APPLICATION FOR EMPLOYMENT
|
|
- Berenice Cecily Dalton
- 6 years ago
- Views:
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.
APPLICATION FOR INITIAL APPOINTMENT TO THE RQIA LIST OF PART II MEDICAL PRACTITIONERS UNDER THE MENTAL HEALTH (NORTHERN IRELAND) ORDER 1986
APPLICATION FOR INITIAL APPOINTMENT TO THE RQIA LIST OF PART II MEDICAL PRACTITIONERS UNDER THE MENTAL HEALTH (NORTHERN IRELAND) ORDER 1986 Please complete electronically or legibly in block capitals using
More informationThe completion of this application form is part of stage one. This application will be reviewed
Application form SLW Limited Sycamore Care Centre Nookside Sunderland Tyne and Wear SR4 8PQ Please supply a photo of yourself opposite Applications without a photo will not be accepted 01915250181 The
More informationDELIGHT SUPPORTED LIVING JOB APPLICATION FORM GUIDELINES
DELIGHT SUPPORTED LIVING JOB APPLICATION FORM GUIDELINES Please complete this application form accurately, giving as much details as possible of your skills and experience relating to this job application.
More information(Please supply copies of certificates)
The recruitment process within this organisation has a minimum of two stages. The completion of this application form is part of stage one. This application will be reviewed and a decision made as to whether
More informationApplication Form Nursing Nurses, Midwives & ODPs
Application Form Nursing Nurses, Midwives & ODPs Please complete in BLOCK CAPITALS Personal Details Mr / Mrs / Miss / Ms Surname First name (as appears on NMC / HCPC register) Other name(s) Maiden name
More informationArticle 3(3) Certification
Kingram House, Telephone: +353 1 4983100 Kingram Place, Facsimile: +353 1 4983102 Dublin 2, Email: registration@mcirl.ie www.medicalcouncil.ie Article 3(3) Certification Application Form and Guidelines
More informationLONDON HEALTHCARE AGENCY
LONDON HEALTHCARE AGENCY 135 Brockley Rise London SE 23 1NJ. Tel: 020 8291 7171 Fax: 020 8291 7480 Email: info@lhca.co.uk Web: www.lhca.co.uk APPLICATION FORM Personal Details Last Title: Mr / Mrs / Miss
More informationKENYLINK SERVICES LTD.
APPLICATION FORM Post: Care-Assistant Please complete this form fully using black ink or type and return to the above address. THE INFORMATION YOU SUPPLY ON THIS FORM WILL BE TREATED IN CONFIDENCE. PERSONAL
More informationCandidate Information Pack. Clinical Lead Plastic Surgery & Burns
Candidate Information Pack Clinical Lead Plastic Surgery & Burns Welcome from Professor Tim Briggs, National Director of Clinical Quality & Efficiency and Clinical Chair of the GIRFT Programme The original
More informationJAK Imaging and Medical Solutions Tel:
Personal Details APPLICATION FORM Title: Mr/Mrs/Miss/Ms: Surname: Forenames: Home telephone: Mobile: Date of birth: Nationality: National Insurance Number: Email: Registered Nurse Pin Number: Name and
More informationISA Referral Form. All information provided to the ISA will be handled in accordance with the Data Protection Act 1998.
ISA Referral Form This form is for use when making a referral (i.e. providing information) to the Independent Safeguarding Authority. A referral is made when there is harm or risk of harm to children or
More informationApplication for registration within a vocational scope of practice
Application for registration within a vocational scope of practice VOC3 Aug 2017 For doctors who hold a postgraduate medical qualification which is not the prescribed New Zealand or Australasian postgraduate
More informationEMPLOYMENT APPLICATION FORM
EMPLOYMENT APPLICATION FORM Lethbridge Primary School Lethbridge Road Swindon Wiltshire SN1 4BY Tel: 01793 535033 E-mail: admin@lethbridgeprimary.co.uk Applicant s Name Title of post applied for GUIDANCE
More informationI.D. badges will only be processed when CRB & two references have been submitted to VKL.
