Chawa HealthcareRecruitment Agency

44 Torvil DriveWollatonNottin hamNG8

Tel No: 07754117787 EMAIL: jnasho@chawaheathcare.com

Registration Form (Chawa Healthcare)

Section 1 - Personal Details

Address:

Number of

Email Address:

Telephone No. (Daytime):Convenient to telephone you at work: Mobile No:

Do you have a car available:Do You Hold A Current Full Driving Licence:

Area of work:

Next of Kin (To be notified in case of Emergency)

Name:

Address:

Telephone No: Relationship:Section 2 - Experience Questionnaire

To enable us to assess our ex erience could ou lease tick the a ro riate boxes

Dependants:

YES/NO

YES/NOYES/NO

Support Worker(Learning Disabilities)

Care Worker(Care Homes & hospitals)

Care Worker(Residential Live-ins)

Care Worker(Home Care)

Ex erience Tick Experience TickBath/shower/strip wash I-DU

Use of bath aids Simple dressings

Mouth Care inc denture care) Recording res irations

Care of feet (excluding toenails) Weight charts

Dressing/undressing Recording pulse

Bed bath Urine testing

Shaving Obtaining simple specimens

Care of hair Preparation of meals

Care of fingernails Feeding patients

Care of eyes Pressure area care

Care of bladder & bowels Ensuring medication has been taken

Use of bed an/commodes etc Observin chan es in atients/clients & re ortin

Emptying catheter bag Assisted with Occupational therapy including sport & play

Chan in colostom ba Assisted with last offices

Recordin fluid balance Assited with return of atient from o eratin theatre

Movin & handlin atients Answerin tele hone,takin ,recordin & conve in messa e

Use of walkin aids Bed makin

Use of hoist Changing a bed/drawsheet with patient in/on it

Current moving & handling course Shopping/collection of pension

Recording blood pressure Light housework, washing of personal laundry

Recordin tem erature Ex erience with Elderle /FraiI

Care of neonatal Ex erience with Mental Health

Portering Experience with dementia/AIzheimers

Sterile Services Experience with Physical Disabilities

ITU Experience with Learning Difficulties

CCU Experience with Terminally Ill

Any other please state: How Long have you been doing Care Work:

Section 3 - Work Experience and EducationPlease give full details of all your employment history, in reverse date order including the month, starting with your present position & continuing on a separate sheet if necessary, including all work employment abroad and any gaps in your employment which must be explained.

Name and Address of Employer Position DateFrom

Date Grade Reason for Leaving

EDUCATION

PLEASE PROVIDE DETAILS OF YOUR SECONDARY EDUCATION.

Name of School:

Address:

Date of Attendance: From:

Qualifications & Grades Qualifiactions & Grades Qualifications & Grades

PLEASE PROVIDE DETAILS OF YOUR FURTHER EDUCATION/TRAINING.

Name of Establishment:

Address:

Date of Attendance: From:

Qualifications & Grades Qualifiactions & Grades Qualifications & Grades

Additional/Professional Qualifications

Section 4 -Work Preference

Full Time Part Time Weekends Weekdays Nights Occassional Weeks

Date available to commence:Please state the specialised areas in which you feel competant and confident to work in:

First Choice

Second Choice

Third Choice

Section 5 - General Information

Do you speak any other languages as well as English?

Language

Written Spoken

Fluent Good Fair Fluent Good Fair

YES/NO

Section 6 - Declaration of Health

Please answer all uestionsYes No Additional Information to 'Yes' response

Have you ever suffered from any of the following Tuberculosis, AsthmaBronchitis, German Measles, Typhoid, Dysentary, Poliomyetilis,Rheumatic Fever, Jaundice/Hepatitis, Varicella (Chicken Pox/ShingIes)Chest pain, heart condition or high or low blood pressure

Are you Pregnant? (to ensure only that any health needs of pregnanacy are addressed & to avoid any hazard or risk to baby development)

Epilepsy, fits, attacks of giddiness, blackouts, fainting, migraine Depression, mental illness or nervose breakdownDermatitis, skin sensitivity (allergies), psoriasis, or eczema

Diabetes, thyroid or other gland trouble

Drug or Alcohol Have you ever had a problemHow many units of Alcohol do you consume per weekBack or neck injury, back or neck problems or back or neck pain

Gastric problems, ulcers, irratable bowel, kidney or urinary conditions

Have you any reason to believe you may be infected by any communicable disease?Any other current or recent medical condition or treatment which might affect your attendance or performance at work?Please give details of any relevant or ongoing medication you are takinAny illness, condition or surgical operation that prevented you from attending work or your normal duties or activities for more than one week during the past year?Any physical disabilities including defect of sight or hearing?

Have you recently been resident outside of the UK?

Have you ever knowingly been in contact with MRSA or worked in an MRSA environment?Are you aware of the need to understand and be screened for MRSA?

Are ou registered under the Disabled Persons Act?

Are you or have you ever been infected with Tuberculosis?

