Professional Registration Policy · Trust assurances surrounding professional registration checks. All organisations used by the trust provide us with a copy of these audit reports

Document name: Professional Registration Ref.: 106

Issue date: 14 March 2016 Status: Final

Author: David Mawdesley – HR Business Partner Page 1 of 19

Professional Registration Policy

Reference Number: 106

Author & Title: David Mawdesley HR Business Partner

Responsible Director: HR Director

Review Date: 03 March 2019

Ratified by: Strategic Workforce Committee

Date Ratified: 03 March 2016

Version: 5.0

Related Procedural Documents

Recruitment and Selection Policy

Managing Conduct Policy

Pre and Post Employment Check Policy




Contents

1. Introduction ...................................................................................................... 4

2. Scope ................................................................................................................ 4

3. Purpose ............................................................................................................ 6

4. Duties ................................................................................................................ 6

4.1 HR Department ___________________________________________________ 6

4.2 Line Managers of Registered Employees _____________________________ 7

4.3 Registered Employees and Applicants for Employment _________________ 7

5. Procedure - Pre-Employment ......................................................................... 8

5.1 Pre-Employment Procedure for Non-Medical Appointments ______________ 8

5.2 Pre-Employment Procedure for Medical Staff: _________________________ 9

6. Procedure – Post Employment ....................................................................... 9

6.1 Maintaining Registration During Periods of Leave from the Trust ________ 10

6.2 Temporary staff _________________________________________________ 10

7. Non-Renewal / Lapse of Professional Registration ..................................... 11

8. Professional Memberships ........................................................................... 12

9. Equality Analysis ........................................................................................... 12

10. Monitoring Compliance with the Policy ....................................................... 12

11. Review ............................................................................................................ 12

Appendix 1: Protected Titles ............................................................................. 13

Appendix 2: Communication to Manager – Two weeks prior to expiry ......... 14

Appendix 3: Communication to Employee – One week prior to expiry .......... 15

Appendix 4: Communication to Manager - One working day before expiry .. 16

Document Control Information ............................................................................. 17

Ratification Assurance Statement _____________________________________ 17

Consultation Schedule _______________________________________________ 18

Equality Impact: (A) Assessment Screening ____________________________ 19




Amendment History

Issue Status Date Reason for Change Authorised

3.0 Approved February 2012

Planned Review TCNC Policy Sub-Group

4.0 Approved 31 January 2013

Planned Review and new policy format

Sue Smith, Deputy Director of Human Resources

5.0 Approved 03 March 2016

Planned Review Strategic Workforce Committee




1. Introduction In order to best serve and protect patients and the public, it is the responsibility of the Royal United Hospital NHS Foundation Trust(“The Trust”) to ensure that all staff, employed in posts subject to registration with a Professional Body, remain registered with that Professional body throughout their employment.

This policy supersedes all previous versions of the Professional Registration Policy.

2. Scope This policy applies to all staff employed at the Trust who are required to be registered with a Professional Body in order to carry out the role in which they are employed. The Trust makes every effort to use only an approved agency as this gives the Trust assurances surrounding professional registration checks. All organisations used by the trust provide us with a copy of these audit reports on a quarterly basis.

The table below outlines the requirements in terms of professional registration for regulated staff groups, including those for whom registration is voluntary.

Staff Group Professional Regulatory

Body Renewal Details

Registered Nurses and Midwives

Nursing & Midwifery Council www.nmc-uk.org 0207 333 9333

3 Yearly/ fees yearly Renewal date varies by individual.

Operating Department Practitioners

Health Professions Council www.hpcheck.org 0845 300 4472 or 0207 840 9802 [email protected]

Every 2 years

Physiologists / Audiologists Registration Council for Clinical Physiologists www.rccp.co.uk Due to become part of Health Professions Council www.hpcheck.org

Voluntary at present

Hospital Play Specialists [email protected] ve.co.uk Aiming to become part of www.hpcheck.org

Voluntary at present. Re-register every 5 years

Medical Staff General Medical Council www.gmc-uk.org 0161 923 6602 [email protected]

5 Yearly/fees yearly Renewal date varies by individual.

http://www.nmc-uk.org/

http://www.hpcheck.org/

mailto:[email protected]

http://www.rccp.co.uk/




http://www.gmc-uk.org/




Medical Staff / Dual Specialty with Restorative Dentistry, Dental Nurses and Dental Technicians

General Dental Council www.gdc-uk.org 0207 887 3800

Yearly Renewal date varies by individual.

