Change of Circumstances Form for Registrants on the NISCC Social Care Register Please note that you may notify us of changes to your personal information via the NISCC Online Portal at: - www.niscc.info Completed forms should be returned to: 1. This section must be completed in full Name you are registered under: NISCC Registration Team ……………………………....................……………………… Date of birth: ………………………………………………… Registration (SCR) Number: ……………………………… 7th Floor Millennium House 19-25 Great Victoria Street Belfast BT2 7AQ or by email to: [email protected] Tel: 028 9041 7600 2. Personal details Please use this section to provide information about changes to your name, home address or contact details. Your NEW name/title Title: …………………………………………… Surname: …………………………………….. Forenames: ………………………………….. ………………………………………………….. Your home address: To validate changes to your title/name you must supply supporting information as follows: Marriage: a copy of your marriage certificate which has been endorsed by your employer as having seen the original. If you are reverting to your name at birth: no supporting evidence is required. Otherwise, (following divorce, separation or other name change): if you are not reverting to your birth name, an endorsed copy of identification with your new name must be provided. House name/number: ……………………… Street/Road: ……………………………….. …………………………………………………. We will be using email and SMS text to communicate with our registrants. Town/City: …………………………………… Country: ……………………………………… Postcode: ……………………………………. Home Phone number: ………………………………………………….. Mobile Phone number: …………………………………………..……… Please ensure you provide a valid mobile phone number and email address. In providing these details you consent to their use in connection with NISCC registration. Email Address: ………………………………………………..… ………………………………… 16.04.2014 Page | 1 4. Employer’s contact details Please use this section to provide information about any changes to the details of your employing organisation, employment location or contact details. If you are working for a second social care employer and you need to advise the NISCC of changes to both employer’s use ‘Employment 1 New Details’ the Employment 1 new contactcontact detailsdetails, (E1) please Employment 2 new contact detailsfor (E2) job you spend most time in. Employment 1 New Details Employment 2 New Details Name of new employer/organisation Name of new employer/organisation ………………………………………………….. ………………………………………………….. New Job title/position: ……………..……… New Job title/position: ……………..……… ………………………………………………….. ………………………………………………….. Date effective from: DD/MM/YYYY Date effective from: DD/MM/YYYY New work address New work address Building name/number: …………………… Building name/number: …………………… Street/road: ………………………………….. …………………………………………………. Street/road: ………………………………….. …………………………………………………. Town/City: …………………………………… Town/City: …………………………………… Country: ……………………………………… Country: ……………………………………… Postcode: ……………………………………. Postcode: ……………………………………. Telephone No:……………………………….. Telephone No:……………………………….. Work Email:………………………………….. Work Email:………………………………….. New employer’s address (if different to work address e.g. organisation headquarters) Building name/number: …………………… New employer’s address (if different to work address e.g. organisation headquarters) Building name/number: …………………… Street/road: ………………………………….. …………………………………………………. Street/road: ………………………………….. …………………………………………………. Town/City: …………………………………… Town/City: …………………………………… Country: ……………………………………… ……………………………………… If you have previously held a role as endorser,Country: do you now wish your name to be removed the NISCC list of nominated endorsers? YES NO Postcode:from ……………………………………. Postcode: ……………………………………. Organisation for which you have been an endorser…………………………………………… 16.04.2014 Page | 2 5. Employment details Please use this section to confirm the work setting and focus of your new job role(s) and which subpart of the register you require registration on. Work Setting - Please tick the box which applies to your employing organisation Commissioning Education/Schools Governance/Learning & Development Management/Corporate Court Fieldwork/Community Health/Health and Wellbeing Centre Other Residential/Supported Living Day Care Further/higher education Hospital Prison/Secure accommodation Regulation Work Focus – Please tick one box. Choose the option that best describes the focus of your work Acute Adult’s Learning Disability CAMHS Children’s Learning Disability Dementia/EMI Family Intervention Justice – restorative Mental Health/Addiction Sensory services Training/Education/ Governance Adoption/Fostering Adult Physical Health Care Management Children’s Physical Health Early Years Homelessness Justice – youth Service development Other Adult Disability Adult Safeguarding Children’s Disability Community Development Education Welfare Justice – criminal Looked After Children Primary Care Specialist centre NISCC Register Sub-Parts: if your job role has changed, please indicate the subpart of the register on which you should NOW be registered ARCW Adult Residential Care Worker AW Advocacy Worker DCCM Day Care Centre Manager DCM Domiciliary Care Manager DCW Day Care Worker DMCW Domiciliary Care Worker DVR Driver with Care Duties ETO Environmental Technical Officer EWOM Education Welfare Officer Manager, not social work qualified EWON Education Welfare Officer, not social work qualified IQSW Internationally Qualified Social Worker OW Outreach Worker PA Personal Adviser QSW Qualified Social Worker RCCW Residential Child Care Worker RFCW Residential Family Centre Worker RHM Residential Home Manager ROB Rehabilitation Officer for the Blind STD Student SWA Social Work Assistant YFSW Youth/Family Support Worker 16.04.2014 Annual st Fee from 1 Apr 2014 £20.00 £20.00 £40.00 £40.00 £20.00 £20.00 £20.00 £20.00 £40.00 £20.00 £155.00 £20.00 £20.00 £40.00 £40.00 £20.00 £40.00 £20.00 £10.00 £20.00 £20.00 Page | 3 6. Suitability to work in social care Please use this section to provide information about changes to your registration with another regulatory body, disciplinary record, health or criminal record Please provide information about any change in the status of your registration with another Regulatory Body. Name of Regulatory Body Date and details of change Registration number or equivalent Name registered as Please provide information about any new disciplinary finding against you. Details of disciplinary finding Date of finding Name of employer or other organisation Please provide information about any change to your physical or mental health that may affect your ability to undertake your work in social care? Details of health condition Date of diagnosis To consent to a health report please provide contact details for your doctor or health professional. Please provide information about any new criminal investigation of which you are the subject, any new criminal convictions or any changes pending or alternatives to prosecution. Details of conviction/charge/alternative to prosecution Date Court/Police Station Removal from the Register I wish to apply for voluntary removal from the NISCC Social Care Register Please state reason……………………………………………………………………………… ………………………………………………………………………………………………………... NB: Social Work Students wishing to withdraw or ‘take a break’ from the Degree in Social Work course must ensure that the appropriate notification form is submitted to the NISCC by their Educational Establishment. ** Signature: …………………………………………………………. 16.04.2014 Date: ………………….. Page | 4
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