PRIMECARE STAFFING SOLUTIONS LIMIT CANDIDATE REGISTRATION FORM Please complete all sections of this form in BLOCK CAPITAL using black ink
PERSONAL DETAILS Surname: Mr./Mrs./Miss/MS (Delete as appropriate) Previous Surname(s)
Forename:
Former name:
Maiden name:
Address:
Home number: Mobile number: Email address:
Post Code: Date of Birth:
Other contact details: Place of Birth:
Marital Status:
Nationality: Are you eligible to work in the UK?
Yes………………….
No……………….
Passport number………………………………
Place of issue …………………………….
Expiry date………………………………………. Do you have a work permit? Yes/ No ………………….
Work permit number…………………….
National Insurance Number ………………….
Post Applied: MNC PIN (if applicable) ……………………………….
Expiry Date: ………………………….
What part of the register are you on (if applicable) ……………………………………………………
Please indicate which organization you are a member of and your membership number (if applicable) Union………………………………………….. Do you hold a current driving license?
Membership number………………………………. Yes………….. No……………
Do you have the use of a regular car?
Yes…………….
No…………….
EMERGENCR NEXT OF KIN DETAILS
Relationship to you: Name: Address: Post Code: Phone number: Mobile number: Email address:
EMPLOMENT HISTORY Please include all your previous employment in the last ten years. Present Employer Name and Address
Position Held:
Full Time: Part Time: Days/Nights: Post Code: Date Employment Commenced:
Date Employment Terminated:
Reasons for leaving: Previous Employer Name and Address:
Position Held:
Full Time: Part Time:
Days/Nights: Post Code: Date Employment Commenced:
Date Employment Terminated:
Please include all your previous employment in the last ten years. Present Employer Name and Address
Position Held:
Full Time: Part Time: Days/Nights: Post Code: Date Employment Commenced:
Date Employment Terminated:
Reasons for leaving:
Previous Employer Name and Address:
Position Held:
Full Time: Part Time: Please include all your previous employment in the last ten years. Present Employer Name and Address
Days/Nights: Position Held:
Full Time: Part Time: Days/Nights: Post Code: Date Employment Commenced:
Date Employment Terminated:
Reasons for leaving: Previous Employer Name and Address:
Position Held:
Full Time: Part Time: Days/Nights: Post Code: Date Employment Terminated:
Date Employment Commenced:
Reasons for leaving:
EDUCATION AND TRAINING Name/Address of School/College/ University
Place of study
Date From
Date To
Level & Subject
Result/ Grade
DETAILS OF RELEVANT COURSES ATTENDED Course Title
Where held
Dates and Duration
REFEREES Please supply names, address and contact telephone numbers of two professional referees. One of which must be your present employer 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 six months duration.
Name: Position: Address: Post Code: Telephone Number: Email address: Relationship:
Name: Position: Address: Post Code: Telephone number: Email address: Relationship:
Referees may be approached before any interview without contacting you. Please state here if this may cause a problem. Reference may be disclosed to a Third party, namely client organisations, for the Purpose of audit and security verification. If you have any concerns in relation to this please contact us at Primecare Staffing Solutions.
REHABILITATION OF OFFENDERS ACT 1974 Because of the nature of the work for which you are applying, this post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act 1974 Exemption Order 1975. Applicants are therefore, not entitled to withhold information about convictions which for other purposes are “ spent” under the provisions of the Act, and in the event of employment, any failure to disclose such convictions could result in disciplinary action on behalf of Primecare Staffing Solutions. Have you ever been convicted of a criminal offence, or been made bound over, cautioned or are you currently the subject of any police investigation/actions, which might lead to a conviction, an order binding you or caution in the United Kingdom or any other Country? Yes/No* You may give details below or in a separate envelope and return it with your completed form. Any information will be confidential and will only be considered in relation to an application for a position which the Order applies.
If yes, please give details: Date ………………………………… Nature of incident……………………………….
In which Authority/Country did this take place? Have you received a police caution? Yes………….
No…………
Have you ever been dismissed from employment, office or other position by reason of misconduct? If yes provide details below continue on a separate sheet if necessary) Yes………………….
No……………….
Have you ever been dismissed from employment? If yes, please provide details (continue on a separate sheet if necessary) Yes………………….
No…………
Have you ever been or are you currently subject to any fitness to proceeding by an appropriate licensing or regulated body in the United Kingdom or other Country (qualified nurses only) Yes……………….
No…………….
a) Details of the proceedings……………………………………………………………………………………………………. b) Date of proceeding………………………………………………………………………………………………………………. c) Country, name and address of licensing or regulatory body…………………………………………………. Have you ever been disqualified from practice? Yes………………….
No………………….