Therapists (Physiotherapists, Occupational Therapists and Speech and Language Orthoptists)


Every 2 years

Biomedical/Clinical Scientists


Every 2 years

Radiographers Health Professions Council www.hpcheck.org 0845 300 4472 or 0207 840 9802 [email protected]

Every 2 years

Pharmacists General Pharmaceutical Council www.pharmacyregulation.or g

Yearly

Pharmacy Technicians General Pharmaceutical Council www.pharmacyregulation.or g

Yearly

Practitioner Psychologists Health Professions Council www.hpcheck.org 0845 300 4472 or 0207 840 9802 [email protected]

Every 2 years.

In addition, this Policy & Procedure outlines the requirements associated with Protected Titles. Protected Titles are protected by law & must be registered with the Health Professionals Council.

An individual commits an offence if they use a protected title when they are not registered with the Health Professions Council. It is also an offence for an employee to intend to deceive by implying that they are a member of one of the professions regulated by the HPC.

A person is not committing an offence if they use a prefix such as ‘assistant’, ‘trainee’, or ‘student’.

A list of protected titles as defined by the Health Professions Council can be found in appendix 1.

http://www.gdc-uk.org/







http://www.pharmacyregulation.or/









3. Purpose The purpose of this document is to provide clear guidance as to the Trust’s expected standards, policy and procedures which are in place to ensure that all professional registrations are appropriately checked, both upon commencement of employment and on an on-going basis throughout employment.

Whilst the Trust recognises that it is the individual employee’s responsibility to ensure that their registration remains current, the Trust will ensure that it has systems in place to check the registration status of staff prior to and during their employment and to identify any lapsed registrations and take appropriate action.

Failure to maintain registration - or loss of registration - for a registered post will be treated as a breach of contractual and professional conditions. Failure to re-register at the appropriate time may result in disciplinary action being taken in accordance with the Trust’s Managing Conduct Procedure, unless there are exceptional circumstances. Lapses in professional registration will be considered as Gross Misconduct and may result in summary dismissal.

4. Duties

4.1 HR Department

• To ensure that timely notification is provided to the relevant employees and their line managers with regards to an expected expiry of registration.

• To provide expert advice with regards to the appropriate action to be taken with regards to any potential lapses in professional registration and any subsequent disciplinary matters or issues related to restriction on practice.

• To own and appropriately maintain all internal information systems related to professional registration checks.

• To ensure that the registration of each member of state-registered staff is made directly with the relevant professional registration body.




4.2 Line Managers of Registered Employees

• To verify and record evidence of professional registration at interview in line with the Pre and Post Employment Check Policy and to inform the HR Department where this has not been possible.

• To act upon information provided by the workforce information team regarding the expiry of employees including the proactive management of either re-registration or a lapse as outlined in this policy.

• Where required to Support staff to re-validate with their

professional body completing any necessary assessments and associated paperwork in a timely manner.

4.3 Registered Employees and Applicants for Employment

• To provide evidence of their professional registration at interview for employment with the Trust, in line with the Pre and Post Employment Checks Policy and related requirements outlined in applicant information and communication.

• To maintain their registration in a timely manner so that throughout their employment they remain registered with the relevant Professional Body. Where revalidation is required in order to re-register with a professional body it is the employee’s responsibility to ensure that all necessary actions are undertaken in order to revalidate and re-register in a timely manner. It is the responsibility of the employee to pay membership fees of any professional body or organisation for which they need to be registered.

• To inform their Line Manager of any restrictions on their practice or issues with their registration whilst employed with, or seeking employment with, the Trust.

• Employees must only use a Protected Title where they have the appropriate, valid registration to do so; any employee or applicant found to be using a protected title which they lack the authorisation to utilise may have their offer of employment withdrawn, be subject to management in line with the Trust’s Managing Conduct Policy & Procedure and face prosecution and a fine of up to £5000.




5. Procedure - Pre-Employment

5.1 Pre-Employment Procedure for Non-Medical Appointments

Individuals must not commence employment in any post for which it is a requirement that they be professionally registered, unless the required checks outlined in the Trust’s Pre and Post Employment Checks Policy have been successfully completed with regards to the registration of the individual. As outlined in that Policy, evidence of registration must be produced at interview by interviewees and documented by the chair of the interview panel.

