Your Nurse - APPLICATION FORM

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www.yournurse.co.uk

Your Nurse

17th Floor 110 Bishopsgate London EC2N 4AY 0207 961 0861 0787 292 2390 0208 440 0687 Head Office info@yournurse.co.uk

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Your Nurse - APPLICATION FORM

Please fill in each box as required. If you are unable to provide the information, please leave blank.

Please fill each box in as required. If you are unable to provide the information, please leave blank.

PERSONAL INFORMATION

Title First Name

Surname Address Line 1 Address Line 2 Address Line 3 Town County Post code Home Tel Mobile Tel E-mail Marital Status Maiden Name

Date of Birth (DD/MM/YYYY) Nationality

National Insurance (NI) Number

BANK DETAILS

Bank or building society Name on account

(if LTD, give limited company name)

Sort code Account number

“I confirm that these are my correct bank details and I acknowledge that my payments will be made directly into this account from Your Nurse.”

NAME: DATE: Mrs Miss Mr

Civil Partnership

Divorced

Single

Married

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NEXT OF KIN

Name of next of kin Relationship Address Post code Telephone

TRAVEL & WORK PREFERENCES

Do you hold a current driving license? YES NO

Do you own a car? YES NO

How far are you willing to travel? Are you willing to relocate for work?

(accommodation can be provided) YES NO

Do you hold a permanent post, or are you an

agency worker? YES NO

Which agencies are you currently registered with?

Are you looking for part-time, or full-time agency work?

What shifts are you looking for? (days, nights, weekends)

Have you ever worked in a prison before? YES NO

Please provide details of your employment history during the past 3 years, most recent first. We also need referencing information for each employer.

WORK HISTORY & REFERENCES

Employer

Date From (month and year) Date To (month and year) Title of post

Reason for leaving Reference name Reference position Reference Tel Reference E-mail

Are you paid through a Limited Company? YES NO

If Yes, Please provide the company registration number

Nights

Days & Nights

Anything

Days

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Reference 2 name Reference 2 position Reference 2 Tel Reference 2 E-mail

Employer

Reason for leaving Reference name Reference position Reference Tel Reference E-mail

Reason for leaving

REFERENCES

Please provide us with any other professionals who would be able to give you a reference. These can be other nurses that you have worked with, as long as they have known you professionally. Please list as many as possible, so that we have a greater chance of contacting them quickly.

Reference Tel

Position (e.g. staff nurse)

Reference Tel

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Reference Tel Position (e.g. staff nurse)

Reference Tel

Please tell us how much clinical experience you have in the following areas (please only fill what is relevant to your job role):

CLINICAL EXPERIENCE

RGN’s Less than 6 months 6-12 months 12 months or more

A&E Cardiac Chemotherapy Community Elderly HDU

Intensive Care Unit

Medical Assessment Unit (MAU) Medical/Surgical Neo-Natal Nursing Homes Orthopaedic Paediatric PICU Practice Nursing Prisons Recovery Other

RMN’s Less than 6 months 6-12 months 12 months or more

Acute Forensic

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Community/CPN Prison

Other

RSCN’s Less than 6 months 6-12 months 12 months or more

A&E Paediatric General Paeds NICU PICU SCBU Other

Theatre Less than 6 months 6-12 months 12 months or more

Anaesthetics

Assisting (ASP qualified) Paediatrics

Recovery Scrub

Scrub – Major Orthopaedic Scrub – Cardiac

Scrub – Neuro Other

Midwifery & Health Visiting Less than 6 months 6-12 months 12 months or more Ante/Post Natal

Health Visiting Labour ward

TRAINING & QUALIFICATIONS

What qualification do you hold? Which establishment did you obtain this qualification?

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What is your job title?

(RGN, RMN, Dual Qualified, Midwife, etc) NMC/HPC pin

NMC Expiry

Please supply dates of your most recent training in:

TRAINING COURSE TRAINING PROVIDER DATE COMPLETED _(DD/MM/YYYY) Manual Handling

Basic Life Support

Health and Safety

Infection Control

Fire Safety

Safeguarding Vulnerable Adults & Children Level 2

Safeguarding Vulnerable Adults & Children Level 3

Lone Worker

Information Governance and Data Protection

Complaints Handling

Conflict Management

Food Hygiene

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REHABILITATION OF OFFENDERS ACT:

Because of the nature of the work for which you are applying, this post is exempt from the provisions of Section 4.2 of the Rehabilitation of Offenders Act 1974 (Exemption Order 1975).

Applicants are therefore, not entitled to withhold information about convictions which for other purposes are spent under the provisions of the Act and in the event of employment, any failure to disclose such convictions could result in dismissal or disciplinary action.

Any information given will be completely confidential and will be considered only in relation to an application for positions in which the Order applies and should be entered at the end of any

Particulars you give in support of your application.

A copy of our written policies is available upon request. A criminal record will not necessarily be a bar to obtaining a position. Please give additional information which you think may be relevant in support of your application:

Have you ever been convicted of a criminal offence?

(NB. The Rehabilitation of Offenders Act 1974)

YES NO

If Yes, please give details

Do you have any previous convictions, whether or not they are “spent” within the Act, including any cautions, reprimands, final warnings, bind-overs or any convictions from overseas?

