NHS Application - TTM

7/26/2019 NHS Application - TTM

1/12

NHS STANDARD APPLICATION FORM

Please fill in the application form below. Do not type usingonly capital letters and please remember to check it carefully,as once the form has been submitted it cannot be changed.Please note that questions marked with an asterisk * aremandatory and therefore must be answered.

APPLICATION FOR EMPLOYMENT WITH

APPLICATION FOR EMPLOYMENTDetails entered in this part of the form will be held in the HR department of the recruitingorganisation. Access to this information will be withheld from the shortlisting panel. Please donot type using only capital letters, as this could lead to your application being automaticallyreected. Please use the appropriate mi!ture of capital and lowercase letters in standard writtente!t.

"ob Reference #umber $$% Healthcare

"ob $itle &and ' #urse

Department

Personal Details

*(urname)amily #ame+&D-/

*irst #ames#0/1H &2/((#-

$itle 3%r)%rs)%iss4 %rs

50 #ational nsurance #o

Address67)68 ("5+2A ($R//$, + A-+ PA2A1/ A9+0+$A. 2A-+( ($A$/

*Postcode) :ip code 6;7

* 1ountry #-/RA

Home $elephone

%obile $elephone


2/12

subect to checking before interCiew. 3f you are from the /5 you haCe indefinite leaCe to remain4

H(%P)$ier

ndefinite 2eaCe to remain)enter Post -raduate Doctors and Dentists

ork Permit)$ier 6 $ier ' $emporary orkers

Dependant ) (pouse Cisa orking Holiday Eisa)$ier ' 9outh %obility

1linical attachment Cisa Refugee

(tudent Eisitor +ther, please specify below

Please supply details of any Cisa currently held, including number, start)e!piry dates and details ofany restrictions.

Eisa #oB(tart DateB 3DD)%%)994/!piry DateB 3DD)%%)994Details of RestrictionB

Does your Cisa haCe a condition restricting employment or occupation in the 50?

9es #o

Are you a Department of ork F Pensions #ew Deal 1andidate? 9es ! #o

Are you an #H( professional returning to practice? 9es ! #o

Do you currently work in the #H(? 9es ! #o

DECLARATION

$he information in this form is true and complete. agree that any deliberate omission,falsification or misrepresentation in the application form will be grounds for reecting thisapplication or subsequent dismissal if employed by the organisation. here applicable, consent that the organisation can seek clarification regarding professional registration details.

agree to the aboCe declaration

(ignature

#ame #0/1H &. +&D-/ Date ;rd"5#/, 6


3/12

APPLICATION FOR EMPLOYMENT

Details entered in this part of the form will be held in the HR department of the recruitingorganisation and will be made aCailable to the shortGlisting panel.

"ob Reference #umber $$% Healthcare+nline referencenumber

#)A

"ob $itle &and ' (taff #urse

Department

E!"cation # Professional $"alifications

nclude in this section all the releCant qualifications. Please also indicate subects currentlybeing studied. All qualifications disclosed will be subect to a satisfactory check.

(ubect)ualification Place of (tudy -rade)result 9ear

RE%ISTERED MIDWIFE &RM' SCHOOL OF MIDWIFERYLA%OS UNI(ERSITY

TEACHIN% HOSPITAL&LUTH'

PASS )*+*

RE%ISTERED NURSE &RN' SCHOOL OF NURSIN%UNI(ERSITY OF NI%ERIATEACHIN% HOSPITAL&UNTH'

PASS )**,

Trainin- Co"rses Atten!e!

nclude in this section any releCant training courses that you haCe attended or details ofcourses that you are currently undertaking.

1ourse $itle $raining ProCider DurationDate1ompleted

%A#DA$+R9 1+#$#5+5(PR+/((+#A2 D/E/2+P%/#$PR+-RA%%/

#5R(#- A#D%D/R9 1+5#12

' DA9( 8th%ay, 6


4/12

Me./ers0i1 of Professional 2o!ies

nclude in this section any releCant professional registrations or memberships. f you areregistered then please enter the releCant details belowI this information will be subect to asatisfactory check.

* Please indicate your Professional Registration status if releCant to this postB

do not haCe the releCant 50 professionalregistration status haCe current 50 professional registration

350 professional registration required and

applied for

50 professional registration required

but not yet applied for am a student

#ot required for this post

f professional registration is not required then go to E.1loy.ent History.

f you are registered then please enter the releCant details belowB

Professional &ody %embership orRegistration type

%embership)Registration P#

/!piry)RenewalDate

#5R(#- A#D %D/R9 1+5#12+ #-/RA

R/-($/R/D #5R(/ R# 6JJ;7 APR2, 6'76J APR2, 6


5/12

E.1loy.ent History

Please record below the details of your current or most recent employer

/mployer #ame2A-+( ($A$/ 5#E/R($9 $/A1H#- H+(P$A2 325$H4

Address D ARA&A, (5R52/R/. 2A-+(. #-/RA

$ype of &usiness $elephone (+1) 234 567 8901

"ob $itle NURSING OFFICER II

(tart Date 'th#oC. 6


6/12

Pre4io"s E.1loy.ent

Please record below the details of your preCious employment, beginning with the most recentfirst. 5p to ' preCious employments can be entered here. f required, please proCide additionalinformation regarding your employment history within the K(upporting nformationL section.

Pre4io"s E.1loyer +/mployer#ame

RA+ (P/1A2($ H+(P$A2

Address RA#D2/ AE/#5/, (5R52/R/. 2A-+( ($A$/. #-/RA.

"ob $itle ($A #5R(/ -rade

rom Date 6


7/12

Pre4io"s E.1loyer 5

/mployer#ame

Address

"ob $itle -rade

rom Date $o Date

Reason for 2eaCing

Description of your duties and responsibilities

Pre4io"s E.1loyer 6

/mployer#ame

Address

"ob $itle -rade

rom Date $o Date

Reason for 2eaCing



8/12

Pre4io"s E.1loyer 7

/mployer#ame

Address

"ob $itle -raderom Date $o Date

Reason for 2eaCing


Please add additional employers)information on a separate sheet.

f you haCe any gaps within your employment history, please state below.

9es, do haCe a gap between %arch and #oCember 6


9/12

S"11ortin- Infor.ation

n this section please giCe your reasons for applying for this post and additional informationwhich shows how you match the person specification for the ob 3you will haCe been sent thisdocument with the application form4. $his can include releCant skills, knowledge, e!perience,Coluntary actiCities and training etc. f releCant to the post for which you are applying you shouldinclude details about research e!perience, publications or poster presentation, clinical care

3knowledge and skills4 and clinical audit.

(upporting information 3Please continue on additional sheets if necessary4.

%y duties and e!periences includes but not limited to the followingB

M 1aring for patients e!periencing physical distress or who haCe an enduring illness.M Assessing and talking to patients about their problems and discussing the bestway to plan and deliCer their care.M &uilding relationships with patients to encourage trust, while listening to andinterpreting their needs and concerns.M /nsuring the correct administration of medication, including inections, andmonitoring the results of treatment.M Responding to distressed patients in a nonGthreatening manner and attempting tounderstand the source of distress.M Applying OdeGescalationO techniques to help people manage their emotions andbehaCiour.M +rganiNing social eCents aimed at deCeloping patientsO social skills and helpingto reduce feelings of isolation.M Preparing and maintaining patient records.M Producing care plans and risk assessments for indiCidual patients.M /nsuring that the legal requirements appropriate to a particular setting or groupof patients are obserCed.M Promoting a OrecoCeryO based approach to care.M %aintaining a safe and secure enCironment for the patient.M Regular ward care, constant monitoring of patient Cital signs and patientprogress and challenges, intraCenous lines setting and monitoring.M Pre and post op care of surgical patients.M (uperCising unior staff.M /nsuring maintenance of a high standard of nursing care during procedures andtreatment.


10/12

A!!itional Personal Infor.ation

Preferred /mployment$ype

3ull $ime Part $ime "ob (hare (econdment

le!ible Hours

f applicable to the post, do you hold a certificate tosupport your responsibilities under R3%/4R 6


11/12

References

Please state the names and contact details of the people who haCe agreed to supply referencescoCering a minimum of ; years employment)training. f you are or haCe been employed, theseshould include your two most recent employers, your line manager or someone in a position ofresponsibility who can comment on your work e!perience, competence, personal qualities andsuitability for the post. f you are a student please proCide contact details of a teacher at yourschool, college or uniCersity. f you haCe not been in employment for a considerable amount of

time but haCe had preCious employment, then you should seek one reference from your lastknown employer and a personal reference from a person of some standing within yourcommunity i.e. doctor, solicitor, %P etc. here it is not possible to obtain any employerreference at all then please obtain two personal references. here no personal reference canbe obtained then references should be sought from personal acquaintances not related to orinColCed in any financial arrangement with you. f you haCe undergone training to return to workthen the academic institution should be contacted. Personal references such as friends andrelatiCes are not acceptable unless stated preCiously.

Please note, all reference requests will be sought through your line manager or other releCantdepartment manager and your employment history will be Cerified through the organisationLsHuman Resources department or other releCant recruitment function. Please ensure that youproCide full contact details. Referees may be contacted prior to interCiew.

Referee +

*(urname)amilyname

$"A# irst #ame HA&//&

$itle Dr

"ob $itle 1+#(52$A#$ 5R+2+-($

*Address 2A-+( 5#E/R($9 $/A1H#- H+(P$A2, DGARA&A, 2A-+(

*Post 1ode) :ip1ode

6;7 *1ountry #-/RA

$elephone


12/12

Referee )

*(urname)amilyname

/"/R/ irst #ame 2519

$itle %R(

"ob $itle :+#A2 1H/ #5R(#- +1/R

*Address#5R(#- (/RE1/ D/PAR$%/#$, 2A-+( 5#E/R($9 $/A1H#-H+(P$A2, DGARA&A.

*Post 1ode) :ip1ode

6;7 *1ountry #-/RA

$elephone

Documents

NHS Application - TTM