Application for a Job

7/27/2019 Application for a Job

1/16

1

QUALIFIELD NURSE CARE/SUPPORT WORKER APPLICATION FORM

What You Need To RegisterAll required documents must be the originals

Passport and if applicable work permit 2 x Proof of Address ( household Bill, Mobile Phone Bill) Proof of NI (National insurance card or P45) Driving Licence (both Photocard and Paper parts) Birth Certificate and/or Marriage Certificate All Training Certificates (M&H, First Aid, Food Hygiene, Skills for Care etc.) Original CRB Disclosures from any previous roles 44.00 for new CRB (Fill in Section A, B, C, only) Any immunisation records held Contacts details for Previous Employment for referencing purpose Qualifications Certificates

2 Passport-sized Photographs

An up to date CV including all work, education and qualifications NMC Number & Indemnity Insurance Details (if applying for Qualified Roles) If you want to be paid by Limited Company we need the details.If sending by post we suggest you send all documents by recorded delivery, once received we will return

the same day also by recorded delivered

NAME


2/16

2

QUALIFIELD NURSE/HCA

APPLICATION FORM

POSITION APPLIED FOR:QUALIFIED NURSE: GRADE: SKILL/S:

HCA GRADE: SKILL/S:

PERSONAL INFORMATION

Forenames: Surname:

Address: Home Tel:

Mobile No:

Email:

Date of Birth: Age: National Insurance Number:

Do you hold a valid driving licence? YES NO

Do you have your own transport? YES NO

Please circle the shifts for which are available:

Nights Days Any Hours

GENERAL INFORMATION

Languages Spoken:

Are you covered by indemnity insurance? Are you a member of a professional union? (if so

which)

Pin No: Expiry: Parts: Banding:

NEXT OF KIN DETAILS

Name: Home Telephone Number:

Address: Mobile Telephone Number:

Relationship to you:

ATTACH

PHOTO


3/16

3


4/16

4

PREVIOUS EMPLOYMENT DETAILS: (Must be full employment history with no gaps)

Current/Last Employer

Company Name:

Company Address:

Telephone Number: Contact Name: Position:

Dates of Employment

Job Title: Job Description:

Reason for Leaving:

Can We contact this

company for a reference? Yes No If no reason

Previous Employer 1

Company Name:

Company Address:


Dates of Employment


Reason for Leaving:

Can We contact this


Previous Employer 2

Company Name:

Company Address:


Dates of Employment



5/16

5

Reason for Leaving:

Can We contact this


Previous Employer 3

Company Name:

Company Address:


Dates of Employment:


Reason for Leaving:

Can We contact this


Previous Employer 4

Company Name:

Company Address:




Reason for Leaving:

Can We contact this


Previous Employer 5

Company Name:

Company Address:





6/16

6

Reason for Leaving:

Can We contact this


PREVIOUS EMPLOYMENT DETAILS CONTINUATION SHEET


7/16

7

Company Name:

Dates:

Job Details:

Company Name:

Dates:

Job Details:

Company Name:

Dates:

Job Details:

Company Name:

Dates:

Job Details:

Company Name:

Dates:

Job Details:


8/16

8


9/16

9

Have you worked for an agency before? Yes No

If yes

Name of Agency 1:

Dates Employed:

From:

To:

What rate were you

Paid?

Where did you work? Names of Companies:

If yes

Name of Agency 2:

Dates Employed:

From:

To:

What rate were youPaid?

Where did you work? Names of Companies:

GENERAL EDUCATION

Please provide details of educations:

Educational

Establishment

Dates from Date to Qualifications Gained

(including Grades)

FURTHER EDUCATION

Please provide details of education gained at college or university, and any relevant courses

(Including Manual Handling, introduction to care/skills for Care. Food hygiene etc)

Educational

Establishment

Dates from Date to Qualifications Gained

(including Grades)


10/16

10

REFERENCE DETAILS (to total 5 years)

1st Reference Name

Name Of Company

Address

Telephone Number Known me for...................Years

2nd

Reference Name

Name Of Company

Address


3rd

Reference Name

Name Of Company

Address


4th

Reference Name

Name Of Company

Address


5th

Reference Name

Name Of Company

Address


11/16

11


Competency Checklist Qualified Nurse/Care/Support WorkerApplicants Name: .......... Date

