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Personal Details

Education Qualifications

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Employment History

Please print details of all your employment for a period of at least the last 10 years, to include all nursing agency memberships, in reverse date order; starting with your present or last position. Please include reasons for gaps.

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General information

  • Do you hold a valid and current British Driver’s Licence?
    Yes If Yes, what type? (E.g. Provisional, Full, LGV, PCV)
  • Do you have any endorsements?
    If Yes, please give details

Preference regarding work

Please specify which types of work you would prefer. You should tick all appropriate boxes. The service we give depends on accurate, up to date information. Please keep us informed of all developments, in your career and work preferences.

  • Positions part time full time
  • Type of work NHS private hospitals nursing home industry
  • Clients in their own home Other, please specify
  • live in days nights visits
  • Do you have any other work commitments? Yes No

Additional Information

Give details of any additional information which you would like to include in support of your application. Such information, for example, may include skills and/or achievements which you think may be of interest, and/or a summary of why you believe that you have the qualities we are looking for. Please provide details of any relatives employed by the Agency and their relationship to you.

HEALTH DECLARATION

Occupational Health Assessment YES NO
Are you in good health?
Are you in good health?
How much time have you lost from work due to illness in the last five years? Please provide details
Have you ever been treated in hospital for serious illness or surgery? Please give dates
Have you been treated in hospital during the last 12 months?
Do you have any physical disabilities that could affect your ability to carry out your assignment?
Have you ever left, been retired or denied a job on health grounds?
Have you ever been denied a driving licence on health grounds?
Are you a registered disabled person?
Have you any disability related to your physical or mental health?
Have you ever suffered from any mental illness, psychological or psychiatric problems?
Do you get discomfort or pain in the chest or shortness of breath on exercise?
Have you ever had any problems with your joints, including pain, swelling or stiffness?
Do you have any difficulty in moving rapidly over short distances?
Would you have difficulty looking over either shoulder?
Do you need to wear glasses or contact lenses?
Do you have any difficulty with your eyesight which is not corrected by glasses or contact lenses?
Have you any problems working with Visual Display Units?
Do you have any difficulty in moving rapidly over short distances?
Have you any problems working in confined spaces/using lifts?
Do you have any difficulty hearing normal conversation?
Are you taking any medication that makes you dizzy or drowsy?
Do you have a medical condition affected by changing sleeping patterns or affecting day time sleep?
Do you have any difficulty in moving rapidly over short distances?
Have you suffered from any alcohol or drug related illness or had an alcohol or drug problem?rapidly over short distances?
Are you having or awaiting any treatment at the moment?
Do you have any difficulty in moving rapidly over short distances?
What is the date of your last chest x-ray?
Are you receiving Medicines, Pills or Tablets from a doctor or on prescription?
Have you ever suffered from any of the following?
Heart Problems/Circulatory Illness/Hypertension
Do you have any difficulty in moving rapidly over short distances?
High or Low Blood Pressure
Do you have any difficulty in moving rapidly over short distances?
Diabetes
Asthma/Hay fever
Bronchitis/Pneumonia/Pleurisy
Tuberculosis
Headaches/Migraine
Psychiatric Illness/Anxiety/Depression
Dermatitis/Skin Sensitivity/Psoriasis/Eczema/Allergies
Back Injury/Back Problems/Back Pains
Recurrent Infections e.g. Sore Throats/Ear Infections/Eye Infections
Hepatitis/Jaundice
Have you ever been Vaccinated, Immunized or Tested for / against any of the following? YES NO
Tuberculosis incl BCG, Heaf, Mantoux or Tine
Poliomyelitis
Hepatitis B Anitbodies Date and ResulT
HIV
Tetanus
Typhoid
Tetanus

Confidentiality declaration

As a general rule, no-one need answer questions about spent convictions. However this general rule does not apply to specified professions, employments and occupations. By virtue of the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Orders, the exemption rule does not apply to: a) any employment or other work which is concerned with the provision of health services and which is of such a kind as to enable the holder of that employment or the person engaged in that work to have access to persons in receipt of such services in the course of his normal duties, or b) any employment or other work which is concerned with the provision of care services to vulnerable adults and which is of such a kind as to enable the holder of that employment or the person engaged in that work to have access to vulnerable adults in receipt of such services in the course of his normal duties One or both of the above apply to work with the Agency, and covers all occupations. You are therefore requested to provide details of all convictions, including those which would otherwise be considered as “spent”. All employment applications will be considered carefully, and the disclosure of a conviction does not imply that this employment application will be rejected.

Records will be checked via the Criminal Records Bureau procedures

I have no convictions I have convictions (see Note below )

Note (To protect the confidentiality of this information, please detail convictions on a separate sheet of paper. Place it in a sealed envelope with your name clearly visible, and headed “Private and Confidential – Criminal Convictions” and attach this to your completed Application Form)

Criminal Records – Disclosure Certificate

The Criminal Records Bureau (CRB/DBS) have issued a Code of Practice regarding Disclosure Information, a copy of which is available upon request. A Disclosure Certificate (standard or enhanced) will be requested from the CRB/DBS which will detail all convictions, including those which would otherwise be “spent”, as well as details of cautions, reprimands or final warnings. You will be advised of the type of certificate being requested and asked to give your approval to this application. The Disclosure Certificate will only be requested in the event that you are successful in your application for employment.

Asylum and Immigration Act 1996

Under Section 8 of the Asylum and Immigration Act 1996 it is a criminal offence to employ a person aged 16 or over who is subject to immigration control unless: That person has current and valid permission to be in the United Kingdom and that permission does not prevent him or her from taking the job in question; or The person comes into a category specified by the Home Secretary where such employment is allowed Any employment offered will be subject to the successful applicant producing appropriate evidence that the Asylum and Immigration Act is not being contravened.

Are you eligible to work in the UK? Yes
No
Please tick as appropriate

Personal Declaration

I declare that to the best of my knowledge the above information, and that submitted in any accompanying documents, is correct, and

  • I give permission for any enquiries that need to be made to confirm such matters as qualifications. Experience and dates of employment and for the release by other people or organisations of such information as may be necessary for that purpose.
  • I give permission for the processing of the personal data contained in this form for employment purposes
  • I understand that any false or misleading information could result in my dismissal.
Signed:
Date: