FULL NAME:

QUALIFICATIONS:

CONTACT NUMBER:

EMAIL ADDRESS:

PAYROLL NUMBER:

OFFICE USE ONLY

BRANCH:

TICKBOX

OFFICE USE ONLY

CRB Paid

All ID Docs Received

3 Refs Given

Tunic Paid

JL Signature

Date

tel: 01244404080email: info@janelewis.co.ukweb: www.janelewis.co.ukpa

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TWO PASSPORT SIZED PHOTOGRAPHS

NAME AND ADDRESSES OF THREE PROFESSIONAL REFEREES

YOUR NATIONAL INSURANCE NUMBER AND BANK DETAILS

PROOF OF IMMUNISATIONS

FOREIGN NATIONALS MUST BRING PROOF OF THEIR ENTITLEMENT TO WORK

PAYMENT FOR CRIMINAL RECORD CHECK

AN UP TO DATE COPY OF YOUR CV

ORIGINAL CERTIFICATE SHOWING ANY RELEVANT QUALIFICATIONS

PROOF OF YOUR PROFESSIONAL REGISTRATION IF APPLICABLE

YOUR PASSPORT, BIRTH CERTIFICATE, PHOTO DRIVING LICENCE AND TWO ITEMS SHOWING YOUR CURRENT ADDRESS

E.G. A RECENT UTILITY BILL, COUNCIL TAX BILL AND / OR BANK / CREDIT CARD STATEMENT

A COPY OF YOUR LAST CRIMINAL RECORD CHECK (Only If Received Within The Last 12 Months)

1

For Permanent Recruitment, Please Refer To Your Cover Letter For Interview Requirements

PERSONAL DETAILS

TITLE: MR MRS MISS MS

SURNAME:

FORENAMES:

MAIDEN NAME:

FORMER NAME:

DATE OF BIRTH:

HOME ADDRESS:

POSTCODE:

TELEPHONE NUMBER:

OTHER CONTACT NUMBER:

EMAIL ADDRESS:

PROFESSION:

QUALIFICATION:

N.I. NUMBER:

LANGUAGES SPOKEN / SIGN LANGUAGE:

UK DRIVING LICENCE YES NO USE OF CAR: YES NO

DETAILS OF ANY ENDORSEMENTS:

DO YOU REQUIRE ANY SPECIAL ADJUSTMENTS FOR INTERVIEW? (If yes please specify): YES NO

2

3PERSONAL DETAILS AND PROOF OF ENTITLEMENT TO WORK

DO YOU HAVE A VISA? YES NO

PASSPORT NUMBER:

PASSPORT NATIONALITY:

PASSPORT PLACE OF ISSUE:

PASSPORT DATE OF ISSUE:

PASSPORT EXPIRY DATE:

KNOWN RESTRICTIONS:

UNDER THE REQUIREMENTS OF THE ASYLUM AND IMMIGRATION ACT, ARE YOU ELIGIBLE TO WORK IN THE UK? YES NO

TO BE COMPLETED BY NON BRITISH AND NON EC NATIONALS ONLY

DATE OF ENTRY INTO THE UK:

DO YOU HAVE A CURRENT VISA? YES NO IF YES, WHAT TYPE AND EXPIRY DATE:

FROM TO NAME OF UNIVERSITY / COLLEGE QUALIFICATIONS OBTAINED

WHERE DID YOU HEAR ABOUT US? RECRUITMENT EVENT LOCAL PRESS NURSING TIMES RCN BULLETIN NURSING STANDARD

INTERNET OTHER PLEASE SPECIFY

QUALIFIED NURSES ONLY

UKCC PIN NUMBER:

EXPIRY DATE:

PROFESSIONAL DETAILS

PLEASE TICK ALL THE NURSING SPECIALITIES OF WHICH YOU HAVE SIGNIFICANT EXPERIENCE

MEMBERSHIP OF PROFESSIONAL BODIES

ARE YOU A MEMBER OF A PROFESSIONAL BODY? (If yes please specify)

REGISTERED BODY REGISTRATION NUMBER EXPIRY DATE

DECLARATION

Each registered nurse shall act, at all times in such a manner as to justify public trust and confidence, to uphold and enhance the

good standing and reputation of the profession, to serve the interest of society and above all safeguard the interests of individual patients and clients.