If yes, please provide details below (continue on a separate sheet if necessary)
Applicants who are found to have criminal record will not necessary be excluded from registration with Primecare however each case will be considered individually and discussed at interview. After an initial interview to discuss the criminal history then Primecare reserve the right to make a final decision based on the outcome of this interview. I confirm that the above information given in this registration form is true to the best of my knowledge Name………………………………. Signature……………………………………
Date……………………………….
DECLARATION OF HEALTH This questionnaire will be used by the Occupational Health and Safety Department to advice on your health suitability to undertake the duties of the post for which you have applied. Please answer the following questions by ticking Yes/No. If your answer to any questions is YES then give details in space provided, please continue on separate sheet and give details. It is your responsibility to inform Primecare immediately if any of the following information changes.
HEALTH & FITNESS QUESTION What is your approximate weight & height?
Weight:
Height:
Please answer all questions to the best of your knowledge Question Have you ever taken a drug overdose or attempted suicide?
Back problems/injuries/pain which may affect your work History of chest pain, heart condition or high blood pressure Have you at any time suffered from epilepsy, blackouts and fainting. Do you think you may need any adjustment or assistance to help you to do the job? Have you been deemed medically unfit to work? Have you ever had major operations or illness which may affect your work? Poor eye sight (do you wear glasses), migraine Have you ever had any problems with you joints, including pain, swelling or stiffness? Dermatitis, skin allergies, psoriasis, eczema Hearing problems which may affect your work Are you currently receiving treatment from your G.P. regarding a problem?
Yes
No
If “Yes� Please give details (if applicable)
Have you at any time suffered from paralysis, numbness, blurred or double vision, known or suspected multiple sclerosis or other nervous system disorder? Have you any psychological illness which has a substantial effect on ability to carry out work? Diabetes or thyroid problems?
Back problems/injuries/pain or neck pain?
Have you ever suffered from heart problems?
Have you, at any time suffered from asthma, bronchitis, shortness of breath or chest trouble? Have you, at any time suffered from rheumatic or arthritic conditions? Have you ever suffered from liver disorder?
Have you ever at any time suffered from alcohol or drug abuse? Have you had any illness linked Methicillin Resistant Staphylococcus Aureus (MRSA)
Have you ever been denied a driving license on health grounds? Have you ever taken time off work due to accident at work? Have you in the last 12 months had any signs or symptoms for which you have not sought advice? If yes, please enclose details in a separate confidential envelope.
Have you in the last 12 months had any signs or symptoms for which you have not sought advice? If yes, please enclose details in a separate confidential envelope.
Clinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE 2006) Have you lived continuously in the UK for the last 5 years Unexplained fever
Unexplained weight loss
A cough which has lasted for more than 3 weeks
Have you had tuberculosis (TB) or been in recent contact with open TB
Have you had a BCG vaccination in relation to TB? Have you ever had shingles?
Any illness or medical condition not specified above
Any other health factors which affect fitness at work
DECLARATION I declare that the information contained in this form or attached to it is correct to the best of my knowledge. I understand if it is subsequently discovered that any statement is false or misleading Primecare Staffing Solutions has the right to dismiss me from my temporary employment. I understand that appointment will be subject to a satisfactory medical report and I give consent for my health and immunization records to be released to Primecare`s Occupational Health Consultant to establish my fitness to work. Please sign below to allow Primecare Staffing Solutions to release your medical details for inspection and determine your fitness to work Name of Applicant:
Applicants signature:
Job Role:
Date:
If your answer to any of the above question is YES, then provide extra details in the space provided
PRIMECARE STAFFING SOLUTIONS LIMITED
HEALTH & FITNESS QUESTIONAIRE WE REQUIRE EVIDENCE OF HEALTH VACCINATIONS FOR ALL TEMPORARY EMPLOYEES Please take this form to your Health Centre and have it completed by either a Nurse or your family Doctor. It is a requirement for all our registered members working in the health-care field to undergo this form of medical screening because of the nature of the work involved. Please have this form stamped by the Health-Centre, signed by the appropriate medical officer and dated accordingly. If you have not had all of the necessary vaccinations, please make an appointment with your Health-Centre to do so and then have the form completed as soon as possible before returning it to the office. Alternatively, you can request a copy of your immunization record from your G.P. and submit it with your application form.
Name:
Role:
Date of birth:
Signature:
Please answer all questions to the best of your knowledge Have you had inoculations for the following: Poliomyelitis
Yes
No
If “Yes� Please give dates below
Rubella (German measles and Mumps)
Please note that we require Certificate of two MMR vaccinations or proof of a positive antibody for Rubella Measles and Mumps
Triple vaccination as a child (Diphtheria / Tetanus / Whooping cough)
Date
Tetanus
Date
BCG (TB)
Please note that we will require evidence in form of a Certificate from your G.P/Health Centre or a positive skin test results
Hepatitis B
You must provide a copy of the most recent pathology report showing titre levels of 100lu/I or above
Please provide details below if you have ticked Yes Course
1
2
3
Boosters
1
2
3
This medical questionnaire will be invalid unless stamped by the Health-Centre or signed by the appropriate medical officer
Thank you for your assistance
EQUALITY AND DIVERSITY Primecare is committed to a policy of equality of opportunity for everyone, regardless of age, Race, Gender, Sexual orientation, religion, marital status or disability. In order to us to monitor the effectiveness of our procedures, please complete the information below.