A CAN PERFORM UNSUPERVISED B REQUIRE SOME SUPERVISION

C UNABLE TO PERFORM

PERSONAL HYGIENE A B C A B C

Bath/Shower/Strip Wash Bed Bath

Use of Bath Aids Shaving

Care of Eyes mouth CareCare of Fingernails care Of feet

Dressing/undressingCare of Hair CA

ELIMINATION

Continence Care use of Commodes, Bedpans

Catheter care Attaching a Nightbag

Stoma CareApplying a Urinary Sheath

MOBILITY

Moving & Handling Cert Use WheelchairsUse of Hoists Use of Moving Aids

NUTRITION

Preparation of Meals Feeding Dependant Clients

Care of PEGs Special Diet Requirements

BASIC CARE

Pressure Area Care Assisting with Medication

Simple Dressing Procedures Basic Obs, Temp, BP, Pulse

PRACTICAL/DOMESTIC TASKS

Bed Making light Housework

Washing Personal Laundry Cooking

Collecting BenefitsShopping

ADMINISTRATIVE ABILITIES

Report Writing Recording Instructions

PREVIOUSEXPERIENCE IN


12/16

12

Hospital Hospice

Residential Home Learning Disabilities

Nursing Home Mental Health

Any other information, experience, specialised areas of work

e.g. First Aid, Dementia, Spinal injury, MS etc.

Acute Area Skills

No

Experience

Requires

support Competent Comments

Venepuncture

Cannualtion

Intravenous Drug Therapy

Care of/Recording CVP

Care of/Recording Arterial lines

Arterial Blood sampling

Interpretation of ElectrolytesInterpretation of Blood gases

Basic ECG interpretation

Recording 12 lead ECG

PCA Management

Entonox Administration

Cardiovascular

Qualification

Yes/No

Cardiac output monitoring

Use of inotropes

Assist/Monitor Intra-Aortic Balloon

PumpAssist with cardio-Version

Post Angiogram care

Post coronary artery by-bass care

Assist with Transcutaneous pacing

Use of streptokinase

Respiratory/ITU/HDU

Qualification

Yes/No

Bi-pap

CPAP

Care of ventilated patient

Assist with Intubation

Tracheotomy Care

Care and removal of chest drains

Care epidural infusions

A & E

Qualification

Yes/No

Eye Irrigation

Eye Ph measurement

Bandaging and support of strains

Application of POP

Minor Suturing and gluingManagement of Epistaxis

Care in minors


13/16

13

Care in majors

Triage

Care is resus area

Paediatric experience

Liase with social worker

Name Signature Date

WORK PREFERENCESPlease specify which type/s of work you are looking for. Tick all that apply

Full time Part time NHS Private Hospital

Nursing Home Private Live In Visits

Days Nights

Do you have any other work commitments? Yes No

If Yes please specify:

Which areas do you which to exclude?

When are you available to commence work?

BANK DETAILS

Sort Code __ __-__ __-__ __ Account Number __ __ __ __ __ __ __ __ __

Branch Address: Account Name:

BSoc No: Other Reference :

PASSORT & WORK PERMIT DETAILSDo you have a UK Passport? Yes No

Do you have a work permit? Yes No


14/16

14

If yes please give the expiry date: / /

Place of Birth Passport Nationality

Passport Place of issue

Restrictions

DECLARATION OF HEALTH

Please provide details of any health problems you have had with any of the following:

Have you ever experienced problems

with:

YES NO If yes please provide details

Raised blood pressure

Heart of circulatory problems

Chest pain

Blood Disorders

Chest complaints e.g. Asthma, Bronchitis,

Pleurisy. TB

Chronic Indigestion

Bowel Complaints

Persistent abdominal pains

Liver disease or jaundice

Diabetes, problems with thyroid or other

glands

Kidney or bladder problemsEpilepsy, blackouts or dizziness

Mental Health problems including

depression, psychiatric treatment, eating

disorders or attempted suicide

Are you taking any medication that may

prevent you from working night shifts

Have you received or receiving

counselling


15/16

15

Substance misuse including alcohol

Persistent or recurrent backache or injury

Ear, nose or throat problems

Rheumatism, arthritis or other joint

problems

Vision problems or eye disease

Hay Fever or allergies

Any other serious illnesses

Any operations

Admission to hospital

Serious accidents/visits to A&E. If yes

How many times in the past years?

Other

FURTHER MEDICAL QUESTIONSWeight: Height

Are you presently taking any medication or receiving any treatment? Please provide details of the past 12 months:

Do you smoke? If yes, how many a day?

Please provide details of any sickness or absence within the previous 2 years?

GP Name:

GP Address:

IMMUNISATIONS (for Qualified Nurses, care/support workers only)Please tick all immunisations you have had:

Name Please

Tick

Date of Immunisation

Please Tick If you

have a Serology

Report Showing

Blood Levels

Date of Blood Test

Rubella

Mumps

Measles

Tuberculosis (BCG)

Varicella (Chickenpox)Hepatitis B


16/16

16

Exposure Prone Procedure workers only:

Have you been tested for the following?

(Please tick all that apply)

Hepatitis B Surface Antigen Date of Test:

Hepatitis c Date of Test:

HIV Date of Test:

other please specify

DISABILITYDo you have a disability?If yes please provide details

Documents

Application for a Job