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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
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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
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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:
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 2
Company Name:
Company Address:
Telephone Number: Contact Name: Position:
Dates of Employment
Job Title: Job Description:
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Reason for Leaving:
Can We contact this
company for a reference? Yes No If no reason
Previous Employer 3
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 4
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 5
Company Name:
Company Address:
Telephone Number: Contact Name: Position:
Dates of Employment:
Job Title: Job Description:
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Reason for Leaving:
Can We contact this
company for a reference? Yes No If no reason
PREVIOUS EMPLOYMENT DETAILS CONTINUATION SHEET
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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:
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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)
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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
Telephone Number Known me for...................Years
3rd
Reference Name
Name Of Company
Address
Telephone Number Known me for...................Years
4th
Reference Name
Name Of Company
Address
Telephone Number Known me for...................Years
5th
Reference Name
Name Of Company
Address
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Telephone Number Known me for...................Years
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
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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
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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
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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
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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
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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