Post on 15-Jul-2020
www.yournurse.co.uk
Your Nurse
17th Floor110 Bishopsgate
London EC2N 4AY
0207 961 08610787 292 23900208 440 0687
Head Office
info@yournurse.co.ukE
Your Nurse - APPLICATION FORMPlease fill in each box as required. If you are unable to provide the information, please leave blank.
Please fill each box in as required. If you are unable to provide the information, please leave blank.
PERSONAL INFORMATION
Title First Name
Surname
Address Line 1
Address Line 2
Address Line 3
Town County
Post code
Home Tel
Mobile Tel
Marital Status
Maiden Name
Date of Birth (DD/MM/YYYY)
Nationality
National Insurance (NI) Number
BANK DETAILS
Bank or building society
Name on account (if LTD, give limited company name)
Sort code Account number
“I confirm that these are my correct bank details and I acknowledge that my payments will be made directly into this account from Your Nurse.”
NAME: DATE:
NEXT OF KIN
Name of next of kin
Relationship
Address
Post code
Telephone
TRAVEL & WORK PREFERENCES
Do you hold a current driving license? YES NO
Do you own a car? YES NO
How far are you willing to travel?
Are you willing to relocate for work? (accommodation can be provided)
YES NO
Do you hold a permanent post, or are you an agency worker?
YES NO
Which agencies are you currently registered with?
Are you looking for part-time, or full-time agency work?
What shifts are you looking for? (days, nights, weekends)
Have you ever worked in a prison before? YES NO
Please provide details of your employment history during the past 3 years, most recent first. We also need referencing information for each employer.
WORK HISTORY & REFERENCES
Employer
Date From (month and year)
Date To (month and year)
Title of post
Reason for leaving
Reference name
Reference position
Reference Tel
Reference E-mail
Are you paid through a Limited Company? YES NO
If Yes, Please provide the company registration number
Reference 2 name
Reference 2 position
Reference 2 Tel
Reference 2 E-mail
Employer
Date From (month and year)
Date To (month and year)
Title of post
Reason for leaving
Reference name
Reference position
Reference Tel
Reference E-mail
Date From (month and year)
Date To (month and year)
Title of post
Reason for leaving
REFERENCES
Please provide us with any other professionals who would be able to give you a reference. These can be other nurses that you have worked with, as long as they have known you professionally. Please list as many as possible, so that we have a greater chance of contacting them quickly.
Reference Tel
Position (e.g. staff nurse)
Reference Tel
Position (e.g. staff nurse)
Reference Tel
Position (e.g. staff nurse)
Reference Tel
Position (e.g. staff nurse)
Reference Tel
Position (e.g. staff nurse)
Please tell us how much clinical experience you have in the following areas (please only fill what is relevant to your job role):
CLINICAL EXPERIENCE
RGN’s Less than 6 months 6-12 months 12 months or more
A&E
Cardiac
Chemotherapy
Community
Elderly
HDU
Intensive Care Unit
Medical Assessment Unit (MAU)
Medical/Surgical
Neo-Natal
Nursing Homes
Orthopaedic
Paediatric
PICU
Practice Nursing
Prisons
Recovery
Other
RMN’s Less than 6 months 6-12 months 12 months or more
Acute
Forensic
Psychiatric Intensive Care
Community/CPN
Prison
Other
RSCN’s Less than 6 months 6-12 months 12 months or more
A&E Paediatric
General Paeds
NICU
PICU
SCBU
Other
Theatre Less than 6 months 6-12 months 12 months or more
Anaesthetics
Assisting (ASP qualified)
Paediatrics
Recovery
Scrub
Scrub – Major Orthopaedic
Scrub – Cardiac
Scrub – Neuro
Other
Midwifery & Health Visiting Less than 6 months 6-12 months 12 months or more
Ante/Post Natal
Health Visiting
Labour ward
TRAINING & QUALIFICATIONS
What qualification do you hold?
Which establishment did you obtain this qualification?
Which year did you obtain this qualification?
What is your job title? (RGN, RMN, Dual Qualified, Midwife, etc)
NMC/HPC pin
NMC Expiry
Please supply dates of your most recent training in:
TRAINING COURSE TRAINING PROVIDERDATE COMPLETED (DD/MM/YYYY)
Manual Handling
Basic Life Support
Health and Safety
Infection Control
Fire Safety
Safeguarding Vulnerable Adults & Children Level 2
Safeguarding Vulnerable Adults & Children Level 3
Lone Worker
Information Governance and Data Protection
Complaints Handling
Conflict Management
Food Hygiene
Please give details of any other training you have which you feel may be relevant
REHABILITATION OF OFFENDERS ACT:
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 dismissal or disciplinary action.
Any information given will be completely confidential and will be considered only in relation 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 necessarily be a bar to obtaining a position.
Please give additional information which you think may be relevant in support of your application:
Have you ever been convicted of a criminal offence? (NB. The Rehabilitation of Offenders Act 1974)
YES NO
If Yes, please give details
Do you have any previous convictions, whether or not they are “spent” within the Act, including any cautions, reprimands, final warnings, bind-overs or any convictions from overseas?
YES NO
If Yes, please give details
Do you hold a Disclosure and Barring Service (DBS) or Criminal Record Bureau (CRB) check?
YES NO
If Yes, please give the reference number and date
Have you ever been issued with a caution of suspension from the NMC or other professional body?
YES NO
If yes, please give details
OCCUPATIONAL HEALTH
When did you last have an occupational health check?
Which department provided the check?
Please give details that may be relevant to your last occupational health check
General Practitioner or Occupational Health Department
Address
Telephone
OCC HEALTH ASSESSMENT
As part of our policy to ensure that all employees are in good health and able to carry out their duties, we are required to ask questions about your occupational health.
Are you in good health? YES NO
How much time have you lost from work due to illness in the last five years? YES NO
Have you ever been treated in hospital for serious illness or surgery? YES NO
Have you been treated in hospital during the last 12 months? YES NO
Do you have any physical disabilities that could affect your ability to carry out your assignment? YES NO
Are you a registered disabled person? YES NO
Have you ever left, been retired or denied a job on health grounds? YES NO
Have you ever been denied a driving license on health grounds? YES NO
Do you need to wear glasses or contact lenses? YES NO
Do you have any difficulty with your eyesight which is not corrected by glasses or contact lenses? YES NO
Have you any problems working with Visual Display Units? YES NO
Do you get discomfort or pain in the chest or shortness of breath on exercise? YES NO
Do you have any difficulty in moving rapidly over short distances? YES NO
Would you have difficulty looking over either shoulder? YES NO
Have you ever had any problems with your joints including pain, swelling or stiffness? YES NO
Have you any disability related to your physical or mental health? YES NO
Have you ever suffered from any mental illness, psychological or psychiatric problems? YES NO
Are you taking any medication that makes you dizzy or drowsy? YES NO
Are you receiving medicines, pills or tablets from a doctor or on prescription? YES NO
Do you have a medical condition affected by changing sleeping patterns or affecting day time sleep?
YES NO
Have you any problems working in confined spaces/using lifts? YES NO
Do you have any difficulty hearing normal conversation? YES NO
Have you suffered from any alcohol or drug related illness or had an alcohol or drug problem? YES NO
Are you having or awaiting any treatment at the moment? YES NO
What is the date of your last chest x-ray? YES NO
Do you smoke? YES NO
Please enter your height
Please enter your dress size (female) or chest size (male) for your uniform
Have you ever suffered from any of the following?
Hepatitis/Jaundice? YES NO
Recurrent Infections e.g. sore throats/ear infections/Eye infections YES NO
Back injury or back problems YES NO
Dermatitis/Skin sensitivity/Psoriasis/Eczema/Allergies YES NO
Psychiatric Illness/Anxiety/Depression YES NO
Headaches/Migraine YES NO
Epilepsy/Fainting/Blackouts/Fits/Sudden Collapse YES NO
Tuberculosis YES NO
Bronchitis/Pneumonia/Pleurisy YES NO
Asthma/Hay Fever YES NO
High or Low Blood Pressure YES NO
Heart Problems/Circulatory Illness/Hypertension YES NO
Have you ever been tested or inoculated for any of the following?
IMMUNISATIONS Date tested/inoculated
Hepatitis A
Hepatitis B
Hepatitis C
HIV
Heaf, Mantoux, or Tine
Tuberculosis including BCG
Measles
Mumps
Rubella
Varicella
Candidate declaration:
“I declare the information I have provided in this form is true and complete to the best of my knowledge and belief. I understand that my occupational health provider may be contracted with my consent for information which may be relevant to this application. I have read and understood the Terms of Engagement booklet given to me. I agree to comply with the current Health & Safety Act. I understand that my appointment is subject to satisfactory reference checks and subject to DBS or CRB disclosure check. I authorise Your Nurse to make enquiries as they deem necessary to support my application. I agree to respect the confidentiality of patients and clients.”
NAME:
DATE:
If you are unable to provide us with a current DBS or CRB check, please fill out the following information (some of the information may be duplicated, please fill in full as we keep this form separately from the application form):
DBS CHECK
Title
Gender
Forename
Surname
Date of Birth
Job Title
Have you ever used another forename?
If yes, state it here
Used this name from (date)
Used this name until (date)
Born in the UK?
Birth Place (Town/City)
Birth Place (County/District)
Nationality
Do you have any unspent criminal convictions?
Please provide 5 years’ worth of address history. Addresses must be filled accurately and in full, and the dates must cover the entire 5 year period without gaps.
ADDRESS 1
At this address from/to (date)
Country
Postcode
Address
Town/City
County
ADDRESS 2
At this address from/to (date)
Country
Postcode
Address
Town/City
County
ADDRESS 3
At this address from/to (date)
Country
Postcode
Address
Town/City
County
ADDRESS 4
At this address from/to (date)
Country
Postcode
Address
Town/City
County
ADDRESS 5
At this address from/to (date)
Country
Postcode
Address
Town/City
County
Thank you so much for completing the application form. We know it takes time, and we really appreciate it. Please send a copy back to your consultant, or e-mail it to Info@yournurse.co.uk and we will pass it over to our registration team.
We should get back to you in 1-2 days at most to give you feedback on your application. If you have any questions in the meantime, please don’t hesitate to give us a call on 0207 961 0861.
Thanks, and we hope to see you soon!
Your Nurse team