Application Forms - Clinical | Healthline Healthcare LTD | Westmidlands Recruitment Nursing Agency

Application Forms - Clinical

PERSONAL DETAILS

Title *

Surname or Family Name *

Name *

Nationality *

Full Address *

Postcode *

National Insurance Number *

Mobile Number *

Home Number

Email *

Date of Birth *

Gender *

Band

Do you own a car? *

Yes

Professional Misconduct * Have there been any proceedings of medical negligence or professional misconduct against you and have you ever been suspended?

Yes

If “YES” please supply details:

NEXT OF KIN

Full Name *

Contact Number *

Relationship *

Address *

YOUR NURSING DETAILS

Registration Number NMC/HCPC

Registration Expiry Date NMC/HCPC

RIGHT TO WORK

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

Yes

What is your current right to work status? *

If you have a visa or permit, please provide the expiry date:

Do you have a share code for your digital right-to-work check? (For non-UK citizens)

REHABILITATION OF OFFENDERS ACT

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 applies. 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.

Do you have any convictions, cautions or bindovers? If yes please give details *

Have you ever had disciplinary action taken against you? If yes please give details *

Are you at present the subject of criminal charges or disciplinary action? If yes, please give details *

Do you consent to Healthline Healthcare Ltd requesting a police check and any appropriate references on your behalf? *

Have you been police checked in the last three years? If so, by whom? (Please supply a copy) *

YOUR DBS STATUS

Do you have a DBS? *

Yes

Is this Certificate registered with the Update Service? *

Yes

Current DBS Disclosure Number Formerly known as CRB

DBS Issue date Formerly known as CRB

Standard or Enhanced Disclosure Number

Standard or Enhanced Disclosure Issue Date

YOUR TRAINING, QUALIFICATIONS AND APPRAISALS

CLINICAL DETAILS * Your speciality and clinical areas you have expertise in. This will enable us to match your skills with the appropriate requirements.

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.

IMMUNISATIONS * Please indicate which of the following immunisations you have been vaccinated against and include your vaccination reports when returning your registration:

Hep B

Varicella

Measles

Rubella

EPP Candidates Only

Hep C

Hep B Antigen

HIV

WORK HISTORY

Please ensure you complete this section if you do not have a CV. Please ensure that you leave no gaps unaccounted for and it covers 10 years or up to your education.

CV * Please attach your CV

Work History Covers 10 years work history or as far back as your secondary education: Dates to and from are shown in an mm/yy format

REFERENCES

Please supply us with two clinical professional references. One must be from your present or most recent employer and both must be from a senior grade to yourself who has supervised your work.

The second reference needs to be a previous employer unless you have been employed more than 3 years with your present or most recent employer. In such cases, then it must be another manager from your current or most recent employer.
(You are giving us authority to contact your referees by putting their details)

Reference 1 *

Reference 2 *

DECLARATION

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 Healthline Healthcare Ltd, or any of its respective clients, or in relation to any of their employees, business affairs, transactions or finances which I may acquire during the term of my agreement and / or engagement with Healthline Healthcare Ltd.

DATA PROTECTION:
I agree that Healthline Healthcare Ltd retains the right to hold this registration and any other data required to process it and to pass on to any authorised third party the details held within, also to retain these details for as long as reasonably necessary in accordance with the Data Protection Act.

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.

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 Healthline Healthcare Ltd to release your information for inspection
consent to Healthline Healthcare Ltd releasing my health and immunisation records for review to Healthline Healthcare Ltd qualified Occupational Health Adviser. 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 Healthline Healthcare Ltd 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 Healthline Healthcare Ltd should my general condition of health change. I will inform Healthline Healthcare Ltd 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 Healthline Healthcare Ltd obtaining further information regarding my health from my GP or Occupational Health Department.

HEPATITIS B:
I have been advised at registration with Healthline Healthcare Ltd, the importance of having the Hepatitis B vaccine.
I acknowledge that I have been/am being vaccinated against Hepatitis B and will continue to maintain my immunity.
I accept responsibility for my decision and I will ensure that I take all precautions to avoid contracting the illness and avoid accepting work within environments which are hazardous.

WORKING TIME REGULATIONS:
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 Healthline Healthcare Ltd not less than three months notice at any time. 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.

