email or College-only websites from off-campus. If you are uncertain about this please sign on to http://www.css.qmul.ac.uk/account/
52. College email address:
This is the email address that ends in @qmul.ac.uk
Administering personnel records
Information relating to disability, ethnicity, religion and nationality is used only for monitoring purposes. In aggregate form, this data can be used to develop, for example, diversity strategies
Managing duties and obligations under the Disability Discrimination Act
HESA requires this data to assist in year on year linking and tracking between records as individuals move between institutions.
HESA requires this data to enable information to be provided about transfer of staff between HE and other sectors of employment and the migration of HE staff to and from the UK.
HESA requires this data to provide information about the qualifications of the HE workforce and development of staff qualified in particular subject areas.
This information is central to the College’s preparations for the Research Excellence Framework (REF).
HESA requires this data to identify the appropriate regulatory body for staff currently registered to practice in medical, health and social care professions.