Patient Transport Services Ltd Domiciliary & Nursing Care Service Provider T: +44 (0)208 381 6254 F: +44 (0)208 327 0165 T: +44 (0)208 207 3441 M: +44 (0)7932 634 240 E: enquiries@vklnursing.co.uk W: www.vklnursing.co.uk
More informationRef No 001/18. Incremental credit will be awarded in accordance with experience and qualifications.
Post Title Consultant Oral and Maxillofacial Surgeon St. James s Hospital 15hrs / HSE Primary Care (Orthognathic) 16hrs / Our Lady s Children s Hospital Crumlin 8hrs. Ref No 001/18 Tenure Permanent This
More informationApplication checklist
Application checklist Before submitting your application check that all sections of the form have been fully completed and that you have enclosed the following: A full CV A personal statement as described
More informationCall: Visit:
Candidate details are logged on Arithon. Ensure all personal information is completed in the tabs. All candidate documents are to be original sight stamp verified and uploaded per document. All conversations
More informationCraigavon Area Hospital Profile
Craigavon Area Hospital Profile 2012 Craigavon Area Hospital Profile Craigavon Area Hospital is located in Craigavon, County Armagh and is an essential part of the hospital network provided by the Southern
More informationSTATEMENT OF PURPOSE
STATEMENT OF PURPOSE This is the Statement of Purpose for Hull and East Yorkshire Hospitals NHS Trust as required by the Health and Social Care Act 2008 (regulated Activities) Regulations 2014 Schedule
More informationP: W: E: APPLICATION FORM FOR POSITION OF. English Teacher
PO Box 64437, Botany, Auckland 2163 P: 09 274 4086 W: www.sanctamaria.school.nz E: admin@sanctamaria.school.nz APPLICATION FORM FOR POSITION OF English Teacher Please complete all details and send with
More informationPlease complete the application form and return it to our office. You may register any time between 9am and 5pm Monday to Friday.
Please complete the application form and return it to our office. You may register any time between 9am and 5pm Monday to Friday. To help us with your application please answer the questions within this
More informationTHE UPWELL HEALTH CENTRE Townley Close. Upwell. Wisbech. Cambs. PE14 9BT
THE UPWELL HEALTH CENTRE Townley Close. Upwell. Wisbech. Cambs. PE14 9BT Dr P.R. Williams Dr E.J. Clarke Dr A.C. Blundell Dr J. A. Haine Dr V Bhardwaj 2612133 3055285 3679188 6075423 5205875 Practice &
More informationBedford Hospital Occupational Health and Wellbeing Services
Bedford Hospital Occupational Health and Wellbeing Services Please read carefully before completing this document. The purpose of this questionnaire is to ensure you are well enough for the proposed job
More informationStatement of Purpose. June Northampton General Hospital NHS Trust
Statement of Purpose June 2016 Northampton General Hospital NHS Trust The statement of purpose is made in compliance with Care Quality Commission (Registration) Regulations 2009: Regulation 12 and Schedule
More informationGuidance notes on the role and function of Organic Old Age Psychiatry wards (NHS Lanarkshire)
Guidance notes on the role and function of Organic Old Age Psychiatry wards (NHS Lanarkshire) Author: Dr Adam Daly, Consultant in Old Age Psychiatry, Clinical Director Old Age Psychiatry November 2014
More informationHealth Facility Guidelines
Health Facility Guidelines Template - Role Delineation Matrix XYZ Hospital, Abu Dhabi Introduction: Role Delineation refers to a level of service that describes the complexity of the clinical activities
More informationDescriptions: Provider Type and Specialty
Descriptions: Provider Type and Specialty PROVIDER TYPE/SPECIALTY ADULT PRIMARY CARE Provides care for adults by treating common health problems, performing check-ups and providing prevention services.
More informationApplication form parts 1 4
Register a care service Application form parts 1 4 The Public Services Reform (Scotland) Act 2010 Before you start completing this application form, please read the Before you begin section. Contents
More informationEmployment Application Form
Version 1.6 Employment Application Form Job Code Ref (NI only): Position Applied For: 1 Title * 2 Forename * 3 Middle (s) 4 Surname * 5 Known As 6a NI Number *UK only 6b PPS *ROI only 7 Date of Birth *dd-mon-yy
More informationApplication for registration in New Zealand Part B: This form is to be accompanied by Part A [checklist] and all documents required on checklist
Application for registration in New Zealand Part B: This form is to be accompanied by Part A [checklist] and all documents required on checklist REG1 August 2017 For office use only Registration no: PO
More informationApplication for registration in New Zealand for orthodontic auxiliaries with prescribed qualifications
Application for registration in New Zealand for orthodontic auxiliaries with prescribed qualifications April 2018 This application is to be used by applicants with prescribed qualifications for the orthodontic
More informationRECRUITMENT AND VETTING CHECKS POLICY
Trinity School RECRUITMENT AND VETTING CHECKS POLICY All new appointments to Trinity School are subject to recruitment and vetting checks. All members of staff at Trinity School are required, under The
More informationSurvey of Research Nurse Training and Experience in a Paediatric Clinical Trial Setting
Survey of Research Nurse Training and Experience in a Paediatric Clinical Trial Setting The following survey has been generated by the European Network of Paediatric Research at the European Medicines
More informationCommunity Nurses Module
Community Nurses Module Community nurses are registered health professionals who provide care in the community at people s homes, residential homes, schools, local surgeries and health centres. The Community
More informationYour application should arrive by 5pm on the closing date which is Friday 26 th January 2018
Telephone: 01902 341203 Fax: 01902 337302 Email: woodlandsquaker@btconnect.com Web: www.woodlandsquakerhome.org QUAKER HOME & SHELTERED HOUSING FOR OLDER PEOPLE 434 PENN ROAD, PENN WOLVERHAMPTON WV4 4DH
More informationCentral Adelaide Local Health Network Clinical Directorate Structures
Central Adelaide Local Health Network Clinical Directorate Structures Consultation Paper February 2014 Version 2 Document Information and Revision History 1. Version 2. Date 3. Comment 1.0 12 February
More informationOvation New Zealand Ltd.
Ovation New Zealand Ltd. PROCESSORS & EXPORTERS OF QUALITY FOOD TO THE WORLD Fax (64) (06) 868-3926 Telephone (64) (06) 868-3921 113 Dunstan Road P.O. Box 1095 Gisborne, New Zealand Employment Application
More informationRegistering as a dental care professional with the General Dental Council
Registering as a dental care professional with the General Dental Council Application form Please note if your application is incomplete it will be returned to you. Your application form and accompanying
More informationApplication for restoration to the New Zealand medical register
Application for restoration to the New Zealand medical register REG6 August 2017 Registration. PO Box 10 509, The Terrace, Wellington, 6143, New Zealand Level 28 Plimmer Towers Wellington, 6011, New Zealand
More informationHospital Generated Inter-Speciality Referral Policy Supporting people in Dorset to lead healthier lives
NHS Dorset Clinical Commissioning Group Hospital Generated Inter-Speciality Referral Policy Supporting people in Dorset to lead healthier lives PREFACE This Document outlines the CCG s policy in respect
More informationThinking about a career in nursing or midwifery?
