NMC enquiry form

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The purpose of this form is for legal support to be arranged for 外网天堂 members who have been contacted by the NMC.

Note that for us to provide legal representation, you must have been in the correct category of membership at the time of the incident(s) cited in the referral.

Before completing this form, please see our advice guides on NMC issues.

If you have been contacted by the NMC, need to self-refer to the NMC, or have a question about the NMC, please complete the below form. Please do not contact or respond to the NMC until you have heard back from the 外网天堂 legal team.

If you have not been contacted by the NMC but believe you have been referred, we will not be able to arrange support until you have been formally notified. Please get back in touch when the NMC has contacted you directly.

If you are a witness and your practice is not being brought into question, you do not need to complete this form. You can find further information on being a witness in our witness advice guide.

Please confirm that you have read our advice

Contact details

Can we update your personal details if any of the below information does not match the data we currently hold on your record? Yes No Full name: 外网天堂 membership number: Address: Best contact number:

Please note that 外网天堂 Direct will not usually call you. Where an onward referral is required, provided you were in the correct category of membership at the time of the incident, we will provide these contact details to the 外网天堂鈥檚 Legal Department.

Do you give us your consent to pass on this information? Yes No Can we leave you a voicemail? Yes No Can we contact you on this matter by email? Yes No If we need to pass your enquiry to your local 外网天堂 office or a specialist 外网天堂 department, would you like any emails from them to be password protected? Yes No Email address you would like us to reply to Please confirm the email address you would like us to reply to Please list any times that you are unavailable for calls during the next week (9am-5pm):

Employment details

Please write out in full, don't use acronyms.

Place of work Employer On what date did you start working with your current employer? Ward or department Job category

Please confirm that you work under the supervision of a registered nurse, midwife or health visitor. If you do not, please call our 外网天堂 team on 0345 772 6100 as you may not be eligible for 外网天堂 membership.

Job title Band Weekly contracted hours Do you have any meetings scheduled? Yes No If yes, please give date, time and location: Are you already being supported by a rep? Yes No If yes, please include details below: Are you in the UK on a visa? Yes No If yes, please include details below (including how long you have been in the UK and when your visa expires):

NMC

Have you been contacted by the NMC? Yes No

Date of incident that led to the referral to NMC What date did the NMC contact you? Is there an interim suspension? Yes No Is there an interim order hearing? Yes No If yes, when and where? NMC officer name: NMC officer email: NMC officer phone number: NMC case reference number: NMC pin number: Is there a deadline to respond to the NMC? Yes No If yes, when is the deadline? Please list the allegations/concerns, as stated in the letter from the NMC: Is your employer aware that you have been contacted by the NMC? Yes No Is your employer taking any action against you following the NMC referral? Yes No If yes, please provide brief details: Do you know if any other nurses/midwives have been referred or may be referred? If yes, please provide details:

By submitting this form, you are giving the 外网天堂 permission to contact you about your submission.

You can control the information you receive from the 外网天堂 by updating your preferences at My外网天堂.

We don’t update your contact details unless you ask us to. The best way to check and update the details we hold for you is by visiting My外网天堂.

The information you provide in this form will be stored by the 外网天堂.

Protecting your privacy is very important to us. Please view our privacy policy to find out more about the information we collect and how it is used.

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