Do you agree to abide by the Government guidelines on AIDS/HIV infected healthcare workers?(HSC 1998/226 'Guidance on theManagement of AIDS/HIV Infected Health Care Workers and PatientNotification')

RECORD OF IMMUNISATIONS

(Lab report from Occupational Health Department or letter from G.P confirming your immunisation status is required)Types of Immunisation yes No Date/ResuIts

Tetanus

Diptheria Schick Test

Rubella (German Measles)

Pliomeyelitis

Hepatitis B

Anitibodies. Date of Result

Tuberculosis BCG

Chest x-Ray

Varicella

Section 7 - Rehabilitation of Offenders Act 1974 and Criminal RecordsBy virtue of the Rehabilitation of Offenders Act 1974 (Exemptions) (Amendments) Order 1986, the provisions of section 4.2 of the Rehabilitation of Offenders Act 1974 do not apply to any employment which is concerned with the provisiion of health services and which is of such a kind to enable the holder to have access to persons in receipt of such services in the course of his/her normal duties. You should therefore list all offences on a separate sheet even if you believe them to be 'spent' or 'out of date' for some reason or another.

Have you ever been convicted of a criminal offence?

Have you ever been cautioned or issued with a formal warning for any criminal offense?

(If you have answered 'yes' please attach details including dates on a separate sheet.)

CRB, The Criminal Records Bureau, is the executive agency of the Home Office responsible for conducting checks on criminal records. We are a registered body for receipt of CRB disclosure information. NHS Trusts and private sector hospitals and nursing homes insist on agencies making informed recruitment decisions which require criminal record checks to be made on all staff. It is a condition of proceeding with your application that you apply for a CRB disclosure. The Disclosure will be compared with the information given above in Section 7 and any inconsistencies could invalidate your application or lead to cancellation of your registration with us.

Signed Date

Section 8 - References for Current or Last Employer DetailsPlease give the names of two professional people of a senoir/grade position to you, including your present or most recent employer whom we may approach for a nursing reference (not relatives or friends). They must be able to provide a credible comment on your ability to undertake the duties of the post applied for. We do verify references, therefore mobile telephone numbers are not acceptable.

Home addresses of referees are not acceptable.

YES/NO

YES/NO

Can we contact your referees before the interview?

Reference 1 Please give Referee Details

Name:

How long has this person known you:

In what capacity does this person know

Reference 2

Name:

How long has this person known you:

In what capacity does this person know you?

Section 9 - Passoort and Work PermitsPeople with an automatic right to work are citizens of the UK., European Union and E.E.A. and certain Commonwealth citizens.

Do you need permission to work in the U.K.? If Yes please provide details below:

Please note that an immigration check will be carried out if found to be necessary. Please circle:I Agree I I DisagreeSignature Date:

Section 10 - Working Time DirectivesThe European Union has laid down guidelines for all workers, governing the length of the maximum working week that it is saef to work. The current limit is 48 hours per week. Because you are under no obligation to accept work offered, you will never be compelled to work more than 48 hours per week but you may choose to do so.

Please would you sign below to confirm that you have read and understood this information, including your preference by ticking the most appropriate box.

YES/NO

you.

Employer Manager/Supervisor Work Colleague

Employer Manaaer/Supervisor Work Colleague

YES/NO

I DO NOT wish to work more than 48 hours per week

I DO wish to work more than 48 hours per week

Signed

Section 1 1 - Data protection Act 1998 and InspectionPart of the Care Standards Commission inspection and other local accredited bodies processes involve checking that we maintain certain information on staff e.g. address, qualifications, a mechanism for checking health and fitness including records of immunisation, record of training, annual leave and sickness, two written references and Rehabiliation of Offenders information. Inspectors will need to know that the Company is maintaining the information as we should; please be assured that they will not wish to read personal information such as supervision notes.We would therefore be grateful if you would complete and sign the declaration box below. If you have any concerns about this or want to discuss it further, please contact your branch manager.

I consent I do not consent (circle as appropriate) to staff from the local registration and Inspection Unit have access to information held on my personal file for inspection purposes.

Print Name:

Signed:

Section 12 - DeclarationThe information that I have given in this registration form is, to the best of my knowledge, complete and accurate in all respects. I understand that knowingly giving false information will disqualify me from registration with the agency. I also agree to keep Chawa Healthcare Limited advised of any changes to any of the information supplied.Print Name: Qualification:

Date

Signed:

Please bring with you to your interview the following documentation with your completed registration form.NB. Please note that if you send photocopies, original documents must be brought with you to the interview so that consultants can sign photocopies as ('original seen').

Documents required Check List Tick box if enclosed

2 passport photographs

Proof of Indentify - birth, marriage cert. or new style driving license photocard, passport (must be original documents)Copy of work permit, visa stamp and entry stamp in your passport for oversea applicants

Valid lab report or letter from doctor regarding your immunisation status

Relevant certificates of training - NVQ, Moving & Handling, First Aid etc

Proof of national Insurance Number - Recent payslip, P45, P60

Completed CRB form & relevant original documentation + E65.00 for the cost of your CRB check

How did you hear about Chawa Healthcare Limited?