Before the Trust employs any health professional they will always check the following three areas:

• That the applicant is registered to carry out the proposed role;

• Whether the registration is subject to any current restrictions which might affect the duties proposed;

• If the applicant is subject to any investigations with regards to their fitness to practise which the regulatory body has a duty to disclose.

These checks will be completed for the successful candidate by the Recruitment Team, prior to any unconditional offer of employment being made. A check of the individual’s details will be made against the regulatory body’s website, and a print out of the check will be placed on the individual’s personal file.

If registration is current at the time an offer is made, but employment is due to commence after registration has expired, the registration will be re-checked before the individual commences work by the Recruitment Team.

Staff may commence work prior to a professional registration being confirmed, but on a fixed term contract and at a grade/level which does not require them to hold that professional registration (e.g. pre-reg Nurses). Once registration has been completed the employee will be paid at the registered grade from either their registration date or the start date of their employment, whichever is the later.

Whether an individual can undertake employment in an un-registered post - as outlined above - will be at the discretion of the line manager; it is the line manager who will be accountable & responsible for ensuring that the individual concerned acts only within the confines of the unregistered role prior to registration being obtained & confirmed. In the event that an individual does not gain registration the employment will be deemed to have ended.




5.2 Pre-Employment Procedure for Medical Staff:

The procedure for medical staff adheres to the same principles outlined in section 5.1 (Non-Medical Staff), with the following exceptions:

• With effect from November 2009 all Doctors must hold a license to practise. It is the license status which informs the eligibility to practise status of a Doctor. The GMC is required by law to issue doctors with a certificate to verify that they have either been granted with provisional or full registration. However, this certificate does not state whether or not a doctor holds a license to practise. Since November 2009, employers must check both the doctor’s registration status and their license to practise prior to engaging them to undertake any form of medical practise in the UK.

• The Medical Staffing team will ensure that a Doctor’s Registration and license status is checked after a successful interview and before any unconditional offer of employment is made.

• Care will be taken when checking GMC certificates that any “exceptions” printed on the certificate are adhered to (e.g. no independent practice) and are made known to the supervising consultant, if appropriate.

6. Procedure – Post Employment It is the responsibility of staff, working in a post which requires registration with a Professional Body, to maintain their Registration and to notify the Trust of any issues affecting it or restrictions placed upon their practice.

The registration of an existing employee whose post requires them to be registered will be checked on a rolling monthly basis by the Workforce Information Team, based within Human Resources. The expiry dates of all employees will be monitored and the procedure outlined below adopted for the management of renewals and lapses:

• Two weeks prior to the expiry of an individual’s registration, and where the

registration has not yet been renewed, the Workforce Information Team will contact the Manager of the employee whose registration is expiring to notify them that the individual has yet to re-register their membership; this communication (Appendix 2) outlines the possible actions that the manager may need to take should re-registration not occur and asks that they ensure that the employee re- register with their Professional Body.

• At one week prior to the expiry of an employee’s registration the Workforce

Information Team will notify the individual whose registration is expiring to inform them that their registration is due to expire. This letter will be copied to the HR Advisor for the Division or Directorate and the Manager of the employee. This notification will outline the process that the individual needs to follow to re-register and the consequences should they fail to do so. (Appendix 3)




• On the working day prior to the expiry of the Employee’s registration the

Workforce Information Team will email the Manager of the employee, copying in the HR Advisor and employee, to explain that the registration of that Employee is due to lapse the following day. This communication will explain that the employee is unable to work in a registered capacity without the correct registration and the steps they will need to take with regard to the lapse in registration as outlined in section 7. (Appendix 4)

Where the registered employee’s line manager is unavailable at the time that a registration is due to lapse, the Workforce Information Team will contact the Line Manager’s Manager to action the notification of the expiring registration.

6.1 Maintaining Registration During Periods of Leave from the Trust

Should an employee’s registration expire during a period of Sick leave, Maternity or Paternity leave, or other form of leave – with the exception of a career break – the employee will be expected to maintain their registration as if actively attending work. Failure to do so will result in the exploration of options as outlined in section 7.

If a member of staff's registration lapses they will not contractually, and in many cases legally, be able to continue to carry out the duties of their post if their post requires them to be registered. It is therefore vital that staff ensure that their registration is maintained and that they monitor the renewal of their own registration.

6.2 Temporary staff

Only agency staff from agencies specified by the Trust can be used because these agencies have a contractual commitment with the Trust to undertake the required pre and post-employment checks. The responsibility to carry out pre-appointment checks has been delegated to the agency and the Trust has satisfied itself that these checks are carried out. If pre-appointment checks are delegated to some other body, it is the responsibility of the manager appointing an agency worker to ensure they are carried out.