Thinking about a career in nursing or midwifery? cancer travel What is nursing? What is midwifery? page 2 Where can I study? page 9 What qualifications do I need? page 4 How much will it cost me to go
More informationApplication for registration as a Veterinary Specialist in New Zealand (Under the Veterinarians Act, 2005)
Application for registration as a Veterinary Specialist in New Zealand (Under the Veterinarians Act, 2005) Specialist Registration Procedures The Veterinary VCNZ of New Zealand (VCNZ) considers and makes
More informationWarrior Programme Veteran Assessment & Registration Form
Personal Details Warrior ID Please fill in all the sections of the registration form as missing information will delay our administration procedure. Please ensure that your referring Agency, Mental Health
More informationNorthern Ireland Social Care Council. NISCC (Registration) Rules 2017
Northern Ireland Social Care Council NISCC (Registration) Rules 2017 April 2017 Produced by: Northern Ireland Social Care Council 7 th Floor, Millennium House 19-25 Great Victoria Street Belfast BT2 7AQ
More informationSubstantive Registration
Substantive Registration Welcome to the Substantive Registration process - we are delighted that you are looking to join NHSP s Staff Bank as a Substantive Worker. In order to make the process as simple
More informationQuestion 1 a) What is the Annual net expenditure on the NHS from 1997/98 to 2007/08 in Scotland? b) Per head of population
NHS SPENDING - SCOTLAND Question 1 a) What is the Annual net expenditure on the NHS from 1997/98 to 2007/08 in Scotland? b) Per head of population Question 2 a) Annual real (GDP deflated) increase in net
More informationEvidence on the quality of medical note keeping: Guidance for use at appraisal and revalidation
Health Informatics Unit Evidence on the quality of medical note keeping: Guidance for use at appraisal and revalidation April 2011 Funded by: Acknowledgements This project was funded by the Academy of
More informationDigital Dictation Project
Digital Dictation Project Pam Green Data Quality Manager Business Case Improve the quality and efficiency of clinical correspondence to benefit patient care Digital dictation is a key enabler to support
More informationSTANDARD NURSING AGENCY
STANDARD NURSING AGENCY 5 Forum House Empire Way Wembley Middlesex HA9 0AB Tel: 020 8900 9519 Fax: 020 8900 9587 recruitment@standardnursing.com REGISTRATION FORM PERSONAL DETAILS Surname Title First Name(s)
More informationReducing Elective Waits: Delivering 18 week pathways for patients. Programme Director NHS Elect Caroline Dove.
Reducing Elective Waits: Delivering 18 week pathways for patients Programme Director NHS Elect Caroline Dove What I will cover 1. Why 18 Weeks is different 2. Where are we now 3. New models of delivery
More informationReferral Guidance DIRECT REFERRAL SERVICE FOR THE ELDERLY DEAF
Referral Guidance A & E GPs are strongly requested to contact the specialty teams DIRECTLY WHEN APPROPRIATE to avoid unnecessary delays for their patients in A & E. Relevant non-urgent conditions can be
More informationBurton Hospitals NHS Foundation Trust
Statement of purpose Health and Social Care Act 2008 Statement of Purpose Health and Social Care Act 2008 Version : 10 Date : July 2017 Date of Next Review : 12 months Service Provider Full name: Address:
More informationThe NI Squirrel Association
The NI Squirrel Association Appointment Process 1. Squirrel Leaders must complete the Northern Ireland Squirrel Association Adult Application Form (Appendix 1) OR Northern Ireland Squirrel Association
More informationSafer School Recruitment Policy
I have come in order that you might have life life in all its fullness. John 10:10 Safer School Recruitment Policy The welfare of the child is paramount. Children Act 1989 Policy accepted by FGB on: 24/5/2017
More informationDear Colleague. Performers List National Application Arrangements. Summary
NHS Circular: PCA(M)(2016)(4) Directorate for Population Health Primary Care Division Dear Colleague Performers List National Application Arrangements Summary 1. This Circular directs 1 NHS Boards in relation
More informationApplication to be restored to the register
Application to be restored to the register (Dental care professional) Please note if your application is incomplete it will be returned to you. Your application form and accompanying documents should be
More informationDriving License (Card & paper counterpart)
VKL Transport Services Ltd Transport & Nursing Agency Unit 210 & 211, Studio 2000, 5 Elstree Way, Borehamwood, Hertfordshire WD6 1SF T: +44 (0)208 381 6254 F: +44 (0)208 327 0165 E: enquiries@vklnursing.co.uk
More informationPharmacy Department PRE-REGISTRATION TRAINEE PHARMACIST INFORMATION PACK
Pharmacy Department PRE-REGISTRATION TRAINEE PHARMACIST INFORMATION PACK 2 INDEX 1. Chelsea and Westminster Hospital 3 2. The Pharmacy 3 3. Services 3 4. Education and Training 5 5. Miscellaneous 5.1 Social
More informationPAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THANK YOU!