YES NO

If Yes, please give details

Do you hold a Disclosure and Barring Service

(DBS) or Criminal Record Bureau (CRB) check? YES NO If Yes, please give the reference number and date

Have you ever been issued with a caution of suspension from the NMC or other professional body?

YES NO

If yes, please give details

OCCUPATIONAL HEALTH

When did you last have an occupational health check?

Which department provided the check?

Please give details that may be relevant to your last occupational health check

General Practitioner or Occupational Health Department

Address

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OCC HEALTH ASSESSMENT

As part of our policy to ensure that all employees are in good health and able to carry out their duties, we are required to ask questions about your occupational health.

Are you in good health? YES NO

How much time have you lost from work due to illness in the last five years? YES NO Have you ever been treated in hospital for serious illness or surgery? YES NO

Have you been treated in hospital during the last 12 months? YES NO

Do you have any physical disabilities that could affect your ability to carry out your assignment? YES NO

Are you a registered disabled person? YES NO

Have you ever left, been retired or denied a job on health grounds? YES NO

Have you ever been denied a driving license on health grounds? YES NO

Do you need to wear glasses or contact lenses? YES NO

Do you have any difficulty with your eyesight which is not corrected by glasses or contact lenses? YES NO

Have you any problems working with Visual Display Units? YES NO

Do you get discomfort or pain in the chest or shortness of breath on exercise? YES NO

Do you have any difficulty in moving rapidly over short distances? YES NO

Would you have difficulty looking over either shoulder? YES NO

Have you ever had any problems with your joints including pain, swelling or stiffness? YES NO

Have you any disability related to your physical or mental health? YES NO

Have you ever suffered from any mental illness, psychological or psychiatric problems? YES NO

Are you taking any medication that makes you dizzy or drowsy? YES NO

Are you receiving medicines, pills or tablets from a doctor or on prescription? YES NO Do you have a medical condition affected by changing sleeping patterns or affecting

day time sleep? YES NO

Have you any problems working in confined spaces/using lifts? YES NO

Do you have any difficulty hearing normal conversation? YES NO

Have you suffered from any alcohol or drug related illness or had an alcohol or drug problem? YES NO

Are you having or awaiting any treatment at the moment? YES NO

What is the date of your last chest x-ray? YES NO

Do you smoke? YES NO

Please enter your height

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Have you ever suffered from any of the following?

Hepatitis/Jaundice? YES NO

Recurrent Infections e.g. sore throats/ear infections/Eye infections YES NO

Back injury or back problems YES NO

Dermatitis/Skin sensitivity/Psoriasis/Eczema/Allergies YES NO

Psychiatric Illness/Anxiety/Depression YES NO

Headaches/Migraine YES NO

Epilepsy/Fainting/Blackouts/Fits/Sudden Collapse YES NO

Tuberculosis YES NO

Bronchitis/Pneumonia/Pleurisy YES NO

Asthma/Hay Fever YES NO

High or Low Blood Pressure YES NO

Heart Problems/Circulatory Illness/Hypertension YES NO

Have you ever been tested or inoculated for any of the following?

IMMUNISATIONS Date tested/inoculated

Hepatitis A Hepatitis B Hepatitis C HIV

Heaf, Mantoux, or Tine Tuberculosis including BCG Measles Mumps Rubella Varicella

Candidate declaration:

“I declare the information I have provided in this form is true and complete to the best of my knowledge and belief. I understand that my occupational health provider may be contracted with my consent for information which may be relevant to this application. I have read and understood the Terms of Engagement booklet given to me. I agree to comply with the current Health & Safety Act. I understand that my appointment is subject to satisfactory reference checks and subject to DBS or CRB disclosure check. I authorise Your Nurse to make enquiries as they deem necessary to support my application. I agree to respect the confidentiality of patients and clients.”

NAME: DATE:

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If you are unable to provide us with a current DBS or CRB check, please fill out the following

information (some of the information may be duplicated, please fill in full as we keep this form

separately from the application form):

DBS CHECK

Title Gender Forename Surname Date of Birth Job Title

Have you ever used another forename?

If yes, state it here

Used this name from (date) Used this name until (date) Born in the UK?

Birth Place (Town/City) Birth Place (County/District) Nationality

Do you have any unspent criminal convictions?

Please provide 5 years’ worth of address history. Addresses must be filled accurately and in full,

and the dates must cover the entire 5 year period without gaps.

ADDRESS 1

At this address from/to (date) Country

Postcode Address Town/City County

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ADDRESS 2

At this address from/to (date) Country Postcode Address Town/City County ADDRESS 3

At this address from/to (date) Country

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Address Town/City County

Thank you so much for completing the application form. We know it takes time, and we really appreciate it. Please send a copy back to your consultant, or e-mail it to Info@yournurse.co.uk and we will pass it over to our registration team. We should get back to you in 1-2 days at most to give you feedback on your application. If you have any questions in the meantime, please don’t hesitate to give us a call on 0207 961 0861.

Thanks, and we hope to see you soon! Your Nurse team