7. Non-Renewal / Lapse of Professional Registration Should an employee be found to have allowed their registration to lapse, immediate action must be taken and one of the three options outlined below (two options for medical staff) should be agreed between the employee and their Line Manager. In the event of a lapse, advice can be sought from the Operational HR Team.

Where an individual’s registration has lapsed they should be invited to a meeting to discuss the circumstances of the case. They may choose to have a colleague, friend who is an employee of the Trust or Trades Union Representative present at the meeting. However, the lack of a colleague or Trades Union Representative will not be sufficient to prevent or delay a meeting where a registration has been allowed to lapse and the individual is unable to continue working within their contracted role due to that lapse.

In this meeting the manager will inform the employee that they are required to take immediate measures to have their professional registration reinstated; in addition, agreement must be reached as to which of the options below will be implemented until such time as the lapse has been resolved. The manager should write to the employee following this meeting to summarise the meeting.

Deliberate or unreasonable failure, by the employee, to re-register may lead to disciplinary action being taken.

Option 1 (Not applicable to medical staff) Pay the employee at the highest unqualified grade for the profession until such time as re-registration can be confirmed by the Professional Body. During this time only the duties of the unqualified post may be undertaken by the employee; there will be no reimbursement for the temporary reduction in salary.

Option 2 Agree with the employee that they take annual leave until re-registration can be confirmed with the appropriate registering body. Payment during this time will be at the highest unqualified grade within the profession and banding payments for Doctors will cease.

Option 3 Agree with the employee that they take unpaid leave until re-registration can be confirmed and there will be no reimbursement for the temporary loss of salary.

Where an employee advises that she/he no longer wishes to be a registered practitioner, she/he will be formally advised that if they proceed with this course of action they will be deemed to have breached their Contract of Employment, to have lost the legal authority to undertake the job for which they were employed and that it will lead to their Contract of Employment with the Trust being terminated in line with the Managing Conduct Procedure.




8. Professional Memberships

In addition to those holding professional registrations there are many members of staff who hold a membership of a professional body, such as those in Finance, HR and Estates and Facilities. Whilst membership of a professional body will not be monitored in the same way as registration (i.e. as outlined in this policy) it is the responsibility of the employee, with oversight from their manager, to ensure that membership is maintained where this is a requirement of the job role. This requirement will be outlined in the person specification of each post.

9. Equality Analysis An Equality Analysis has been carried out on the content of this policy and can be found at the end of the document.

10. Monitoring Compliance with the Policy

Key Performance Indicator

Lead Responsible for Audit

Evidence Reviewed by / Frequency

Lead Responsible for any Required Actions

100% of staff and their manager will be informed of an upcoming lapse in registration in line with the process set out above

Workforce Assistant

Prof registration report and letters/email sent afterward

Workforce Assistant Monthly

HRBP

100% of employees who’s registration lapses will be met with and 1 of the three options outlined in this policy implemented

HR Advisor

Letter of meetings

HR Manager for operational area monthly

HRBP

The quarterly audits from the organisations used by the trust for temporary staffing are reviewed by the Clinical Services Manager.

11. Review This policy will be subject to a planned review every 3 years as part of the Trust’s Policy Review Process. It is recognised however that there may be updates required in the interim, arising from amendments or release of new regulations, codes of practice or statutory provisions or guidance from the department of health or professional bodies. These updates will be made as soon as practicable to reflect and inform the Trusts revised policy and practice.




Appendix 1: Protected Titles

Profession Protected Titles

Arts Therapist • Art psychotherapist

• Art therapist

• Dramatherapist

• Music therapist

Biomedical Scientist • Biomedical Scientist

Chiropodist / Podiatrist • Chiropodist

• Podiatrist

Clinical Scientist • Clinical Scientist

Dietician • Dietician

• Dietitian

Hearing aid dispenser • Hearing aid dispenser

Occupational therapist • Occupational Therapist

Operating department practitioner • Operating department practitioner

Orthoptist • Orthoptist

Paramedic • Paramedic

Physiotherapist • Physiotherapist

• Physical therapist

Practitioner Psychologist • Practitioner psychologist

• Registered psychologist

• Clinical psychologist

• Counselling psychologist

• Educational psychologist

• Forensic psychologist

• Health psychologist

• Occupational psychologist

• Sport and exercise psychologist

Prosthetist / Orthotist • Prosthetist

• Orthotist

Radiographer • Radiographer

• Diagnostic radiographer

• Therapeutic radiographer

Speech and language therapist • Speech and language therapist

• Speech therapist




Appendix 2: Communication to Manager – Two weeks prior to expiry Dear Manager Name,

Professional Registration Expiry:

It has come to my attention that Employee’s Name’s registration with the Name of Professional Body is due to expire on Date. To date this registration has not been renewed.

