Norfolk and norwich health care nhs trust

ID C/P-App NO A1 A2 A3 A3a A4 A5 A5a E R/R Acc Cot Job Change/Addition / /

(Office Use Only)

Travel Office (ext 3666): NORFOLK AND NORWICH UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

All On Site Personnel - ID/Access And Parking Application Form

1. ID / ACCESS – Complete all sections:

Surname:

First Name:

Medical/Academic Title:

Job Title:

Dept/Ward:

Work Tel No:

Address:

Home Tel No:

Bleep:

Date Commencement:

End date if known

Post Code:

Date of Birth:

When collecting your ID Badge you will need to provide personal photo ID: Driving Licence, Passport. ID BADGES MUST BE WORN AT ALL TIMES AND REMAIN THE PROPERTY OF THE TRUST. FOR SECURITY REASONS ID BADGES MUST BE RETURNED TO YOUR HEAD OF DEPARTMENT ON LEAVING 2. CAR PARKING APPLICATION All applications for parking are assessed against the current Trust criteria (see below) NO PARKING ON SITE UNTIL APPLICATION, IF SUCCESSFUL, IS APPROVED. Staff, when working, are not permitted to park on the Patient/Visitor Car Parks (except nights and weekends). Please complete all sections applicable below especially start/finish times or forms will not be assessed.

Car Registration

1.

Make & Model

Colour

Car Registration

2.

Make & Model

Colour

Which days do you work? (please tick as applicable)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Do You Work Shifts

Yes

No

If Yes, please complete below.

Early Shift Start

Late Shift Start

Night Shift Start

Early Shift End

Late Shift End

Night Shift End

Day Work Start

Day Work End

Please note your entry/exit times are monitored for compliance with the conditions of your parking permit. Proof of address may be requested.

Do you work evenings/nights only?

Yes

No

Evening/Night Start

Evening/Night End

Do you Provide “On Call” duties out of hours?

Yes

No

Are you officially required to use your own car regularly for Trust Business whilst at work?

Yes

No

If Yes, how many times per week? (please tick as applicable)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Is public transport available from your home to work and back? (This information will be verified by the Travel Office)

Yes

No

Are you a blue or green badge holder (disabled)

Yes

No

Staff Car Park Charges (Please circle applicable salary band)

Gross Salary	Monthly from 1^st January 2014 *	Monthly from 1^st April 2014 *
Up to and including £17,425	£9.74	£12.00
Above £17,425 less than £46,000	£19.34	£24.00
£46,000 and above	£22.34	£30.00

*Before salary sacrifice arrangements are applied

AUTHORISATION
I confirm that the information I have provided above is true and accurate. I understand that it will be assessed against Trust criteria (see below), in order to determine whether I am eligible for a permit. If I am found eligible for a parking permit I acknowledge and agree that a condition for me to receive and continue to use the permit is that I shall agree to a reduction in my basic salary or authorise deduction of the cost of the permit from my monthly salary by completing (and renewing as appropriate), such form as the Trust shall use for this purpose from time to time. I further acknowledge and agree that I shall not receive or be able to use of the permit until such time as the completed form has been returned to and processed by the Trust.
The cost of the parking permit is in line with the bandings above, and is subject to regular review at the absolute discretion of the Trust. The Trust has a right to vary and change the costs of the car parking permit at any time at its absolute discretion, provided that any increase in the charge shall not apply unless and until 1 month’s prior written notice has been provided to you by the Trust. The allocation of a permit does not guarantee a space.
I agree to abide by the conditions applicable upon receipt of my permit, and realise that failure to do so (including in particular, but without limitation, any withdrawal of my authorisation for the Trust to deduct the cost of the permit from my monthly salary) shall result in my permit being withdrawn with immediate effect. There will be a charge of £5.00 for the replacement of lost or damaged ID Badges.
The Trust reserves the right to withdraw a permit for any reason, and you will be provided with one month’s notice if this is the case (save where withdrawal is due to breach of these conditions in which case withdrawal will take effect immediately).
Applicant’s Signature: ………………………….………………….……… Date: …………………..
Employer (please tick appropriate box): NNUH □ Serco □ PCT □ Social Services □ Other □
It is the responsibility of the Head of Department to verify the information given is correct and to indicate if the applicant is eligible for a parking permit in accordance with the criteria (please circle below)
Blue Badge Holder… Yes/No Shift Pattern……. Yes/No

Regular car user… Yes/No NROC (Doctors Only)….. Yes/No

(STAFF BASED OFF SITE)

Needs to travel to the NNUH as a regular part of their role… Yes/No

If ‘Yes’ 3 or more times a week … Yes/No If ‘Yes’ will they usually be able to use a shuttle to travel… Yes/No

If ‘No’ reason why not?.....................................................................................................................................................

Do you confirm the information given as being correct and has the employee’s address been verified….. Yes/No
Signed: .....................…….............. ………………………..………………... Date: ………..……….

Head of Department (Full name)

Authorised:............................……....... ………………………………………..… Date: …………..…….

Operational Manager/Director (Full name)

Company Name …………………………………….

NB. This application must be checked and signed by the Head of Department and authorised by the Operational Manager/Director. It can be sent or brought in person by the applicant to the Travel Office.
TRAVEL OFFICE OPENING TIMES: Monday to Friday 0900–1300 & Wednesday 0900 - 1600
Park & Save Salary Sacrifice Scheme

This scheme is only open to Trust Staff

Through Park and Save you will save money because your Gross basic annual salary will be reduced by the charge for the car park permit. This means you will pay a reduced amount of Tax, National Insurance and, where appropriate, Pension contributions because they will be calculated on your salary after the charge for the car park permit has been taken. As a Trust we will also make savings on the National Insurance and, where relevant, the pension contributions that we make as an employer.

A series of frequently asked questions is available for you to read, which can be found on the Trust Intranet – Travel Office site. It is important that you read these carefully in order to understand the implications of the salary sacrifice scheme for you. This may be particularly important for those groups of staff who are retiring in the coming years and those who will shortly be taking maternity leave. If you still have questions please contact the Travel Office as detailed within question 28.

Taking part in Park and Save will mean a variation to your terms and con

ditions of employment and this application provides written notice of this change to your current terms and conditions of employment from the date at which the permit is approved (if your application is successful).

If you wish to join the Park and Save scheme, you should complete and sign the ‘opt in’ section below and you should retain a copy of this for your records. If you do not wish to join the Park and Save scheme, you will pay for your car parking charges out of your net pay.

OPT IN – CAR PARKING SALARY SACRIFICE SCHEME
Having considered all the implications of joining the salary sacrifice scheme I would like to request to participate in Park and Save. Should the Trust agree to my request, I authorise that my Basic Salary should be reduced by an agreed amount and I will receive access to car parking as outlined in the scheme FAQs.
I understand that this constitutes a contractual change to my Terms and Conditions of Employment. I agree to a reduction in my basic salary of the agreed sum, in accordance with the pay bands above and as applicable for my pay band as in force from time to time. I can opt out of this agreement at the time of my annual renewal date or at the discretion of the Trust (see examples of Lifestyle events in the scheme FAQ booklet).

• 
  I have read the FAQ Booklet and agree to the Variation in Terms and Conditions of Employment in respect of the Park and Save salary sacrifice scheme
  
• 
  I confirm that I am an employee of Norfolk & Norwich University Hospitals NHS Foundation Trust
  

P

lease tick box to confirm

Signed: ……………………………………………… Date: ………………………….
Please note that any employees who receive an annual car parking permit will be bound by the rules associated with it. For the avoidance of doubt the permit is attached to an individual not a vehicle and therefore is non-transferable.
Variation to Terms and Conditions of Employment
The variation which the Trust is proposing to make to your contract of employment is as follows:

(a) With effect from the date your Salary Sacrifice begins, and annually thereafter, (i) you will receive access to car parking at the onsite car park. The car parking will be made available on the same basis as now and cannot be guaranteed and (ii) you agree to a reduction in your basic salary in accordance with this agreed parking arrangement. Subject to the conditions outlined in paragraph (b) below, the Trust will advise you of any increase/decrease in the Salary Sacrifice. The amount of salary exchanged will be adjusted accordingly*.