SIGNED: DATE:

4

A & E

AIDS / HIV

ANAESTHETICS

BURNS & PLASTICS

CARDIOLOGY

CARDIO THORACIC

CCU

COMMUNITY

DERMATOLOGY

ELDERLY CARE

ENT

GYNAECOLOGY

HAEMATOLOGY

ICU

INFECTIOUS DISEASES

ITU

LIVER UNIT

MARIE CURIE

MEDICAL

MENTAL HEALTH

MIDWIFERY

NEUROLOGY

NNU

OCCUPATIONAL HEALTH

ODA

ONCOLOGY

OPTHALMICS

ORTHOPAEDIC

OUTPATIENTS

PAEDIATRICS

PHLEBOTOMY

PSYCHIATRY

RADIOTHERAPY

RECOVERY

RENAL ANALYSIS

SCBU

SURGICAL

PALLIATIVE CARE

THEATRE

TROPICAL

VENEPUNCTURE

X-RAY

LEARNING DISABILITY

CHALLENGING BEHAVIOUR

HOME CARE

DETAILS OF EMPLOYMENT

Please include all previous employment over the last 10 years. Please account for any time taken out from employment in the space provided on the opposite page. If you are registered with another agency please give details below.

FROM TO NAME AND ADDRESS OF EMPLOYER (Most Current First)

JOB DESCRIPTION (please include reason for leaving)

GRADE & SALARY

5

GAPS IN EMPLOYMENT

Please indicate any gaps in employment or time taken out for training below:

6

DETAILS OF EMPLOYMENT

Please include all previous employment over the last 10 years. Please account for any time taken out from employment in the space provided on the opposite page. If you are registered with another agency please give details below.

FROM TO NAME AND ADDRESS OF EMPLOYER

JOB DESCRIPTION (please include reason for leaving)

GRADE & SALARY

SUPPORTING STATEMENT

Please explain how you see your experience, skills and knowledge meeting the requirements of the type of work you are applying for.

7

CURRENT VACCINATION STATUS

Record of immunity full written all can be obtained by blood test from gp / occupational health department.

CONFIRMATION OF CURRENT VACCINATION STATUS DATE OF ORIGINAL DATE OF BOOSTER

BCG SCAR IF SCAR IS NOT PRESENT EVIDENCE OF HEAF TEST

HEPATITIS B (Titre level > 100)

TITRE LEVEL

TESTED NEGATIVE TO HEPATITIS C

RUBELLA

VARICELLA

CHICKEN POX

MEASLES

MUMPS

TETANUS

POLIO

ANY ADDITIONAL VACCINATIONS

ADDITIONAL NOTES

VACCINATION STATUS DECLARATION

I UNDERSTAND THAT IS IT MY RESPONSIBILITY TO ENSURE ALL OF MY VACCINATIONS ARE KEPT UP TO DATE AND APPROPRIATE FOR ANY PLACEMENTS I MAY UNDERTAKE.

CANDIDATE SIGNATURE: DATE:

EVIDENCE OF VACCINATIONS SEEN, CHECKED AND COPY FILED BY JANE LEWIS OCCUPATIONAL HEALTH REPRESENTATIVE.

SIGNED ON BEHALF OF JANE LEWIS: DATE

PLEASE STATE YOUR DOCTORS NAME, ADDRESS AND TELEPHONE NUMBER:

DOCTORS NAME

ADDRESS

TELEPHONE NUMBER

8

REFERENCES

Please supply names, company addresses and telephone numbers of professional referees and state their job title. You must include your most recent employer.