Please could you contact Employee’s Name as soon as possible to inform them that their professional registration is due to expire and that it is their responsibility to ensure that they have renewed their registration prior to its expiry date. Failure to re-register prior to expiry may result in disciplinary action being taken in accordance with the Trust’s Managing Conduct Procedure, unless there are exceptional circumstances.

If re-registration does not occur prior to the expiry date Employee Name will be unable to work in a registered capacity and you will need to hold a meeting with the Employee to discuss one of the following three options:

Option 1 (Not applicable to medical staff) Pay the employee at the highest unqualified grade for the profession until such time as re- registration can be confirmed by the Professional Body. During this time only the duties of the unqualified post may be undertaken by the employee; there will be no reimbursement for the temporary reduction in salary.

Option 2 Agree with the employee that they take annual leave until re-registration can be confirmed with the appropriate registering body. Payment during this time will be at the highest unqualified grade within the profession and banding payments for Doctors will cease.


I will continue to monitor the registration status of Employee Name and will contact them in one week’s time if re-registration has not occurred, outlining the procedure they need to follow and the consequences of not re-registering with their Professional Body. I will copy you into all communication regarding this matter.

If you have any questions or queries please do not hesitate to contact me on ext

XXXX. Your sincerely,

Name. Title




Appendix 3: Communication to Employee – One week prior to expiry Dear Employee Name

Professional Registration Expiry:

It has come to my attention that your registration with Professional Body is due to expire on Date. As at the date of this letter I am unable to confirm with your professional body that you have renewed your registration. I am therefore writing to remind you that your registration is due for renewal by Date.

It is your responsibility to ensure that you renew your registration prior to its expiry date. Failure to do so may result in you being placed on unpaid leave until your registration is renewed. If, upon investigation, there are no exceptional circumstances for your lapse in registration, disciplinary action in line with the Trust Managing Conduct Policy may be taken against you. I have enclosed a copy of the Trusts Professional Registration Policy for your information.

If you are in the process of re-registering or have received confirmation from the NMC please could you let me know by contacting me on extension XXXX in order that we may update our records.

If you have not yet begun the re-registration process then I must stress the importance of acting quickly to ensure that your registration does not lapse.

The contact details for Professional Body are outlined below: Telephone -

XXXXXXXXXX Fax Number – XXXXXXXXXX Email – XXXXXXXXXX Web Address - XXXXXXXX

Please note that some Professional Body websites can take up to 48 hours to update once you have re-registered. As such, if your re-registration occurs less than 48 hours prior to the expiry date you must provide your Line Manager with a fax from your professional body stating that they have received your payment and that re-registration has occurred.

If you have any other queries please do not hesitate to contact me on Extension XXXX.

Name Title

cc. Name, HR Advisor

Name, Line Manager Enc. Professional Registration Policy




Appendix 4: Communication to Manager - One working day before expiry Dear Name of Manager

Urgent: Professional Registration Expiry

Further to my previous correspondence, I write to inform you that Employee’s Name has failed to re- register their professional registration and that this registration is due to expire imminently on Date.

As of Date, Employee’s Name will be unable to practice within their registered capacity until we have received confirmation that they have re-registered with Professional Body.

If you have not received confirmation of re-registration by Date, please arrange a meeting with Employee Name to discuss the circumstances surrounding the lapse in registration. At this meeting the employee may be represented by a colleague or accredited trade union representative, however, the arrangement of representation should not delay the meeting.

In this meeting you should inform the employee that they are required to take immediate measures to have their professional registration reinstated; in addition, agreement must be reached as to which of the options below will be implemented until such time as the lapse in registration has been resolved. You should also inform the employee that depending on the circumstances of the lapsed registration disciplinary action may be taken in line with the Trust’s Managing Conduct Policy. You should write to the employee following this meeting to summarise the discussion.

Option 1 (Not applicable to medical staff) Pay the employee at the highest unqualified grade for the profession until such time as re-registration can be confirmed by the Professional Body. During this time only the duties of the unqualified post may be undertaken by the employee; there will be no reimbursement for the temporary reduction in salary.