(b) If you decide to enter into the arrangement, the variation to your contract of employment is expected to run for a minimum of twelve months, you will continue to participate in the Salary Sacrifice unless your written request to cancel the arrangement in advance of your annual renewal date is accepted by the Trust (following completion and submission of the Lifestyle Event form).

Any savings are subject to any changes in income tax, NIC and pension rates, and allowances that the Government and the NHS may introduce at any time.

You will be able, subject to the Trust’s discretion, at specified annual intervals or at times of Lifestyle Events as stated in the FAQ Booklet, to either cancel the arrangement and revert to your previous salary level (in this event you will then pay for car parking from your net salary), or enter into a new Salary Sacrifice arrangement.

The arrangement will not affect the current practical arrangements that exist for you at the car park. The rules and regulations that apply to the use of the car park and the availability or otherwise of car parking spaces will continue to apply (as amended from time to time) and are not affected by you entering into the Car Parking ‘Park and Save’ Salary Sacrifice scheme.

* There may be periodic adjustments to the level of Salary Sacrifice. You will be notified of any changes in the level of charges in writing and will be given the opportunity to opt out of the Park and Save scheme and have the choice of either having the cost of parking deducted from your net pay on a monthly basis (which requires completion of the car parking mandate form), or, to cancel your car parking permit. If you do not take up any of these options it will be assumed that you accept the changes in the value of your Salary Sacrifice.

CRITERIA FOR STAFF CAR PARKING AT THE NORFOLK AND NORWICH UNIVERSITY HOSPITAL
Please note that Child Care or Parental Care DO NOT form part of the criteria for Car Parking
The criteria for parking gives the following staff priority when allocating permits:
(a) Requirements

(i) Staff required to work specific shift patterns – those contracted to start at or before 07:30 and those contracted to finish at or after 21:00.

2. 
   Staff who are required to use their cars on hospital business on a regular basis (at least 3 times per week).
   

3. 
   Staff who are Blue Disabled Badge holders. (Other applications on health grounds should be referred to Workplace Health & Wellbeing).
   
4. 
   Priority for spaces will be given to staff for whom there is no suitable public transport from home to work and back. Suitable public transport is defined as a bus stop or railway station no further than ¾ mile or 15 minutes walk from the applicant’s address. Travel and walking time should not take more than 1½ hours each way to and from work and may include changing transport. Transport should arrive at the hospital at least 5 minutes before contracted working hours
   

2. 
   Distance Criteria
   

Staff living less than two (2) miles by road from the hospital will not be eligible for a permit, unless criteria in (a i-iii) apply.

2. 
   Waiting List
   

If the number of eligible applications exceeds the number of car parking permits available a waiting list will be maintained. Staff names will only be added to this list if they meet the criteria.

2. 
   Additional Conditions
   

1. 
   A breach of the conditions for the use of the car park will result in the immediate removal of the car-parking permit.
   
2. 
   The charges for car parking are based on salary bandings for basic earnings whether full or part time. The charges will be reviewed at least annually at the absolute discretion of the Trust. Charges will be deducted from salaries.
   
3. 
   Staff, when working, are not permitted to park on the Patient/Visitor car parks (except nights and weekends).
   
4. 
   There will be a charge of £5.00 for the replacement of lost ID Badges.
   
5. 
   Agency staff are asked to use the Park & Ride for day shifts and for night shifts or weekends can use the validation system for a minimum charge.
   
6. 
   All visitors from other Trusts and organisations will pay the public car-parking charge.
   
7. 
   A vehicle identification label(s) will be issued and must be displayed in the car(s).
   
8. 
   The Trust cannot accept liability for vehicles or their contents whilst on Trust property.
   

The allocation of parking permits will be subject to periodic reviews.
APPEALS

Staff who are not considered eligible for a permit based on these criteria may appeal against that decision. They need to complete a Car Parking Appeal Form, obtainable from the Travel Office. Appeals will be considered by a representative panel of managers and staff representatives.

DATA PROTECTION

This Trust follows the Data Protection principles of keeping relevant, accurate and up to date information. When you sign your application you agree the Trust can collect information about you and store it on the Hospital ID/Access/Parking database. It will be used for the analysis and management of access to the N&N University Hospital.

Travel Office November 2013