1

NAME

TITLE / QUAL

ADDRESS

POSTCODE

TELEPHONE NUMBER

EMAIL ADDRESS

2

NAME

TITLE / QUAL

ADDRESS

POSTCODE

TELEPHONE NUMBER

EMAIL ADDRESS

3

NAME

TITLE / QUAL

ADDRESS

POSTCODE

TELEPHONE NUMBER

EMAIL ADDRESS

ADDITIONAL REFEREE DETAILS:

9

10

HAVE YOU RECEIVED A POLICE CAUTION? YES NO

IF YES PLEASE GIVE DETAILS:

DATE:

NATURE OF INCIDENT:

HAVE YOU EVER BEEN CONVICTED OF A CRIMINAL OFFENCE? YES NO

IF YES PLEASE GIVE DETAILS:

DATE:

NATURE OF CONVICTION:

Please note that care standards regulations require Jane Lewis Health and Social Care to complete criminal record checks on all applicants prior to placement.

DATA PROTECTIONS ACTS 1984 AND 1998

I am aware that personal data including where relevant, sensitive personal data relating to myself or from any other sources, will be retained by Jane Lewis Health and Social Care indefinitely for purposes of providing me with temporary work and / or training. I acknowledge that this may require my personal data to be forwarded to third parties or other departments within Jane Lewis Health and Social Care.

DECLARATION

I declare that all the information I have given is correct. I understand that if I knowingly make false statements I could be subject to police investigation and prosecution. I have read, understood and agreed to the conditions of service as laid down in Jane Lewis Health and Social Cares terms and conditions for temporary workers which I have been given at interview. I understand that my registration is subject to three satisfactory references and a satisfactory result after checking with the criminal records bureau. I undertake to inform you immediately I am engaged through your induction, including the offer of permanent employment following temporary assignment.

I hereby confirm that my personal details may be held and disclosed by Jane Lewis Health and Social Care in the manner contained herein.

APPLICANT SIGNATURE DATE

REHABILITATION OF OFFENDERS ACT 1974

Any work undertaken through Jane Lewis Health & Social Care is exempt from the Rehabilitation of Offenders Act 1974. This means that you are not entitled to withhold information about convictions, prosecutions pending, cautions, or bindovers which for other purposes may have expired under the Act. Your failure to declare any such information may result in instant dismissal from the agency register. All applicants that are offered assignments will be subject to an enhanced criminal record check by the Criminal Records Bureau (CRB) before commencing assignments. This will include cautions, reprimands or final warnings as well as convictions. The Protection of Children Act (PoCA) and Protection of Vulnerable Adults (PoVA) lists will also be checked for all applicants. The outcome of these checks may or may not affect your application. For further details see the Company Policy on Offering Assignments to Applicants with a Criminal Record.

48 HOUR OPT OUT AGREEMENT

1 DEFINITIONS

1.1 In this agreement the following definitions apply: the company means Jane Lewis Health And Social Care.

Worker means

1. 2 References to the singular include the plural and references to the masculine include the feminine and vice versa.

1. 3 The headings contained in this agreement are for convenience only and do not affect their interpretation.

2 RESTRICTIONS

2.1 The working time regulations 1998 provide that the worker shall not work in excess of the working week unless he / she agrees in writing that this limit should not apply.

3 CONSENT

3.1 The Worker hereby agrees that the working week limit shall not apply.

4 WITHDRAWAL OF CONSENT

4.1 The Worker may end this agreement by giving 14 days notice in writing.

4.2 For the avoidance of doubt, any notice bringing this agreement to an end shall not be construed as notice of termination by the Worker.

4.3 Upon the expiry of the notice period set out in clause 4.1 The working week limit shall apply with immediate effect.

5 THE LAW

5.1 These terms are governed by the law of England and Wales and are subject to the jurisdiction of the courts of England and Wales.

SIGNED DATE

11

INTERVIEW NOTES OFFICE USE ONLY

DRIVER NON DRIVER WILLING TO TRAVEL

PREVIOUS RELEVANT EXPERIENCE

LOOKING FOR

HAVE YOU OR ARE YOU CURRENTLY SUBJECT TO ANY DISCIPLINARIES (If yes please specify)

PERM RECRUITMENT ONLY

SALARY EXPECTATIONS

HAVE YOU ANY HOLIDAYS BOOKED?

WHAT IS YOUR NOTICE PERIOD?

12

INTERVIEW NOTES OFFICE USE ONLY

13

NEXT OF KIN

INFORMATION DOCUMENTS STATING THE NEXT OF KIN DETAILS, AS STIPULATED BY CQC AND CARE STANDARDS INSPECTORATE FOR WALES.