Option 2 (Not applicable to medical staff) Agree with the employee that they take annual leave until re-registration can be confirmed with the appropriate registering body. Payment during this time will be at the highest unqualified grade within the profession.


Following the meeting, if you feel that the circumstances surrounding this lapse in registration warrant disciplinary action, in line with the Managing Conduct and Professional Registration Policies, please contact your Operational HR Lead (copied into this communication) to discuss this matter.

If you have any queries with regard to this communication then please do not hesitate to contact me on extension XXXX or your Operational HR Lead, Name, on extension XXXX.

Yours Sincerely, Name Title

cc. Name, Operational HR Lead




Document Control Information

Ratification Assurance Statement

Dear Strategic Workforce Committee

Please review the following information to support the ratification of the below named document.

Name of document: Professional Registration (Reference 106)

Name of author: David Mawdesley

Job Title: HR Business Partner

I, the above named author confirm that:

The Policy presented for ratification meets all legislative, best practice and other guidance issued and known to me at the time of development of the Policy;

I am not aware of any omissions to the Policy, and I will bring to the attention of the Executive Director any information which may affect the validity of the Policy presented as soon as this becomes known;

The Policy meets the requirements as outlined in the document entitled Trust-wide Policy for the Development and Management of Policies (v4.0);

The Policy meets the requirements of the NHSLA Risk Management Standards to achieve as a minimum level 2 compliance, where applicable;

I have undertaken appropriate and thorough consultation on this Policy and I have documented the names of those individuals who responded as part of the consultation within the document. I have also fed back to responders to the consultation on the changes made to the Policy following consultation;

I will send the Policy and signed ratification checklist to the Policy Coordinator for publication at my earliest opportunity following ratification;

I will keep this Policy under review and ensure that it is reviewed prior to the review date.

Signature of Author: David Mawdesley Date: 03 March 2016

Name of Person Ratifying this policy: Claire Buchanan

Job Title: Director of HR

Signature: Date: 03 March 2016

To the person approving this policy:

Please ensure this page has been completed correctly, then print, sign and post this page only to: The Policy Coordinator, John Apley Building.

The whole policy must be sent electronically to: [email protected]





Consultation Schedule

Name and Title of Individual Date Consulted

Andy Howse, Senior Workforce Analyst 14/12/2015

Rebecca Sawkins, Deputy HRBP 14/12/2015

Georgina Holland, HR Advisor 14/12/2015

Alex Clare, HRBP 14/12/2015

Katy Coulam, HRBP 14/12/2015

Naomi Adams, Deputy HRBP 14/12/2015

Gayle Williams, Deputy HRBP 14/12/2015

Emily Saad, HR Advisor 14/12/2015

Clare Grainger, HR Manager 14/12/2015

Jan Lynn, Lead Nurse Workforce Development 14/12/2015

Maggie Bruniges, Chair of Staff Side 14/12/2015

Pauline Burey, RCN Rep 14/12/2015

Andrea Rawle, UNISON Rep 14/12/2015

Name of Committee/s (if applicable) Date of Committee

TCNC Policy Sub Group 28/01/2015

Strategic Workforce Committee 03/03/2016




Equality Impact: (A) Assessment Screening To be completed when submitted to the appropriate Executive Director for consideration and approval.

Person responsible for the assessment:

Name: David Mawdesley

Job Title: HR Business Partner

Does the document/guidance affect one group less or more favourably than another on the basis of:

Yes/No Comments

Race Yes No

Ethnic origins (including gypsies and travellers) Yes No

Nationality Yes No

Gender (including gender reassignment) Yes No

Culture Yes No

Religion or belief Yes No

Sexual orientation Yes No

Age Yes No

Disability (learning disabilities, physical disability, sensory impairment and mental health problems)

Yes No

Is there any evidence that some groups are affected differently? Yes No

If you have identified potential discrimination, are there any valid exceptions, legal and/or justifiable? Yes No N/A

Is the impact of the document/guidance likely to be negative? Yes No

If so, can the impact be avoided? Yes No N/A

What alternative is there to achieving the document/guidance without the impact? Yes No N/A

Can we reduce the impact by taking different action? Yes No N/A

If you answered NO to all the above questions, the assessment is now complete, and no further action is required.

If you answered YES to any of the above please complete the

Equality Impact: (B) Full Analysis