Application for Employment

CONTACT DETAILS - Step 1 of 6

Personal Details 1

Title

Name *

First

Middle

Last

Date of Birth *

Gender *

Male
Female
Other

Gender if selected other*

NMC Pin/HCPC Number

If Applicable

National Insurance No: *

Contact Details

Mobile Number *

Home Phone

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Personal Details 2

Nationality *

Specify nationality

Race / Ethnicity *

Specify your ethnicity

Do you have the right to work in the UK? *

Emmanuel Healthcare is required to check that all applicants are legally entitled to work in the UK. In line with UKBA guidance on the prevention of illegal working we will need to verify and take a copy of your original ID documentation as evidence of your right to work in the UK if you are to be engaged by Standby Healthcare for temporary work. UK candidates are asked to provide a passport or full birth certificate with a P45/P60 or National Insurance card. Overseas and EEA candidates are asked to provide a passport, national identity card, travel document or official Home Office letter certificate endorse to show that the holder is allowed to stay in the UK and is allowed to do the type of work in question.

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EXPERIENCE

POSITION APPLYING FOR *

Healthcare Assistant
Support Worker
Registered General Nurse
Registered Mental Health Nurse

Years of experience *

Are you a driver with access to a vehicle? *

Have you completed mandatory training within the last year?* *

Mandatory Training

Moving & Handling
Basic life support
Health and Safety
Fire Safety
First Aid
Infection Control
Food Safety & Nutrition
Medication Administration
Safeguarding Vulnerable Adults & Children

Please tick if you have completed the following training within the last 12 months

Training Dates:

Are you available to work? *

Up to 24 Hours per week
Above 24 Hours per week

Which agencies are you working with at the moment? *

Employment History

Employer

Position

Duties

Date From - To

Qualifications

Please give details of your education and qualifications obtained. This includes any qualification which you are studying for now.

Name of awarding body *

Examinations passed, qualifications, skills gained *

Year *

Grade *

DECLARATION OF CRIMINAL RECORD

Have you ever been convicted by the courts or cautioned, reprimanded or given a final warning by police?* *

Are you aware of any police enquiries undertaken following allegations made against you, which may have a bearing on your suitability for this work? *

Do you have a disability as outlined in the Disability Discrimination Act 1995 and 2005? *

Please state the type of disability you have:

In relation to any disability, do you have any particular requirements?

Do you have a current DBS Disclosure? *

MEDICAL HISTORY

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.

Any impairment that may affect your ability to work or perform duties safely? *

Eyesight problems not corrected by glasses/contact lenses? *

Difficulties in walking, bending, lifting or any other movement? *

Difficulties in hearing, not correctable by hearing aid? *

Muscular-skeletal problems including arthritis or back problems? *

Significant discomfort when using a keyboard? *

Psychological conditions including stress at work? *

Fits/blackouts or epilepsy? *

Suffered any accidents that significantly affected you physically or mentally? *

Treated for tuberculosis? *

Have you ever had chicken pox or shingles? *

Gastrointestinal problems including hepatitis? *

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

Cardio-vascular problems including hypertension or a blood disorder? *

Dysentery, typhoid, paratyphoid, food poisoning, salmonella, severe gastroenteritis or diarrhoea? *

If you are under any medication (please give name of drug and dosage) *

Are you waiting for any medical treatment investigation or tests at the moment? *

Have you ever suffered from any serious/ frequent headaches or episodes of migraine? *

Do you think you have had any illness that was made worse by your work? *

Have you ever had any drug or alcohol problems? *

Have ever had any concern/fear that you may have a health problem? *

Coughing/vomiting/diarrhoea/rash in the last 12 months? Have you had a cough for more than 3 months? Coughing/vomiting/diarrhoea/rash blood or any unexplained loss of weight or fever? *

If you have answered ‘yes’ to any of the above, please give details:

REFERENCES

All candidates – please give details of two employment referees whom we may contact about your suitability for the post. One of these should be your most recent employer. Referees must not be related to you. If you are a school/college leaver, please give the name and address of a head teacher and also the manager of your most recent work experience placement – if applicable.

Referee 1

Name of Referee 1 *

First

Last

Job Title *

Organisation *

Referee Email Address

Referee Contact No. *

Referee 2

Name of Referee 2 *

First

Last

Job Title *

Organisation *

Referee Email Address

Referee Contact No. *

Please state where you saw this post advertised:

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 our appointed Occupational Health Services provider to make recommendations to my employer.

Right To Work

It is a legal requirement that before any offer of work can be made all candidates provide the company with confirmation of their eligibility to work in the UK by providing one of the original documents detailed below.

A passport which describes the holder as a British Citizen or as having a right of abode in the United Kingdom or a passport or other travel document to show that the holder has IDENFINITE LEAVE TO REMAIN in the United Kingdom and is not precluded from taking the work in question.
A passport or identity card issued by a State which is party to the European Union and EEA Agreement and which describes the holder as a national or a state which is a arty to that agreement.
A letter issued by the Home Office or the Department of Education and Employment indicating that the person named in the letter has permission to take agency work in question or a biometric residence permit.

Registration form Declaration

I declare that all information given in this registration form is to the best of my knowledge complete and accurate in all respects and that I am eligible to work in the UK.

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Name *

First

Last

Date / Time

Name