PATIENT INFORMATION FORM PATIENT DATA: - - PATIENT NAME (LAST, FIRST, MIDDLE) SOCIAL SECURITY # SEX ( ) - ( ) - ADDRESS HOME PHONE NUMBER MOBILE PHONE NUMBER CITY STATE ZIP CODE OCCUPATION / / DATE OF
More informationDIPLOMA IN DENTAL HYGIENE AND DENTAL THERAPY APPLICATION FORM FOR ADMISSION IN Jan 2017
DIPLOMA IN DENTAL HYGIENE AND DENTAL THERAPY APPLICATION FORM FOR ADMISSION IN Jan 2017 Please complete clearly in BLACK ink Use the information on the website to ensure that you complete this form correctly
More informationJOB DESCRIPTION. The hospital has been consistently growing over the past few years, almost doubling since 2008.
JOB DESCRIPTION JOB TITLE: Paediatric Pre Assessment Nurse CLINICAL UNIT: Paediatric Department BASE: The Portland Hospital for Women and Children MANAGED BY: Children s Services Manager ACCOUNTABLE TO:
More informationRegistering as a dentist with the General Dental Council (EU/EEA/Switzerland)
www.gdc-uk.org Registering as a dentist with the General Dental Council Application Form This application form, accompanying documents and registration fee should be posted to: Registration Team (New Registrations)
More informationSCHOOL OF NURSING APPLICATION FORM
SCHOOL OF NURSING APPLICATION FM PRESCRIBING F HEALTHCARE PROFESSIONALS COMMUNITY NURSE PRESCRIBING PRESCRIBING F PHARMACISTS (delete as appropriate) Please complete in black ink in the spaces provided
More informationEmployer Link Service
Employer Link Service Joint Regulator Workshop for Managers of Regulated Services Michele Harrison - Regulation Adviser, NMC 7 th March 2018 What we aim to cover Part 1 Who are the Employer Link Service?
More informationStatement of Purpose
Statement of Purpose Contents as set out in Schedule 3, The Care Quality Commission (Registration) Regulations 2009. Guy's and St Thomas' NHS Foundation Trust provides integrated hospital and community
More informationPatient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name
*SHAREDID-42* Date of Birth: Page 1 of 2 Patient Registration Account # Patient Name Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex City, State & Zip Code
More informationFilling out this form will help us provide the best possible care for you. What are the main questions or problems you would like help with?
Filling out this form will help us provide the best possible care for you. What are the main questions or problems you would like help with? 1. 2. 3. IMPORTANT PLEASE BRING A COMPUTER DISK WITH ANY BRAIN
More informationLittle Owls Day Nursery Bank Nursery Assistant Role
Little Owls Day Nursery Bank Nursery Assistant Role Recruitment Pack January 2017 1 Dear Applicant Re: Bank Nursery Assistant Thank you for the interest you have shown in the above role. Please find enclosed
More informationPatient s Full Name DOB Age. Patient s SSN Sex: Male Female Preferred Language. Place of Birth: City State Country
Hoover Hearing Clinic A division of Hoover ENT Hoover, Alabama 35244 205-733-9694 Tel PATIENT INFORMATION ACCOUNT # DATE MD NEW UPDATE Patient s Full Name DOB Age Patient s SSN Sex: Male Female Preferred
More informationAnaesthesia Registrars
Studley Road, Heidelberg, 3084 Anaesthesia Registrars - 2017 Name of Unit / Specialty: Head of Unit: CSU / Department: Anaesthesia A/Prof Larry McNicol Anaesthesia Contact person: Dr Shiva Malekzadeh,
More informationApplication to be restored to the register
Application to be restored to the register (Dentist / Dental Specialist) Please note if your application is incomplete it will be returned to you. Your application form and accompanying documents should
More informationApplication for Recognition or Expansion of Recognition
Application for Recognition or Expansion of Recognition Notes for applicants All Applicants Should Read This Section This form is for applicants who are: o applying to become a recognised awarding organisation
More informationPlease select the scope of practice and any additional scopes of practice which you are seeking registration in.
