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Health and Safety

Executive

FODMS38 Application for appointment as an appointed doctor

under Regulations

This form is for use by doctors applying for appointment for the first time (complete parts 1 and 2) or by established

appointed doctors applying to have their appointment extended to cover additional regulations (complete part 1 only).

*Are you currently an appointed doctor?

Part 1 - Appointment Details

*Full name of doctor

If you are applying for an appointment under the Control of Lead at Work Regulations, do you intend undertaking medical surveillance of lead workers at more than one company during the first year of appointment?

If 'Yes', you should provide evidence with your application that you can meet at least one of the following criteria

(select as appropriate)

Page 1


HSE Logo

Health and Safety

Executive

FODMS38 Application for appointment as an appointed doctor

under Regulations

Part 2 - Doctor's details if applying for appointment for the first time

*Address for official correspondence

*Do you consent to having your name, address, email and telephone number included in

a list of appointed doctors published on HSE's website?

To apply, select Print/Save Form button, print out and sign the declaration on the form summary document and send the

summary plus scanned copies of the information requested in the checklist to: appointed.doctor@hse.gsi.gov.uk -

incomplete applications will not be considered.

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