Healthcare Assistant

Application form - Confidential

The information supplied on this application form will be used to evaluate your suitability for employment at Unique Personnel UK Limited. Please read the guidance notes before completing the forms. Once completed, please return the forms to us.

Position applied for:
Healthcare Assistant
Post reference no:
UPL-25636
Personal information
First Name
Last Name
Title (Please specify) eg Ms/Mr
Previous Surname(s) (if applicable):
National Insurance number:
Do you require a work permit to enable you to work in UK?
Image will be cropped to 300px X 300px,
so upload larger or same size of image.
Image should be jpg or png format.
Address for correspondence
Daytime telephone number
Evening telephone number
Mobile number
Postcode
Email

Please answer the following question if the job/person profile for the job requires this.

Do you hold a current full driving license?
If yes is it a clean driving license?
If no please give details
Next of Kin:
Relationship to the Applicant
Day Phone:
Evening Phone:
Qualifications and Training
Date (From/ To) Secondary school /college /university /training organization Qualifications Subject Grade obtained
Membership of Professional Bodies (Nursing and Midwifery Council, General Social Care Council or Other)
Name:
Membership/Status
Renewal date:
Number:
Employment Experience

Please give details of your present or most recent employment/voluntary work first and work backwards. Include all periods of unemployment; travel etc, in the space provided so there are no gaps in the record. (If you have additional previous employment, please give details on a separate sheet using the same format).

Date: from/to (month/year) Employer’s name and address and nature of business Job titles and brief description of duties Current salary or final salary (for last post only) and reason for leaving
Gaps in your employment

Please provide information of any gaps in employment (Verification of employment gaps will be required if an offer of employment is made)

From (month/year) To (month/year) Reason
References

Please ensure that you give a minimum of two references which cover at least the last five years of your employment. The first of your references must be your present employer and your relevant line manager. If you are unemployed, this should be your last employer, or if this is your first job, your head-teacher or college tutor. Please note that Unique Personnel UK Ltd reserves the right to take up references in respect of any previous employment paid or unpaid, without further notification to you.* You may also provide the name of a personal referee as well as your employment references if you wish.

Current Employee:
Name:
Job title:
Organization address (in full):
Postcode:
Tel No:
Fax No:
Email:
In what capacity do you know them?
Previous employer/Character Reference:
Name:
Job title:
Organization address (in full):
Postcode:
Tel No:
Fax No:
Email:
In what capacity do you know them?
Can we contact your current employer prior to any conditional offer of employment?
*** Please note that it is Unique Personnel UK Ltd’s policy to obtain references prior to interview for any post in a residential establishment. For all posts, we will ask your referees for comments on your suitability for the post and for employment referees request details on attendance, sickness levels and salary.
Notice Period : If appointed how soon you could join us:
Disability : Unique Personnel UK Ltd has a policy of interviewing applicants who have a disability and who meet the essential short-listing criteria. In order to ensure that this happens, please complete the following:
a) The Disability Discrimination Act 1995 defines disability as' a physical or mental impairment which has a substantial and long-term adverse effect on the ability to carry out normal day-to-day activities'. Do you consider yourself to have or have had a disability?
If yes please give details
b) If the answer to the above is yes, are there any reasonable adjustments that need to be made, should you progress beyond this stage?
If yes please give details
Relevant Experience

Please tell us how your experience, skills and qualifications meet the requirements of the person and job profiles. Please focus your response on the abilities and/or competencies required for the role giving evidence of your experience to date. The information you provide will be the basis for shortlisting and you may find it useful to refer to the guidance notes attached before completing this section.

REHABILITATION OF OFFENDERS
Applicant Declaration

Because of the nature of the work for which you are applying, the provisions of Section 4(2) of the Rehabilitation of Offenders Act (1974) do not apply by virtue of the Rehabilitation of Offenders Act (1974) (exceptions) Order 1975. Applicants are therefore required to give information about convictions, which for other purposes are '‘pent’ under the provisions of the Act. Any information given will be completely confidential and will be considered only in relation for positions to which the Order applies.

Have you at any time been convicted of an offence?
If yes, please give details below: -

I declare that the information given above is, to the best of my knowledge, true, I am permitted to work in the UK. I have read, understood and agree to the conditions of work for temporary nurses and carers, of which I have been given a copy. I understand that my registration is subject to the receipt of at least two satisfactory references and a satisfactory result after checking with the Department of Health and/or Police records. I undertake to inform Unique Nursing Agency should I be convicted of an offence in the future. I undertake to inform Unique Nursing Agency, a Division of Unique Personnel Agency immediately if I am engaged through Unique Nursing Agency’s introduction, including the offer of permanent employment following a temporary assignment. I also acknowledge that this information may form the basis of a computerized personnel system to which I will have access as determined by the Data Protection Act 1984. I agree to respect the confidentiality of Patients and any other information I may have access to all times.

