PERSONAL DETAILS

Title*:

—Please choose an option—MrMrsMissMsDrProfRevOther

Other Title:

Surname*:

Maiden Name:

First Name(s)*:

Other Name(s):

Marital Status*:

—Please choose an option—SingleMarriedDivorcedWidowed

Gender*:

—Please choose an option—MaleFemale

Date of Birth(DD/MM/YYYY)*:

National Insurance No:

You can upload a passport photo of yourself below which we will use to create your Staff ID.

Current Address*:

Post Code*:

Email Address*:

Mobile Phone*:

Home Phone:

Do you have a driving licence?*

—Please choose an option—YesNo

Do you have use of a car?*

—Please choose an option—YesNo

JOB DETAILS

Position Sought:

Speciality 1:

Speciality 2:

Current Place of Work:

Work Sought:

—Please choose an option—Full TimePart TimeDaysNights

OTHER DETAILS - BANK DETAILS

Name of Bank/Building Society:

Account Name:

Personal/LTD:

—Please choose an option—PersonalLTD

Branch Address:

Account No:

Sort Code:

OTHER DETAILS - NEXT OF KIN

Name of Next of Kin*:

Relationship*:

Telephone*:

Email:

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

Moving and Handling:Basic Life Support:Intermediate Life Support:Advanced Life Support:Complaints Handling:Handling Violence and Aggression:Fire Safety:COSHH:RIDDOR:Caldicott Protocols:Data Protection:Infection Control:Lone Worker Training:Food Hygiene (where required to handle food):Personal Safety (Mental Health and Learning Disabilities):Resuscitation of the Newborn (Midwifery):Interpretation of Cardiotocograph Traces (Midwifery):

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:

Address:

Phone Number:

Post Code:

E-mail:

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)*:

YesNo

Is DBS
Clear?*:

YesNo

Issue Date:

Disclosure Number:

Is this certificate registered with the update service?*

YesNo

Attach Current DBS:

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.

You can upload your Current CV below.

Attach CV:

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 PRM Consultants to release your information for inspection.

I consent to PRM Consultants releasing my health and immunisation records for review to PRM Consultants 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 PRM Consultants 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 PRM Consultants should my general condition of health change.

I will inform PRM Consultants 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 PRM Consultants obtaining further information regarding my health from my GP or Occupational Health Department.

Please tick the box to acknowledge that you agree with the statements above.*

YesNo

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.

Please tick the box to acknowledge that you agree with the statements above.*

YesNo

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 PRM Consultants not less than three months’ notice at any time.

Please tick the box to acknowledge that you agree with the statements above.*

YesNo

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.

Please tick the box to acknowledge that you agree with the statements above.*

YesNo

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 (PRM Consultants) 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 (PRM Consultants) under the Terms of Engagement.

Please tick the box to acknowledge that you agree with the statements above.*

YesNo

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

YesNo

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

If yes please give details below

YesNo

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

If yes please give details below

YesNo

4. Do you consent to PRM Consultants requesting a police check and any appropriate references on your behalf?

YesNo

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

If so, by whom?

YesNo

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:

EU Citizen:Spouse of an EU Citizen:Work Permit:Permit Free Visa:Right of Abode in the UK:Admitted to UK as Doctor Prior to 1985:

Passport Copy:

Visa Copy:

Home Office Letter:

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.

Please tick the box to acknowledge that you agree with the statements above.*

YesNo

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 PRM Consultants 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 PRM Consultants terms of engagement and Staff Handbook.

*Please tick the box to acknowledge that you agree with the statements above.

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 PRM Consultants and may need to be seen by an occupational health advisor or physician.

PERSONAL INFORMATION

Title:

—Please choose an option—MrMrsMissMsDrProfRevOther

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?

YesNo

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

YesNo

Are you having, or waiting for treatment (including medication) or investigations at present?

YesNo

If your answer is yes, please provide further details of the condition, treatment and dates.

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

YesNo

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.

EPP and Non EPP*

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.

PRM Consultants 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.

Please tick the box to acknowledge that you agree with the statements above.*

YesNo

TUBERCULOSIS

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

YesNo

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If you answered no above, please list all of the countries that you have lived in over the last 5 years

Have you had a BCG vaccination in relation to Tuberculosis?

YesNo

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

YesNo

Unexplained weight loss

YesNo

Unexplained fever

YesNo

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

YesNo

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?

YesNo

Date:

IMMUNISATION HISTORY

Have you had any of the following immunisations?

YesNo

Date:

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

YesNo

Date:

Polio

YesNo

Date:

Tetanus

YesNo

Date:

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

YesNo

Date:

Course:

1:

2:

3:

Booster:

1:

2:

3:

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

YesNo

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 PRM Consultants to make recommendations to my employer.

Full Name:

Date:

If you are have finished completing the application form, please click "Submit Registration Form" below. If you would like to make any changes please select "Back" below.