APPLICATION FOR EMPLOYMENT

Transcription

1 APPLICATION FOR EMPLOYMENT PLEASE COMPLETE IN BLACK INK INCORPORATING Bank Temporary Permanent Fulltime Parttime Reference Number: POSITION APPLIED FOR: PERSONAL DETAILS Title: Surname: First Name: Home Address: Post Code: Address: Contact Number: Which languages do you speak?: Do you hold a current clean driving licence?: Yes No Do you have access to a car for business purposes?: Yes No PROFESSIONAL MEMBERSHIP Are you a member of any Professional Body?: Yes No If yes please state name: Level of membership:

2 KEY NURSING SPECIALTIES If applicable, please indicate the specialties in which you have experience and length of experience by ticking the relevant column. If your preferred specialty is not listed, please add your relevant specialty next to Other. Specialty: Less than 1 Year A&E Anaesthetics Cardiology Cardiothoracic Surgery Dermatology ENT Surgery Gastroenterology Genitourinary Treatment Rooms Neurology Neurosurgery Endoscopy Theatres 1-2 Years 2 Years+ Specialty: Less than 1 Year Obstetrics & Gynae Ophthalmology Oral Surgery Orthopaedics & Trauma Paediatrics Paediatric Surgery Plastic Surgery Respiratory Medicine Rheumatology Urology Recovery Outpatients 1-2 Years 2 Years+ Other: ALLIED HEALTH PROFESSIONALS Occupation: NMC REGISTRATION If applicable, please provide details of your NMC registration. The question regarding fitness to practice must be answered. NMC HPC PIN: Date of registration: Valid until: Have you ever been, or are you currently, the subject of any fitness to practice/professional misconduct proceedings by any Professional Body having regulatory functions ie. NMC? Yes No If yes, please provide details on a separate sheet

3 EDUCATION & TRAINING DETAILS Qualifications. Please list your Educational and Professional Qualifications and provide details of any membership of Professional Bodies. Date Qualification Educational Establishment (Please continue on a separate sheet, if necessary) Training. Please list the training you have received, starting with that undertaken in the last 12 months. Course Date (Please continue on a separate sheet, if necessary)

4 EMPLOYMENT HISTORY Please state in reverse chronological order [i.e. most recent first) your full employment history including both paid and voluntary. Please do not write refer to CV as an answer - full employment history descriptions are required. Name and address of previous employer: Position Held: Dates from/to: Reason for leaving: Type of organisation: Job Duties: Please indicate salary: Name and address of previous employer: Position Held: Dates from/to: Reason for leaving: Type of organisation: Job Duties: Please indicate salary:

5 EMPLOYMENT HISTORY Please state in reverse chronological order [i.e. most recent first) your full employment history including both paid and voluntary. Please do not write refer to CV as an answer - full employment history descriptions are required. Name and address of previous employer: Position Held: Dates from/to: Reason for leaving: Type of organisation: Job Duties: Please indicate salary: Name and address of previous employer: Position Held: Dates from/to: Reason for leaving: Type of organisation: Job Duties: Please indicate salary:

6 REFEREE DETAILS REFEREES: Please name two referees one of whom should have knowledge of your present or most recent work as your Line Manager/Employer. (Relatives should not be named as referees). If you have worked in the HPSS/NHS, your last HPSS/NHS Line Manager/Employer must be one of these Referees Name: Address: Post Code: Tel. Designation: Name: Address: Post Code: Tel. Designation:

7 CONVICTIONS/OFFENCES Under the Rehabilitation of Offenders (Exceptions) Order Northern Ireland, 1979, 3fivetwo Healthcare as a Provider of Health care is included in the list of excepted employers. As such, all criminal convictions may never be regarded as spent and must be disclosed when applying for a post in 3fivetwo Healthcare. It is necessary therefore to ask the following questions: Have you ever been convicted of any criminal offence? Yes No PERSONAL DECLARATION 1. I declare that all the foregoing statements are true, complete and accurate. 2. I understand that if I give wrong information or leave out important information I could be dismissed if I take up this position. 3. I understand that if I take up this job I must have satisfactory references, health assessment and POCVA checks (if applicable). 4. I understand that I will be asked to provide formal identification and evidence of qualifications obtained. 5. I confirm that as far as I am know there are no medical reasons that would stop me from carrying out the duties of this job. 6. I agree to you making any necessary enquiries during the recruitment and selection process. 7. I understand that canvassing will disqualify me from the selection process for this job. 8. I consent to the information I have provided being used within the context of the Data Protection Act Are you currently the subject of police investigation or have you any prosecutions pending? Yes No List below details of ALL charges, prosecutions, convictions, caution; bind over orders even if they happened a long time ago. You must include any minor matters, any road traffic or motoring offences and any which may be pending Please note that disclosure of a conviction does not necessarily debar any applicant from obtaining employment.

