03300 430 005

PERSONAL DETAILS

Title*:

Surname*:

First Name(s)*:

Other Name(s):

Marital Status*:

Gender*:

Current Address*:

Mobile Phone*:

Home Phone:

Do you have a driving licence?*

Do you have use of a car?*

JOB DETAILS

Position Sought:

Speciality 1:

Speciality 2:

OTHER DETAILS - BANK DETAILS

Name of Bank/Building Society:

Account Name:

Personal/LTD:

Branch Address:

Account No:

Sort Code:

OTHER DETAILS - 
NEXT OF KIN

Name of Next of Kin*:

Relationship*:

Telephone*:

Address:

QUALIFICATIONS

Nurses

NMC Number:

RCN Number:

Band:

ODPS

HPC Number:

This does not apply to HCA’s

MANDATORY TRAINING

Please tick if you have completed the following training within the last 12 months. Please enclose copies of your training certificates

APPRAISALS

In order to work in the NHS you will need to be appraised annually by a Senior Practitioner of the same discipline, this person will become your “appraiser” Please give details below of the Senior Practitioner who you have made arrangements with to act as your appraiser.

Please give the date of your last appraisal:

Name of Appraiser:

Position and Grade of Appraiser:

REFERENCES

Please supply us with two professional referees. One must be from your present or most recent employer and must be a senior grade to yourself and you must have worked for that person for a period of not less than three months duration.

Reference 1

Reference Name:

Position:

Work Address:

Postcode:

Email:

Telephone:

Fax:

Reference 2

Reference Name:

Position:

Work Address:

Postcode:

Email:

Telephone:

Fax:

DBS DISCLOSURE

Please enclose, with your application a copy of your registration and membership card

Do you have a current DBS Disclosure (formally known as CRB)*:

Is DBS
Clear?*:

Issue Date:

Disclosure Number:

Is this certificate registered with the update service?*

You will be requested to carry out a DBS at registration and annually upon employment

WORK HISTORY

Please ensure you complete this section even if you have a CV. The NHS states that “Employment history should be recorded on an Application Form which is signed” Please ensure that you leave no gaps unaccounted for and it covers 10 years or up to your education.

• Covers 10 years work history or as far back as your education
• Dates to and from are shown in a mm/yy format
• Dates are continual with NO gaps
• Where there have been gaps in work history please state the reason for the gaps
• Lists all relevant training undertaken

Current or Most Recent Employment

From:

To:

Name of Employer:

Job Title:

Grade:

Address:

Main Responsibilities:

Reason for Leaving:

Previous Employment 2

From:

To:

Name of Employer:

Job Title:

Grade:

Address:

Main Responsibilities:

Reason for Leaving:

Previous Employment 3

From:

To:

Name of Employer:

Job Title:

Grade:

Address:

Main Responsibilities:

Reason for Leaving:

Previous Employment 4

From:

To:

Name of Employer:

Job Title:

Grade:

Address:

Main Responsibilities:

Reason for Leaving:

Previous Employment (Continued)

If you have more employment details please list in the
space provided below specifying Job Title, Job Description,
Start - End Dates, Name of Employer and Reason for Leaving.

DECLARATIONS

HEALTH DECLARATIONS

All applicants must complete the enclosed health questionnaire to enable us to establish your fitness for work. We would ask all OVERSEAS candidates to provide a medical statement from their GP or medical department confirming your state of health. Your details will be passed to our Occupational Health Doctors to establish your fitness for work. Please sign the declaration below to allow Dwell-In Social Care/Care Providers Recruitment to release your information for inspection.

I consent to Dwell-In Social Care/Care Providers Recruitment releasing my health and immunisation records for review to Dwell-In Social Care qualified Occupational Health Advisor. I understand that based on this review I may be required to undergo a medical examination to establish my fitness for work.

I confirm that I will immediately inform Dwell-In Social Care /Care Providers Recruitment in confidence if I am HIV Positive, HepB positive or if I have AIDS in accordance with the Department of Health guidelines. I am aware of my obligations regarding MRSA contact and the need for screening. I agree to immediately inform Dwell-In Social Care /Care Providers Recruitment should my general condition of health change.

I will inform Dwell-In Social Care /Care Providers Recruitment immediately if I discover that I am pregnant. I understand that withholding information or giving false answers may lead to dismissal. I also hereby consent to Dwell-In Social Care /Care Providers Recruitment obtaining further information regarding my health from my GP or Occupational Health Department.

PERSONAL DECLARATIONS

I hereby confirm that the information provided on my application is correct and true to the best of my knowledge and that I have not withheld any information that should be taken into account when offering me work.

I understand that providing false or inaccurate information may result in the termination of any placement. I agree that I will make best endeavours to make myself aware of the Health and Safety procedures for each client I am assigned to.

I confirm that I have read and understood the Terms of Engagement and the terms of the declaration and agree to be bound by them.

WORKING TIME REGULATIONS DECLARATIONS

For the purposes of the Working Time Regulations 1998 (as amended) I, consent to work in excess of an average of 48 hours per week, averaged over 17 weeks. I understand that I may withdraw this consent by giving Dwell-In Social Care /Care Providers Recruitment not less than three months’ notice at any time.

OTHER DECLARATIONS

In addition, I also consent to work in excess of the maximum number of hours permitted to work at night under the directive. Please note you are under no obligation to sign either declaration.