Print Name *

Signature *

Date *

Personal Declaration

• I confirm that the information given in this registration is, to the best of my knowledge, true and that an attempt to gain placement by deception is a criminal offence.
• I am permitted to work in the UK.
• I understand that my registration is subject to the receipt of at least two satisfactory references and
an Enhanced Disclosure from the Disclosure and Barring Service (DBS). I give my permission for Healthline Healthcare Ltd to carry out a status check using the Update Service on my DBS Certificate and may be asked to provide a written statement regarding any information revealed on my DBS Certificate.
• I undertake to inform Healthline Healthcare Ltd immediately should I be convicted of an offence in the future and will reveal ALL information contained in any Enhance Disclosure or police check.
• I undertake to inform Healthline Healthcare Ltd immediately, if by virtue of their introduction, I receive an offer of permanent employment following a temporary assignment.
• I agree to respect the confidentiality of patients and any other information I may have access to, at all times.
• I am clear that Healthline Healthcare Ltd cannot guarantee assignments and that they have no responsibility to pay for hours not worked no matter the situation.
• I have read, understood and agree to the conditions of work for temporary nurses contained within the Agency Workers Staff Handbook. Made available in hard copy or online as discussed.
• I give permission for any enquiries that need to be made to confirm such matters as qualifications experience and dates of employment, and for the release by other people or organisations of such information as may be necessary for that purpose.
• I agree that my personal details including my DBS Enhanced Disclosure may be viewed by third party auditors and potential employers.
• I give permission for the processing of the personal data contained in this form for employment purposes.

REGISTRATION FORM DECLARATION:

PLEASE READ THE COMPLETED

REGISTRATION 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 relevant permission, my employment will be terminated with immediate effect and all details passed to the relevant authorities.

I agree that Healthline Healthcare Ltd 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 all the information provided is true and accurate and that I received and agree to Healthline Healthcare Ltd’s Terms of Engagement and Agency Workers Staff Handbook.

Print Name *

Signature *

Date *

INDUCTION INFORMATION

INDUCTION INFORMATION:
Thank you for selecting Healthline Healthcare Ltd as your agency of choice. Our team is committed to ensuring that your work requirements are met whenever possible. Healthline Healthcare Ltd is a professional organisation specialising in providing high calibre nurses to a wide range of health institutions.

Healthline Healthcare Ltd’s continuing success depends on how well we work together. In order to achieve this, there has to be a set of agreed rules, guidelines and standards of conduct for all. These are fully explained in the Agency Workers Staff Handbook in conjunction with our Policy and Procedures. Copies of this are available on our website.

The amount of work that we receive depends not only on us, but fundamentally on your performance. We therefore, have some basic expectations that are expected of you which are listed in our Agency Workers Staff Handbook. I have taken time out to summarise some of these for you:

• Please make sure you arrive on time for your placement, or preferably 10 minutes early. If you are running late, you must ring us as soon as possible and advise us of this so that we can ring the client.
• You are our representative at the client; please ensure that you are wearing a valid photo ID badge and are presented in appropriate uniform and are able to perform your expected duties professionally and willingly at all times.
• If you cannot make your shift, you must give adequate notice in order for a replacement to be arranged.
• Healthline Healthcare Ltd will only pay on receipt of an authorised timesheet. Please ensure you submit your timesheet to us every week. Weekly payments are made provided the timesheet arrives by Monday 10.00AM for payment on Friday.
• In the case of National Health Service Professionals (NHSP) and other managed services where electronic timesheets are used, it is your responsibility to ensure the timesheet is submitted and approved by Monday 10.00AM.

If for any reason you are unhappy with any aspect of the service that Healthline Healthcare Ltd provides, please feel free to contact us on 0121 392 7554 and ask for the Operations Director.

Prior to your placement, it is your responsibility to familiarise yourself with the terms of your engagement that apply to your assignment. Please feel free to ask your contact within Healthline Healthcare Ltd if there is anything that you are unsure of, as we are always here to support you.

Thank you for choosing Healthline Healthcare Ltd.

Please send your completed registration to if you are having issues completing it on the website or emailing it:

Healthline Healthcare Ltd The CIBA Building,
146 Hagley Road, Edgbaston, Birmingham, B16 9NX

Healthline Healthcare LTD | Westmidlands Recruitment Nursing Agency

01213927554
admin@healthlineltd.co.uk