8 OCCUPATIONAL HEALTH We require completion of the following Occupational Health questionnaire. This information will be assessed by our inhouse Occupational Health Service. 3fivetwo Healthcare is registered with the Information Commissioner s Office and, accordingly, processes personal data in compliance with the ICO standards and the Data Protection Act Disclosure of information is only with your informed written consent. Requests for information directed to your employer will be strictly for essential information regarding your health and the hazards and risks of your employment and with due reference to other relevant statutory requirements and professional practice. GP Details: Name: Address: Postcode: Telephone: Basic Health Screening: Is there any aspect of your health which may restrict your ability to work? Are you currently or regularly taking any medicines, tablets, or injections? General: Have you seen a doctor within the last year for any kind of health problem? Are you on a special diet? Are you pregnant? Is there any aspect of your medical history which an employer should or might wish to know? Would you require any adjustments to your working environment to undertake your chosen occupation? Do you have any conditions of vision, hearing or speech which may affect your ability to work? Have you ever suffered from any mental illness, depression, alcoholism or drug dependency? Are you attending any hospital for treatment or are you currently on a waiting list for treatment? Have you ever been medically retired or offered medical retirement in previous employment?

9 OCCUPATIONAL HEALTH Have you ever suffered from, or received treatment for: Respiratory [including asthmatic or allergic) symptoms, disorders or diseases? Cardiovascular symptoms, disorders or diseases? Gastrointestinal symptoms, disorders or diseases? Neurological [including epileptic) symptoms, disorders or diseases? Psychiatric symptoms, disorders or diseases? Genitourinary symptoms, disorders or diseases? Skin symptoms, disorders or diseases including reactions to gloves and glove powder? Endocrine [including diabetes) symptoms, disorders or diseases? Haematological symptoms, disorders or diseases? Recurrent sore throat [including treatment for MRSA infections)? Bone or joint symptoms, disorders or diseases including back pain? Immunodeficiency symptoms e.g. HIV positive diseases or disorders? Stress related disorders or diseases? Alcohol/Drug related symptoms, disorders or diseases? Overseas travel symptoms, disorders or diseases? Chicken Pox/Shingles Tuberculosis History/Symptoms Have you ever had a positive TB skin test? Have you ever had an abnormal chest x-ray? Have you recently had mucous tested for TB? If yes, were you told it was positive? Have you ever been told you have infectious TB? Have you ever been treated with medication for infectious TB? If yes, are you still taking TB medicine? If answered yes to any of the above please provide further information:

10 DECLARATION Please ensure you read and fully understand the entire Declaration before signing and dating. Please ensure that you have included all the supporting documents before submitting your application as failure to do so will result in your application being rejected. I certify that I have responded to the above questions truthfully and in full. I understand that any false or incomplete statements could result in my not being employed by 3fivetwo Healthcare. If any statement is found to be false while employed by with 3fivetwo Healthcare, I understand my employment may be terminated. I agree to inform 3fivetwo Healthcare of any health problems so that my health and safety and that of colleagues and patients can be protected. In the event of any injury, illness or diagnosis of a medical condition, I agree to report this to 3fivetwo Healthcare. I understand that, prior to each shift, I will be required to declare if I am unfit to practice and to inform my line manager if I am suffering from vomiting, diarrhoea or a rash. I give consent to be medically examined, if necessary. I understand that an opinion regarding my fitness for work will be provided to 3fivetwo Healthcare. I confirm that 3fivetwo Healthcare can verify the information I have provided in this application as well as any supporting documents. I understand that 3fivetwo Healthcare shall undertake a face-to-face interview with me prior to any offer of employment. I confirm that all the information provided is true and accurate. I understand that I have supplied information which constitutes sensitive data, as defined by the Data Protection Act I give my consent to 3fivetwo Healthcare to hold and process such data for the purposes of processing this application. In terms of the access to Medical Records Act 1988 and The Data Protection Act 1988, I hereby consent to a medical report or full medical records being supplied in confidence to 3fivetwo Healthcare by their approved occupational health service provider. I understand that the report will include appropriate information and recommendations about my medical condition in relation to my current or potential future fitness for work. Signature: Date: Please return completed application forms to: Human Resources Department, 3fivetwo Group, Channel Wharf, 21 Old Channel Road, Belfast BT3 9DE. If you require any special assistance please do not hesitate to contact us.