FOR USE IN THE UNFORTUNATE EVENT OR ACCIDENT OR INJURY TO AID POLICE OR EMERGENCY SERVICES.(Please note 2 x next of kin required)

1.

NAME OF NEXT OF KIN

RELATIONSHIP

CONTACT NUMBER

ADDRESS

2.

NAME OF NEXT OF KIN

RELATIONSHIP

CONTACT NUMBER

ADDRESS

SIGNATURE DATE

PAY DETAILS

YOU WILL BE PAID WEEKLY BY BACS AUTOMATIC TRANSFER DIRECTLY INTO YOUR BANK ACCOUNT AND RECEIVE A DETAILED PAYSLIP ON A WEEKLY BASIS.

BANK / BUILDING SOCIETY SORT CODE:

ACCOUNT NUMBER:

BUILDING SOCIETY REFERENCE NUMBER:

ACCOUNT HOLDER NAME / S:

N.I. NUMBER:

BANK / BUILDING SOCIETY NAME:

BANK / BUILDING SOCIETY ADDRESS:

14

Check Box6: Check Box7: Check Box8: Check Box9: YesCheck Box10: YesCheck Box11: Check Box12: YesCheck Box13: Check Box14: Check Box15: YesCheck Box16: Check Box17: Check Box18: Check Box19: Check Box5: Check Box20: Check Box21: Yes22: 23: 1: Yes2: 3: Yes4: 5: 7: 8: Yes9: Yes10: 11: 12: 13: 14: 15: 16: 17: Yes18: 19: 20: 21: 24: 25: Yes26: 27: Yes28: 29: Yes30: 31: 32: 33: 34: 35: Yes36: 37: 38: Yes39: 40: Yes41: 42: Yes43: 44: Yes45: 46: 47: Yes48: 49: Yes50: 51: Yes52: 53: Yes54: 55: Yes56: 57: Yes58: Yes59: Yes60: Yes61: 62: 63: 64: Yes65: 66: 67: 68: 69: 70: 71: 72: 73: 74: 75: 76: 78: 79: Yes80: 81: Yes6: Yes82: 83: Text23: Text24: Text25: Text26: Text27: Text28: Text29: Text30: lawrenceText31: sharronText32: edwardsText33: collinsText34: 22/04/1967Text35: flat 2, llwyn, gloddaeth avenue, llandudno, conwy.Text36: ll332ahText37: 07917331270Text38: 01492330093Text39: sharronlawrence1@hotmail.co.ukText40: support worker/ HCAText41: Text42: nm896473bText43: english/welshText44: noneText45: Text46: Text47: Text48: Text49: 507751027Text50: britishText51: united kingdomText52: 13/02/2012Text53: 13/02/2022Text54: noneText55: Text56: Text57: Text58: Text59: Text61: Text62: Text64: Text65: Text66: Text67: Text68: Text69: Text70: Text71: Text72: Text73: Text74: Text75: Text76: Text77: Text78: Text79: Text80: Text81: Text82: Text83: Text84: Text85: Text86: Text87: Text88: Text90: 2012Text91: 2013Text92: Kim Mason ManagerAdvantage Health Care GrpSuite 22, Durham Tees Valley Business Centre, Orde Way. Stockton on Tees.Text93: hca on all units of general hospital, complex care specialist area of spinal injury,bp,bm,sats,dip test,bowel regime,trachy care,respiratory care,suctionText94: 10/14per hourText96: 2012Text97: 2013Text98: Samantha Chapman HRThe Priory Hospital, Middleton St George, Darlington, County Durham.Text99: Bank Hca, on all mental health male and female units, challenging behavior, personality disorder, forensic unit, drug and alcohol rehab.Relocated to walesText100: 9/12per hourText101: 2008Text102: 20012Text103: Pin Point Care Agency,93-105 St James Boulevard,Newcastle upon TyneText104: Hca in learning disabilities Centre,chaperoning,activities, maths, English, swimming, gym, personal care. Working in elderly nursing homesText105: 8per hourText106: 2006Text107: 2008Text108: Haven Care Ground Floor, lyster court, the millfields, PlymouthText109: Hca working in clients homes on 1 on 1 basis, with challenging behaviour,learning disabilities, schizophrenia.relocation to plymouthText110: 16995per annText111: 2004Text112: 2008Text113: Nhs Dental practiceapplebywestmoorlandCumbriaText114: Head Receptionist, filing, faxing,e-mailing,answering calls, making appointments, scanning,diary management,minutes meeting, cash managementText115: 15000per annumText116: 2004Text117: 2008Text118: Esport Country ClubHumberstonGrimsbyClethorpesText119: Receptionist, cash handling, making appointment, memberships, filing, faxing,ledger management,e-mailing, dealing with enquiries, Text120: 14995per annText121: Hair Company35 Verwood closeStockton on TeesText122: manager of hairdressing business.relocationText123: 16000per annText124: cut above the rest Hair salon llandudno JunctionText125: apprentice hairdresser, moving onto senior stylistText126: 9000per annText127: Text128: Text129: Text130: Text131: Text132: Text133: Text134: I have great experience in all areas of the care sector, working in general hospitals, mental health hospitals and learning disabilities centers and also working with spinal injury patients on a 1 on 1 basis. my key skills are that I am able to deliver high standards of 1 on 1 care to meet the individual needs, I have an understanding of and able to demonstrate commitment to equal opportunities and diversity, able to deal with aggressive people in a calm and professional manner, Mva trained in control and restraint. I possess excellent written and verbal communication skills. Experience in the implementation of care plans and risk assessments. Helping patients to develop and maintain social self help. occupational and personal skills. Patient money and confidentiality management. Awareness of patients right as well as their cultural beliefs. The ability to record patients observations accurately and report all issues. Encouraging patients to achieve highest possible quality of life. Responding well to emergency situations. Being responsive and flexible to change. Experienced in complex care packages for spinal and respiratory patients, trained in passive movements and physio to upper and lower limbs, use of nebuliser, sutioning, yanker,tracheostomy care, fully trained in bowel regime, nippy 3 machines,omitting medications via peg feed or orally and preparing medications. Specialing in hospitals, working in rehab and palliative care units. Ensuring patients dignity and independence is always respected. Providing emotional support to patients and the team I work with. Safeguarding patients property and belongings, building relationships and getting to know patients needs and interests.Text135: dr zahid cohenText136: westshore surgery,9 bryiau road, llandudno, conwy , ll30 2blText137: 01492 872915Text138: kim masonText139: office managerText140: advantage health care group, suite 22, durham tees valley business centre, orde way.stockton on tees. teesideText141: ts19 0gaText142: 01642 606805Text143: kimmason@advantagehealthcare.co.ukText144: Samantha ChapmanText145: H R departmentText146: The Priory HospitalMiddleton st GeorgeDarlingtonCounty DurhamText147: DL2 1 TSText148: 01325 333883Text149: Text150: Jenny JacksonText151: Head TeacherText152: 14 Hazel sladeEaglescliffeStockton on TeesText153: TS16 9HSText154: 07969246610Text155: jenniajackson@hotmail.co.ukText156: Text157: Text158: Text159: Text160: Text161: Text162: Text163: Text164: Text165: HCA work in mental health, general hospitals, complex care packages, learning disabilities centers, 1 to 1 work with supported living. Spinal injury/ respiratory .Text166: NoneText167: No less than 7 per hourText168: noneText169: noneText170: Text171: 77/56/02Text172: 15724660Text173: Text174: Mrs Sharron LawrenceText175: NM896473BText176: LLoyds TSBText177: 5-6 King Street, PenrithCumbria CA11 7APText178: Eric LawrenceText179: HusbandText180: 07527176528Text181: flat 2, LLwyn, Gloddaeth Avenue, Llandudno, conwy.Text182: Text183: Text184: Text185: Text186: 1994Text187: 2004Text188: 1984Text189: 1994Text190: Text191: Text192: Text193: Text194: 1980Text195: Text196: Text197: 1981Text198: Text199: Text200: Text201: Text202: Text203: Text204: Text205: Text206: Text207: Text208: Text209: Text210: Text211: Text212: Text213: Text214: Text215: