Personal Details Title First Name Known As Middle Name Last Name Maiden Name Gender MaleFemale Date of Birth Nationality Marital Status SingleMarriedWidowedSeparatedDivorced Date of Marriage Address Town/City County Postcode Date moved to this address: Email Address Home Phone Mobile Number How Did You Hear Of Us: Work Status Self Employed or PAYE National Insurance No Passport No Passport Expiry Date Driving License YesNo Car Owner YesNo Is it ok to contact you at work YesNo Contact Availability: We are open 24 hours a day Please specify times at which you are not to be contacted CAREER HISTORY Please confirm your career history details for the last 10 years. Please list using most recent first. Employer Address Phone Number Job Title Date started Date Left Full or Part Time Grade Dept/Ward Reason for leaving: Employer Address Phone Number Job Title Date started Date Left Full or Part Time Grade Dept/Ward Reason for leaving: Employer Address Phone Number Job Title Date started Date Left Full or Part Time Grade Dept/Ward Reason for leaving: Employer Address Phone Number Job Title Date started Date Left Full or Part Time Grade Dept/Ward Reason for leaving: QUALIFICATIONS & TRAINING Date Qualified NMC Pin Number Expiry Date Where did you train?: Please give details of training undertaken and qualifications obtained: You should supply any certificates such as ENB or Diplomas etc -please note that we require manual handling/CPR certifications that have been updated in the last 12 months. BAND (NEW TERMINOLOGY) 1-8 2345678 TYPE OF WORKER RNLDRHVENRSCNRFNRMRGNRMNRHENMENGENMHRNMH RECORDABLE QUALIFICATIONS RN1-1st Level General Nursing YesNo RN2-2nd Level General Nursing (England & Wales) YesNo RN3-1st Level Mental Illness YesNo RN4-2nd Level Mental Illness (England & Wales) YesNo RN5-1st Level Learning Disabilities YesNo RN6-2nd Level Learning Disabilities (England & Wales) YesNo RN7-2nd Level Nurses (Scotland & Wales) YesNo RNB-1st Level Sick children YesNo RN9-Fever Nurse YesNo RN12-1st Level Adult Learning YesNo RN13-1st Level Mental Nursing YesNo RN14-1st Level Learning Disability YesNo RN15-1st Level Children YesNo MRM-Midwifery YesNo HRHV-Health Visiting YesNo SPAN-Special Practitioner Adult Nursing YesNo SPMH-Special Practitioner Mental Health Nursing YesNo SPCN-Special Practitioner Children’s Nursing YesNo SPLD-Special Practitioner Learning Disabilities YesNo SPGP-Special Practitioner General Practice YesNo SPCM-Special Practitioner Community Mental Health YesNo SCLD-Special Practitioner Community Learning Disabilities YesNo SPCC-Special Practitioner Community Children’s Nursing YesNo SPOH-Special Practitioner Occupational Health YesNo SPSN-Special Practitioner School Nursing YesNo SPDN-Home/District Nursing with integrated nurse prescribing YesNo V100-Independent Nurse Prescribing V100 YesNo V200-Extended Nurse Prescribing V200 YesNo V300-Extended/Supplementary Prescribing YesNo TTTT-Lecturer/Practice Educator YesNo MIDWIFES ONLY Practising YesNo Intention to practice completed (you cannot work without this as a Midwife) YesNo Expiry Date Mentor Name Address MEDICAL HISTORY Have you ever suffered from any of the following Heart/Circulatory Illness/Hypertension YesNo Diabetes YesNo Asthma/Hay fever YesNo Bronchitis/Pneumonia/Pleurisy YesNo Epilepsy YesNo Headaches/Migraine YesNo Tuberculosis YesNo Psychiatric Illness/Anxiety/Depression YesNo Dermatitis/Psoriasis/Eczema YesNo Back Problems YesNo Recurrent infections YesNo Hepatitis/Jaundice YesNo Are you taking any prescription drugs? YesNo If you have answered yes to any of the above questions please give details on separate paper attached to the back of the application form. Have you ever been vaccinated, immunized or tested for/against any of the Following? Varicella YesNo Tuberculosis including BCG YesNo Heaf, Mantoux or Tine YesNo Rubella (German Measles) YesNo Poliomyelitis YesNo Hepatitis B YesNo Hepatitis YesNo HIV YesNo Tetanus YesNo Typhoid YesNo Any Other Please State Name Of GP Telephone Address Post Code REFERENCES Essential Care Service LTD requires 2 professional references. It is essential that you have had professional dealings with both of your references within the last 2 years. Name of Referee Place of Work Position Work Address Country Post Code Telephone Number Fax Email Mobile Number Name of Referee Place of Work Position Work Address Country Post Code Telephone Number Fax Email Mobile Number OPT-OUT AGREEMENT DEFINITIONS In this Agreement the following definitions apply:- “Assignment” means the period during which the Temporary Worker is engaged in service to a Client. “Client” means the person, firm or corporate body that has engaged the services of the Temporary Worker. “Employment Business” means Essential Care Service LTD. “Temporary Worker” means a Qualified Nurse, care assistant or other Temporary Worker. “Working Week” means an average of 48 hours each week as calculated over any 17 weeks period. THE AGREEMENT The Working Time Regulations of 1998 state that a Temporary Worker shall not work on an Assignment with a client in excess of the Working Week unless they agree in writing that this limit should not apply. The Temporary worker, by signing the declaration below, agrees that the Working Week shall not apply to their Assignments. The Temporary Worker can end this Agreement at anytime by giving the Employment Business 14 days notice in writing. After the 14 day notice period has expired the Working Week shall apply immediately. It should be noted, that any notice ending this Agreement does not mean that a Temporary Worker has ended an Assignment with a Client. These laws are governed by English Law and are subject to the jurisdiction of the English Courts. THE DECLARATION I have read and fully understand the above OPT OUT AGREEMENT. I hereby consent that the Working Week limit shall not apply to my Assignments. I understand that I can end this Agreement by giving the Employment Business 14 days notice in writing. Print Name Date TEMPORARY WORKER DETAILS Name of Temporary Worker Registration Number Home Phone Mobile Number Address NEXT OF KIN DETAILS Full Name Relationship to Temporary Worker Home Phone Mobile Number Address ANY OTHER OR SPECIAL NOTES DISCLOSURES Rehabilitation of Offenders Act Due to the nature of the work for which you are applying, this post is exempt from the provisions of section 4.2 of the rehabilitations of offender’s 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. Failure to disclose such convictions could result in dismissal or disciplinary action. Any information given will be completely confidential and will be considered only in elation to an application for positions in which the order applies, and should be entered at the end of any particulars you give in support of your application. A copy of our written policies is available upon request. A criminal record will not necessary be a bar to obtaining a position. Have you ever been convicted of a criminal offence? YesNo Do you have any spent or unspent criminal convictions or cautions? YesNo With an enhanced disclosure, under section 4.2 of the rehabilitation of offenders act 1974 (exemption order), all previous cautions, warnings and convictions will always be detailed regardless of how long ago Any conviction, caution, reprimand will require a written statement of each and every event and how it does not affect your suitability for the role you are applying for. Have you supplied additional information with this application for any spent/ unspent convictions, cautions or reprimands? YesNo Have you ever been involved in court proceedings? YesNo Please give any additional information which you think may be relevant in support of your application on a separate page. ADDITIONAL INFORMATION/CHECKLIST On receipt of a satisfactorily completed application form, Go-Tec Nursing will provide/send the following:- Assist you with your CRB application for an enhanced CRB. The charge for this will be £56.00 (cheques to be made payable to Essential Care Service Ltd). Please bring this Application Form to your interview along with the following ORIGINAL documentation for us to view and take copies. Without this information we cannot progress with your application. NMC pin card and your statement of entry Ok Valid Passport Ok Valid Visa/Work Permit/Certificate of British Nationality (if applicable) Ok National Insurance Number Card Ok 2 additional forms/proof of Identity & Address - (Driving Licence or copy bills etc.) Ok Full Immunisation record : Hep B Ok MMR 1 Ok MMR 2 Ok Varicella Ok Hep B (IVS) HBSAg Ok Hep C (IVS) Ok HIV (IVS) Ok Training Certificates including Moving and Handling (practical) Ok BLS / ILS / ALS Ok Complaints Handling Ok Conflict Resolution (inc management of violence & aggression) Ok Fire Safety Ok Information Governance (including Caldicott Protocols and Data Protection) Ok Health & Safety at Work (including COSHH and RIDDOR) Ok Infection Control (including MRSA and C-Diff) Ok Lone Worker Training (if applicable) Ok Food Hygiene (if applicable) Ok IV Certificate (if applicable) Ok Full CV Ok Addresses covering the past 6 years and dates of residency Ok 2 Passport size photos Ok We will also need details of your Bank / Building Society account for our Payroll Department We try to make our registration process as swift and painless as possible but we are sure that you understand that owing to the sensitive nature of your profession that our checks have to be thorough. 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