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REALCARE HEALTH SERVICES
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Personal Details:

  • Title
    Surname
  • Forenames
    Maiden/Former Name
  • Date of Birth
    Age To
  • Address
  • Post Code
    Email address
  • Home Telephone No
    Mobile Telephone No
  • Country of Birth
    Nationality
  • Ethnic Origin
    Date of Arrival in UK

Travel & Work Preferences

Do you hold a current driving license?
Do you own a car?
How far are you willing to travel?
Are you willing to relocate for work? (accommodation can be provided)
Do you hold a permanent post, or are you an agency worker?
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?

It is your responsibility to keep us updated with any changes to your personal details.

NMC pin number
NMC expiry date
NMC Part(s) of register
HPC number (AHP only)
HCPC expiry date (AHP only)

If you have any issues or investigations outstanding on your NMC Pin please let us know in writing via email to info@realcarehealthservices.com

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Education and Qualifications

Professional qualification
Year of graduation
Any additional Qualifications

Please supply dates of your most recent training in:

TRAINING COURSE TRAINING PROVIDER DATE COMPLETED
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
Please give details of any other training you have which you feel may be relevant
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Your Passport Details

National Insurance number
Date of birth
Your nationality:

Please tell us about your eligibility to work in the UK:

I am eligible to work in the UK and do not require a work permit:
I am already in possession of a work permit to work in the UK.
If other please specify
I need to obtain a work permit to work in the UK

Your Next of Kin Details

Name
Relationship to you
Address
Postcode
Daytime phone number
Mobile phone number
Name
Relationship to you
Address
Postcode
Daytime phone number
Mobile phone number
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Employment History

Please supply us with your work employment history. Please do not leave any gaps.
A detailed CV is acceptable.

DATE FROM DATE TO EMPLOYER’S NAME AND ADDRESS PRINCIPLE DUTIES BAND REASONS FOR LEAVING
Attach Your CV Please

Clinical Experience

RGN’s
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
Acute
Forensic
Psychiatric Intensive Care
Community/CPN
Prison
Other
RSCN’s
A & E Paediatric
General Paeds
NICU
PICU
SCBU
Other
Theatre
Anaesthetics
Assisting (ASP qualified)
Paediatrics
Recovery
Scrub
Scrub – Major Orthopaedic
Scrub – Cardiac
Scrub – Neuro
Other
Midwifery & Health Visiting
Ante/Post Natal
Health Visiting
Labour ward

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
Telephone

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?
How much time have you lost from work due to illness in the last five years?
Have you ever been treated in hospital for serious illness or surgery?
Have you been treated in hospital during the last 12 months?
Do you have any physical disabilities that could affect your ability to carry out your assignment?
Are you a registered disabled person?
Have you ever left, been retired or denied a job on health grounds?
Have you ever been denied a driving license on health grounds?
Do you need to wear glasses or contact lenses?
Do you have any difficulty with your eyesight which is not corrected by glasses or contact lenses?
Have you any problems working with Visual Display Units?
Do you get discomfort or pain in the chest or shortness of breath on exercise?
Do you have any difficulty in moving rapidly over short distances?
Would you have difficulty looking over either shoulder?
Have you ever had any problems with your joints including pain, swelling or stiffness?
Have you any disability related to your physical or mental health?
Have you ever suffered from any mental illness, psychological or psychiatric problems?
Are you taking any medication that makes you dizzy or drowsy?
Are you receiving medicines, pills or tablets from a doctor or on prescription?
Do you have a medical condition affected by changing sleeping patterns or affecting day time sleep?
Have you any problems working in confined spaces/using lifts?
Do you have any difficulty hearing normal conversation?
Have you suffered from any alcohol or drug related illness or had an alcohol or drug problem?
Are you having or awaiting any treatment at the moment?
What is the date of your last chest x-ray?
Do you smoke?
Please enter your height
Please enter your size (for uniform)
Have you ever suffered from any of the following?
Hepatitis/Jaundice?
Recurrent Infections e.g. sore throats/ear infections/Eye infections
Back injury or back problems
Dermatitis/Skin sensitivity/Psoriasis/Eczema/Allergies
Psychiatric Illness/Anxiety/Depression
Headaches/Migraine
Epilepsy/Fainting/Blackouts/Fits/Sudden Collapse
Tuberculosis
Bronchitis/Pneumonia/Pleurisy
Asthma/Hay Fever
High or Low Blood Pressure
Heart Problems/Circulatory Illness/Hypertension
If You say yes to the above that need explanation please give detail below:

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

IMMUNISATIONS   Date tested/inoculated
Hepatitis A
Hepatitis B
Hepatitis C
HIV
Tuberculosis including BCG
Measles
Mumps
Rubella
Varicella
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References

  • Please supply the names and work addresses of at least 2 clinical professional referees.
  • One must be from your present or most recent employer and must be a senior grade to yourself.
  • You must have worked for that person for a period of more than three months duration.
  • 2nd needs to be a employer unless you have been employed more than 3 years then it must be
  • someone from your current or most recent employer.

Clinical Reference 1

Name
Position
Address
Postcode
Daytime phone number
Fax number
Email address
What was your professional relationship with this person?

Clinical Reference 2

Name
Position
Address
Postcode
Daytime phone number
Fax number
Email address
What was your professional relationship with this person?

Clinical Reference 3

Name
Position
Address
Postcode
Daytime phone number
Fax number
Email address
What was your professional relationship with this person?

Your Professional Conduct

Have there been any proceedings of medical negligence or professional misconduct against you and have you ever been suspended or dismissed?
If "YES" please supply details:

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)
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?
If Yes, please give details
Do you hold a Disclosure and Barring Service (DBS) or Criminal Record Bureau (CRB) check?
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?
If yes, please give details
Data Protection Statement.
The information that you provide on this form and on any CV given, will be used by RealCare Health Services to provide you work finding services. In providing this service to you, you consent to your personal data being included on a computerised database and consent to us transferring your personal details to our clients.
Equal Opportunities Statement

Realcare Health Services is committed to a policy of equal opportunities for all work seekers and shall adhere to such a policy at all times and will review on an on-going basis on all aspects of recruitment to unlawful or undesirable discrimination. We will treat everyone equally irrespective of sex, sexual orientation, marital status, age, disability, race, colour, ethnic or national origin, religion, political beliefs or membership or non-membership of a trade union and we place an obligation upon all staff to respect and act in accordance with the policy

Realcare Health Services shall not discriminate unlawfully when deciding which candidate/temporary worker is submitted for a vacancy or assignment, or in any terms of employment or terms of engagement for temporary workers

Realcare Health Services will ensure that each candidate is assessed only in accordance with the candidate’s merits, qualification and ability to perform the relevant duties required by a particular vacancy.

Final Statement and Declaration.

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 Realcare Health Services to make enquiries as they deem necessary to support my application. I agree to respect the confidentiality of patients and clients.�?

Name
Date

CONFIDENTIALITY

Registration implies acceptance of our code of confidentiality.

In the course of your duties you may have access to confidential information about your clients. On no account must information relating to identifiable client be divulged to anyone other than the manager of the agency. You should not disclose ANY information to your family, friends or neighbours.

If you are worried by any information you have obtained and consider that you should talk about it to someone else MAKE AN APPOINTMENT TO SPEAK IN PRIVATE TO YOUR MANAGER.

Failure to observe these rules will be regarded as serious misconduct which could result in removal from the agency register.

I have read and I understand the above and I agree to abide by the contents therein

Name
Date
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