PLEASE TICK ALL THE BOX THAT APPLY TO YOU
GENDER
GENDER IDENTITY
Please tick one of the following:
Do you identify as transgender/transsexual?
Male
Yes
Female
No
Prefer not to say SEXUAL ORIENTATION: I would describe my
Prefer not to say ETHNIC ORIGIN: I would describe my Ethnic origin as: (Please tick one only)
sexual orientation as: Bi-sexual
Asian or Asian British
Gay Woman/Lesbian
Black or Black British
Heterosexual/ Straight
Chinese
Gay Man
Mixed
Prefer not to say
White
Other, please provide details:
Other
AGE 16 - 20
21 - 30
31 - 40
41 - 50
51 - 60
61 - 70
71 and over
Prefer not to say
DISABILITY Do you have a disability? Yes
No
MARRIED STATUS Married
Single
Other
Prefer not to say
PRIMECARE STAFFING SOLUTIONS LIMITED CHECK LIST
You will be required to bring original copies of the following documents with you to Primecare interview 1 Current passport 2 For Non – European Union Citizen, your passport must contain the following status:
Right to Work in the UK documents Indefinite leave Exceptional Leave to Remain 3 Detailed CV with all gaps accounted for 4 3x Passport Size Photograph 5 3x proof of address, dated within 3 months 6 National Insurance Number 7 Your most recent DBS 8 Proof of RCN/Unison Membership – Qualified Nurses 9 Driving Licence both parts (If applicable) 10 Proof of insurance cover including Business Use(Drivers only) 11 NMC Pin Card and Statement of Entry(Qualified)
12 Vaccination record/ Path lab reports
WORKNG TIME REGULATION The European Union laid down guidelines for all workers, governing the length of maximum working week which it is safe to work. The current limit is 48 hours per week. Because you are under no obligation to accept work offered, you will never be compelled to work more than 48 hours but you may choose to do so. The Temporary worker may end this agreement by giving one weeks notice. Please would you sign below to confirm that you have read and understood this information, indicating your preference by ticking the most appropriate box. I have read this information regarding Working Time Regulation and I understand that I do not have to work for more than 48 hours per week.
I DO NOT wish to work more than 48 hours per week (please tick the appropriate box)
I DO WISH to work more than 48 hours per week (please tick the appropriate box)
Name of Applicant:
Signature of Applicant:
Job Role
Date:
PRIMECARE STAFFING SOLUTIONS LIMITED
TAX STATUS Please complete the section that applies to you. COMPANY NAME: COMPANY VAT NUMBER: COMPANY REGISTRATION NAME: We will require original copies of the following documentation if you require to be paid through a United Kingdom Limited Company: Certificate of Incorporation VAT Certificate: Limited Company Bank Statement Original copies to be submitted upon processing your application.
PAYE: NI NUMBER:
P45 P46
Name:
Date:
Grade:
Signature:
PRIMECARE STAFFING SOLUTIONS LIMITED
Please tick the areas that describe your work experience.
Placements
Hospitals Brain Injury Units
Nursing Homes Residential Settings Private Hospitals Learning Disability Facilities Challenging Units Mental Health Units Secure Facilities Complex Care Units Specialist Care Facilities Specialist Tracheostomy Facilities
Less than twelve months
Less than two years
Over two years
PRIMECARE STAFFING SOLUTIONS LIMITED
DECLARATION OF TRAINING NAME:
DATE:
JOB ROLE:
SIGNATURE:
Please tick if you have completed the following training within the last 12 months
COURSE
DATE ATTENDED
DATE ATTENDED
CHALLENGING BEHAVIOUR BASIC LIFE SUPPORT INFECTION CONTROL DATA PROTECTION
RIDDOR FOOD HYGIENE RECORD KEEPING CONFIDENTIALITY
FIRE SAFETY MOVING & HANDLING HEALTH & SAFETY FIRST AID CALDICOTT PROTOCOLS
EQUALITY & DIVERSITY CHILD PROTECTION ADULT SAFEGUARDING MENTAL CAPACITY ACT CONFLICT RESOLUTION
INTERMEDIATE LIFE SUPPORT
DEPRIVATION OF LIBERTY SAFEGUARDS
Please add any other relevant courses below that you have attended: COURSE
DATE ATTENDED
You will be required to produce original copies of your training certificates
DATE ATTENDED