CONFIDENTIALITY

I hereby declare that at no time will I divulge to any person, nor use for my own or any other person’s benefit, any confidential information in relation to the Client or the Company (Dwell-In Social Care /Care Providers Recruitment) or in relation to any of their employees, business affairs, transactions or finances which I may acquire during the term of my agreement with the Company (Dwell-In Social Care) under the Terms of Engagement.

REHABILITATION OF OFFENDERS ACT 1974

Because of the nature of the work for which you are applying , Section 4(2), and further Orders made by the Secretary of State under the provision of this section of the Rehabilitation of Offenders Act (1974) (Exceptions) Order 1975 apply. Applicants are therefore required to give information about convictions which for other purposes are “spent” under the provisions of the Act. Any information given will be completely confidential and will be considered only in relation for positions to which the order applies.

1. Do you have any convictions, cautions or bindovers?

If yes please give details below

2. Have you ever had disciplinary action taken against you?

If yes please give details below

3. Are you at present the subject of criminal charges or disciplinary action?

If yes please give details below

4. Do you consent to Dwell-In Social Care requesting a police check and any appropriate references on your behalf?

5. Have you been police checked in the last three years?

If so, by whom?

RIGHT TO WORK IN THE UK

Please complete this form, regardless of your nationality, as it is a legal requirement. If you are an overseas national or require a work permit to work in the UK please include copies of supporting documentation.

Your entitlement for working in the UK is based upon what status:

HEALTH AND SAFETY

Each agency worker has a responsibility at the start of their first shift to become familiar with the Client’s general policies including, without limitation, those relating to Crash Call Procedures, the Hot Spot Mechanism for alerting security staff that an individual is in trouble, Fire Policy and the Violent Episode Policy.

REGISTRATION FORM DECLARATIONS

Please read before signing

I declare that by signing this form I am stating that I am legally entitled or allowed to work in the United Kingdom, with or without necessary permission from the Home Office or any other relevant authority. If I have secured permission to work, I have included copies of all documentation. I also acknowledge that if it is found that I am working without the relevant permission, my employment will be terminated with immediate effect and all details passed to the relevant authorities.

I agree that Dwell-In Social Care /Care Providers Recruitment retains the right to hold this registration form and any other data required to process it and pass onto any authorised third party and the details held within. I also agree to use all reasonable efforts to assist to comply with the Data Protection Act 1998.

In addition, I confirm that that all the information provided is true and accurate and that I have received and agree to Dwell-In Social Care / Care Providers Recruitment terms of engagement and Staff Handbook.

Employee Medical Questionnaire

CONFIDENTIAL

The purpose of the questionnaire is to see whether you have any health problems that could affect your ability to undertake the duties of the post you have been offered or place you at any risk in the workplace. We may recommend adjustments or assistance as a result of this assessment to enable you to do the job. Our aim is to promote and maintain the health of all people at work. Before health clearance is given for employment you may be contacted by the Dwell-In Social Care and may need to be seen by an occupational health advisor or physician.

PERSONAL INFORMATION

Title:

First Name:

Surname:

D.O.B

Home Telephone

Mobile:

Work Telephone:

Email:

Home Address:

GP Address:

MEDICAL HISTORY

Do you have any illness/impairment/disability (physical or psychological) which may affect your work?

Have you ever had any illness/impairment/disability which may have been caused or made worse by your work?

Do you think you may need any adjustments or assistance to help you to do the job

ADDITIONAL INFORMATION (If you have answered yes to any questions above please provide additional information below)

IMMUNISATIONS

Please indicate which off the following Immunisations you have been vaccinated against and include your vaccination reports when returning your registration.

Hep B:TB:Varicella:Measles:Rubella:

All applications who cannot provide a registered DBS or full immunisation record will be required to complete at their own cost.

Dwell-In Social Care Providers will cover the cost of any Mandatory Training updates however cancellations outside of 48 hours and late attendances will be charged to the candidate. Candidates will be required to purchase uniform if required at the cost of £20 this will be deducted from your timesheet once you have started working through us.

TUBERCULOSIS

Have you lived continuously in the UK for the last 5 years?

Have you had a BCG vaccination in relation to Tuberculosis?

If you answered yes please state when

Date:

Do you have any of the following

A cough which has lasted for more than 3 weeks

Unexplained weight loss

Unexplained fever

Have you had tuberculosis (TB) or been in recent contact with open TB

ADDITIONAL INFORMATION (If you have answered yes to any questions above please provide additional information below)

CHICKEN POX OR SHINGLES

Have you ever had chicken pox or shingles?

Date:

IMMUNISATION HISTORY

Have you had any of the following immunisations?

Date:

Triple vaccination as a child (Diptheria / Tetanus /
Whooping cough)

Date:

Polio

Date:

Tetanus

Date:

Hepatitis B (If Yes is ticked please give dates below)

Date:

Course:

PROOF OF IMMUNITY

(Please send the following)

Varicella

You must provide a written statement to confirm that you have had chicken pox or shingles however we strongly advise that you provide serology test result showing varicella immunity.

Tuberculosis

We require an occupational health/GP certificate of a positive scar or a record of a positive skin test result (Do not Self Declare).

Rubella, Measles and Mumps

Certificate of “two” MMR vaccinations or proof of a positive antibody for Rubella Measles and Mumps.

Hepatitis B

You must provide a copy of the most recent pathology report showing titre levels of 100lu/l or above.

EXPOSURE PRONE PROCEDURES

Will your role involve Exposure Prone Procedures

DECLARATION

I declare that the answers to the above questions are true and complete to the best of my knowledge and belief. I also give consent for Dwell-In Social Care to make recommendations to my employer.

Date:

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