Assessment of eligibility for registration in New Zealand for holders of non-prescribed qualifications seeking individual assessment under s.15(2) of the Health Practitioners Competence Assurance Act 2003
More informationTrust Management Structure July 2016
Chief Executive Clare Panniker Managing Director Lisa Hunt Chief Medical Chief Nursing Chief Operating Chief Finance Trust Secretary Director of Strategy and Corporate Services Director of Human Resources
More informationA Beginner s Guide to the NIHR/ UKCRN Specialty Group for Reproductive Health and Childbirth. Professor Billie Hunter Swansea University
A Beginner s Guide to the NIHR/ UKCRN Specialty Group for Reproductive Health and Childbirth Professor Billie Hunter Swansea University UK Clinical Research Network (UKCRN) The UKCRN comprises of managed
More informationApplying to join the pharmacist pre-registration scheme guidance and application form
Applying to join the pharmacist pre-registration scheme guidance and application form Post your form to: Pre-registration New Trainees Customer Services General Pharmaceutical Council 25 Canada Square
More informationSouth Yorkshire Police Federation
If you re not a member of a healthcare scheme, did you know you can pay-as-you-go for first class private healthcare? South Yorkshire Police Federation It s easy to access your private healthcare 1 Visit
More informationOCCUPATIONAL HEALTH QUESTIONNAIRE
PLEASE COMPLETE THIS FORM ON YOUR COMPUTER AND SAVE BEFORE PRINTING OCCUPATIONAL HEALTH QUESTIONNAIRE Please ensure you complete the highlighted sections of the Questionnaire (except where indicated as
More informationPOLYTECHNICS MAURITIUS LTD
Please complete all sections SECTION ONE: PREAMBLE NATIONAL DIPLOMA IN NURSING APPLICATION FORM You have taken an important step to submit an application for the National Diploma in Nursing at Polytechnics
More informationSTATEMENT OF PURPOSE August Provided to the Care Quality Commission to comply with The Health & Social Care Act (2008)
1. Trust Profile STATEMENT OF PURPOSE August 2015 Provided to the Care Quality Commission to comply with The Health & Social Care Act (2008) 1.1 Worcestershire Acute Hospitals NHS Trust was formed on 1
More informationNon-Medical Prescriber Registration Policy
Non-Medical Prescriber Registration Policy REFERENCE NUMBER Non medical prescribing policy VERSION V1 APPROVING COMMITTEE & DATE Clinical Executive Committee 4.8.15 REVIEW DUE DATE August 2018 1 1. Introduction
More information53. MASTER OF SCIENCE PROGRAM IN GENERAL MEDICINE, UNDIVIDED TRAINING PROGRAM. 1. Name of the Master of Science program: general medicine
53. MASTER OF SCIENCE PROGRAM IN GENERAL MEDICINE, UNDIVIDED TRAINING PROGRAM 1. Name of the Master of Science program: general medicine 2. Providing the name of level and qualification in the diploma
More informationIsle of Wight NHS Primary Care Trust:
WESSEX FOUNDATION SCHOOL TRUST PROFILES Isle of Wight NHS Primary Care Trust Address Website The Trust and Hospital St Mary s Hospital Newport Isle of Wight PO30 5TG Tel: 01983 534 231 Fax: 01983 521 963
More informationLittle Owls Day Nursery Nursery Practitioner Role
Little Owls Day Nursery Nursery Practitioner Role Recruitment Pack April 2018 1 Dear Applicant Re: Nursery Practitioner Thank you for the interest you have shown in the above role. Please find enclosed
More informationRegistration as a pharmacy technician
Registration as a pharmacy technician Send your completed application to: Pharmacy Technician Applications to Register Customer Service Team General Pharmaceutical Council 25 Canada Square London E14 5LQ
More informationEmployment Application Form
Employment Application Form YOUR APPLICATION WILL BE KEPT ON FILE UNTIL POSTIONS BECOME AVAILABLE Please fill out electronically and SAVE when completed (changes will be lost if you don t save) and email
More informationColumbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR fax Physician
Columbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR 97031 541-387-6125 fax 541-387-6315 Physician Welcome to the Columbia Gorge Heart Clinic. We welcome you as a patient and
More informationInformation for patients
Information for patients 18-Weeks Maximum Waiting Time from Referral to Treatment (RTT): What does this mean for you? Your rights under the NHS Constitution You have the right to access NHS services within
More informationRegistering as a dentist with the General Dental Council (Overseas qualified)
www.gdc-uk.org www.gdc-uk.org Registering as a dentist with the General Dental Council Application Form This application form, accompanying documents and registration fee should be posted to: Registration
More informationAlfred Health Pharmacy Internships 2019
Alfred Health Pharmacy Internships 2019 Alfred Health 55 Commercial Road Melbourne VIC 3004 Campuses at which pharmacy intern will work The Alfred, Caulfield Hospital & Sandringham Hospital Hospital Information
More informationWard Clerk - Shrewsbury
Bicton Heath, Shrewsbury, SY3 8HS Re : Ward Clerk - Shrewsbury Please find attached the following documents:- 1. Job Description 2. Information to Candidates 3. Equal Opportunities Monitoring Form 4. Person
More informationSOUTH INFIRMARY-VICTORIA UNIVERSITY HOSPITAL Old Blackrock Road, Cork
SOUTH INFIRMARY-VICTORIA UNIVERSITY HOSPITAL Old Blackrock Road, Cork Job Description for the post of: Temporary Phlebotomist 22.5hours per week Contract Duration: 12 months This document sets out the
More informationHOSPITAL STAFF. Identify hospital services, staff, specialties, specilaists by means of pictures and flowcharts. Aims:
HOSPITAL STAFF Aims: Identify hospital services, staff, specialties, specilaists by means of pictures and flowcharts. Professor: Viviam Batista Pérez. AREA HOSPITAL WARD Intensive Care Casualty & Emergency
More informationPATIENT INFORMATION. Address: Sex: City: State: address: Cell Phone: Home Phone: Work Phone: address: Cell Phone:
PATIENT INFORMATION Name: _ DOB: _ Age: Address: _Sex: City: _ State: _ Zip: _ Email address: Cell Phone: _ Home Phone: Work Phone: _ Responsible Party (if different from above) Name: DOB: Address: E-mail:
More informationDiploma in Enrolled Nursing Application Checklist
T e T a r i M ā t a u r a n g a H a u o r a F a c u l t y o f N u r s i n g a n d H e a l t h S t u d i e s Diploma in Enrolled Nursing Application Checklist Name of Student... Nursing & Health Studies:
More informationPractice One. The three decision branches we have decided to use within the practice to identify the course of action for each letter are:
Practice One Incoming Letter Protocol Introduction This protocol is to give guidance on a new system of processing incoming letters within the practice. All letters that the practice receives (whether
More informationChoosing your hospital
For more help with choosing your hospital, contact: Patient Choice Coordinator Referral Management Centre Chipping Sodbury Memorial Day Centre 248 Station Road Yate Bristol BS37 4AF Choosing your hospital
More informationStudent Privacy Notice
Student Privacy Notice Queen s University Belfast collects, holds and processes personal information or data relating to its students. We need to do this in order for the University to carry out its functions
More informationNUMBER OF PERSONS AS AT 2011/12/31 ADDITIONAL QUALIFICATION FEMALES MALES TOTAL
07:02:13 (figures for 2010 in brackets) PAGE: 1 ADVANCED CLINICAL NURSING SCIENCE ADVANCED MIDWIFERY AND NEONATAL NURSING SCIENCE 672 ( 710 ) 3 ( 3 ) 675 ( 713 ) ADVANCED NURSING DYNAMICS: NURSING UNIT
More informationBoard of Directors Meeting
Board of Directors Meeting Date: 30 July 2008 Agenda item: 10.2, Part 1 Title: Prepared by: Presented by: Action required: Elaine Hobson, Director of Operations Elaine Hobson, Director of Operations The
More information