Your registration with Unique Nursing Agency can be terminated at any time following unsatisfactory work reports.

PROFESSIONAL INDEMNITY (MALPRACTICE) INSURANCE FOR QUALIFIED NURSES MIDWIVES, NURSING AUXILIARIES AND CARERS. Contribution to the scheme is compulsory and a small charge (currently £2.38p per week) is automatically deducted from your payment.

Date
Criminal Records, Disqualification & Declaration
Please refer to covering letter before completing section B, C or D below
Section A- All applicants
Are you subject to any current outstanding disciplinary action or legal proceedings?
If yes please give details
Section B-General posts
Criminal convictions
Have you ever been convicted of a criminal offence (‘unspent’ only)?
If yes, please give us details of all offences, penalties and dates on the page marked Criminal Record/Disqualification/Other in this application form.
Section C-Posts working with children or vulnerable adults
Criminal record
Have you ever been convicted of a criminal offence or cautioned, reprimanded or given a final warning by the police (‘spent’ or ‘unspent’)?
If yes, please give details of all offences, penalties and dates on the page marked Criminal Record/Disqualification/Other in this application form
Regulatory body sanctions
Are you subject to any sanctions imposed by a regulatory body, Yes No eg GSCC,NISCC, SCCC, CCW, GTC?
If yes, please give details on the page marked Criminal Record/ Disqualification/Other in this application form.
Disqualification from working with children or vulnerable adults
Are you disqualified from working with children or vulnerable adults?
Section D- Enhanced Disclosures only
Are you aware of any police enquiries undertaken following allegations made against you that may have a bearing on your suitability for the post?
If yes, please give details on the page marked Criminal Record/ Disqualification/Other in this application form
Declaration- To be completed by all applicants

I confirm that the information I have given is correct and complete and that any false statements or omissions may render me liable to dismissal without notice or in some instances, referral to the police.

I understand and agree that data contained in the application form will be used and processed for recruitment purposes.
I also understand and agree that should I become an employee; the information will also be used for employment related purposes.
I agree to Unique Personnel UK Ltd’s holding and processing this information

Date
Criminal Records/ Disqualification/ Other

Details of Declaration of Criminal Convictions (Please give details below):

Declaration of Health (Ref 5U)
Name
Maiden Name
Home Address
Postcode
Phone

Please answer the following questions by ticking the appropriate YES/NO box. If the answer to any questions is YES then give details in the space provided or on the back of this form. It is your responsibility to inform us immediately if any of the following information changes.

Have you ever had in your life, including childhood, any of the following?
Description of Illness Yes/No Details / Dates
1 Cardiac/Vascular Illness
2 Eye Disease/ Inquiry or Defect of Vision not Corrected by Lenses
3 Asthma
4 Tuberculosis
5 Diabetes
6 Epilepsy, Frequent Fainting Attacks
7 Chicken Pox
8 Any Degree of hearing Loss
9 Hepatitis
10 Back pain, Sciatica
11 Do you have any deformities, which effect movements?
12 Are you receiving any medication from a doctor?
13 Have ever been treated for any other serious illness / operation
14 Are you a registered disable person?
15 Mental Illness
16 I believe that I am medically fit to carry out the duties of the position I have applied for
17 Are there any reasonable adjustments that an Employer should make to enable you to work?
Please give details of last immunization or vaccination for:
Tuberculosis
(We will require a statement of evidence regarding TB immunity i.e. Heaf / Mantoux status)
Rubella (German Measles)
Anti-body level:
Poliomyelitis
Anti-body level:
Varicella
Anti-body level:
Tetanus
Anti-body level:
Hepatitis B
Anti-body level:
Any Other
Additional Information
General Practitioner’s:
Name:
Address or Occupational health Department:
I declare that all the foregoing statements are true and complete to the best of my knowledge and belief.
I hereby give Unique Nursing Agency permission to contact my General Practitioner to obtain further information should it be required.
Date
Availability Form
Type of work :
Hours of Work :
Hours Available:(please tick as applicable)
Morning (7am – 2.30pm)
Afternoon (2pm – 9.30pm)
Night/Sleep-In (9.30pm – 7am)

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Unique-Personnel (UK) Ltd. was established in 2001 to provide specialised home care services to the Local Communities in England. We have successfull build over 6 branches over the years including; East London, Lambeth, Croydon, Tower Hamlets, Bexley, Lewisham, Brent and Ealing. We aim to be one of the Leading Care Providers in England.

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Report date is june 2018

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