Driving 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 W: www.vklnursing.co.uk Health Care Assistant Requirements for Membership Requirements Evidence to present at interview Tick Utility Bill (Gas, Electric etc)(less than 2 months old) Proof of Address ID Check Driving License (Card & paper counterpart) Bank Statement Valid Passport / EU ID Card etc. One recent passport photo Eligibility to work in UK Employment Record Written proof of vaccination is required from your Doctor. Non-compliance will result in a delay in work placement. Current Training Certificates. Please supply any / all up to date certificates pertaining to health care and / or mental health care. Including any NVQ certificates. Registration Ask office for which documents you need to submit for CRB. VKL I.D Badge Training *A 5.00 deposit for each on-line course is required at time of registration. Valid Visa / Work Permit NI Card / Official NI letter / P60 or P45 Rubella Varicella Tetanus Tuberculosis Hepatitis B (titre level) Health & Safety* - Fire Safety* - First Aid* Mental Capacity* - Infection Control* Manual Handling* - Medication Administration* Communication (Verbal & Written)* - S.O.V.A* Any Mental Health Awareness Training* Fully completed application form Details of two referees (UK ONLY) CRB payment 55.00 Updated Yearly (FULL payment required at time of recruitment) I.D Badge payment 5.00 (FULL payment required at time of recruitment) On-Line training Health & Safety, First Aid, Fire Training, Mental Capacity Act, Challenging Behaviour etc Completion of training does not Tutor based Training ~ guarantee registration with VKL. Manual Handling & Mental Health Awareness etc Student letter of acceptance from college. (Student Visa Only) When you have ALL the documents listed above. Call the office on 0208 381 6254 to make an appointment for registration or send application form to office. No one can start work without providing the required documents. I.D. badges will only be processed for successful applicants. See Page 13 See Pages 9 & 10 PLEASE DO NOT COME WITHOUT AN INTERVIEW. 1

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 Application Form for Registration Health Care Assistant Date of application: UK STATUS/VISA British Indefinite leave to remain/permanent Residence Dependant Student Nurse Student Work Permit Holder Asylum Seeker Other Valid from: Valid Until: Ref Number: PERSONAL DETAILS Title: Mr. Mrs. Miss. Ms. First Name: Surname: Date of birth: Marital Status: Married Unmarried Divorced Separated Current address: City: County: Postal Code: Email: Telephone 1: Telephone 2 (mobile): NATIONAL INSURANCE (Card or official NI Letter) National Insurance Number: PASSPORT DETAILS Nationality: Date of Issue: Passport Number: Expiry NEXT OF KIN (IN CASE OF EMERGENCY) Full Name: Title: Mr. Mrs. Miss. Ms. Capacity in which the person is know to you: Address: City: Country: Postal Code: Email: Telephone 1: Telephone 2 (Mobile): Professional References UK based only (Compulsory) REFERENCE 1 (PRESENT/MOST RECENT) REFERENCE 2 Name: Name: Position: Position: Employment Address: Employment Address: Email: Email: Telephone: Telephone: May we approach this referee: Yes/No May we approach this referee: Yes/No 2

Employment Details Please give full details of work history for the previous six years, identifying and giving details of any significant breaks. Current / most recent position first.. Continue on separate sheet if required NAME AND ADDRESS OF EMPLOYER POSITION HELD FROM TO SUMMARY OF RESPONSIBILITIES TYPE AND SIZE OF UNIT Education NAME OF SCHOOL COLLEGE UNIVERSITY ATTENDED FULL OR PART TIME FROM TO COURSES TAKEN OR CURRENTLY STUDYING EXAMINATION RESULTS INCLUDING GRADES 3

Other Qualifications OTHER QUALIFICATIONS (non-nursing) Qualification: Diploma Degree Masters Higher Date of Qualification(s): Professional Body No.: Date of registration: ENGLISH LANGUAGE IELTS TEST RESULTS (if you have taken IELTS exams please indicate your results below) Listening: Reading: Writing: Speaking: Overall band score: HEALTH CARE COURSES UNDERTAKEN IN ENGLAND: (please provide certificates) Course (please tick if you have attended the following courses) Mental Health Awareness: Control & Restraint: Moving & Handling: Principal of Care Principal of Administration & Control of Medicine: Health & Safety at Work: Infection Control: Food Hygiene: First Aid & CPR: Risk Assessment: Fire Training: Dealing with Vulnerable people and abuse: Alzheimer s: Epilepsy: Other (please specify): Other (please specify): Date of Course Experience Please tick the areas that describe your work experience Experience Less than 6 months More than 6 months 1-2 years 2+ years Experience Less than 6 months More than 6 months 1 2 years 2+ years Nursing Homes Home Care Residential Homes Senior Care Private Homes Catheter Care Hospitals Fluid Charts Schools Urinalysis Community Care NVQ Learning Disability Observations BP/TPR Mental Health Observations Paediatrics NNEB 4

Rehabilitation of Offenders Act 1974 England The provisions relating to the non-disclosure of criminal convictions do not apply to certain occupations and activities. The position for which you are applying is one which is exempted under the above order. Therefore it is necessary for you to disclose any criminal convictions, even if, under the Rehabilitation of Offenders Act, they would otherwise be regarded as spent Have you ever been convicted of any criminal offence? Do you have any criminal charges pending? YES / NO YES / NO If you have answered YES to either of the above, please give details: NB. Any information disclosed will be taken into consideration but will not automatically prevent your application from proceeding. However, if you are appointed, failure to disclose any criminal conviction could lead to termination of our ability to act as your agent. Rehabilitation of Offenders Act 1974 England I confirm that the information set out in this form is true and correct, is not misleading and that no material information had been omitted. I understand and agree that if I submit any false or misleading information, this may result in any offer of registration with the agency being withdrawn, or, if already accepted in my dismissal. I hereby authorise VKL Patient Transport Services Ltd to secure all information it may require in connection with my application for registration, Subject to any specific direction I have made related to contacting my referees. I confirm that I have read and understand the conditions of engagement offered by VKL Patient Transport Services Ltd. and agree to be bound by and comply with the same. I have no objection to my details being held on computer records and utilised by the company in pursuit of its legitimate business. I understand that my application is subject to the receipt of satisfactory references, Police clearance and any other checks (where appropriate) including UKBA. I agree to inform VKL Patient Transport Services Ltd of any changes or additions to the information I have supplied. Declaration I declare the information given in this application form is true and complete to the best of my knowledge and belief. I authorise VKL Patient Transport Services Ltd to make any other enquiries to support my application. I agree to respect the confidentiality of patients and clients and any other information I may have access to at all times. Signed. Date 5

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 W: www.vklnursing.co.uk Please answer the following questions: Why do you want to work for this company? What kind of experience do you have to work in the Care Industry? How did you get on with your previous manager/supervisor, coworkers and subordinates? How would you describe yourself? What are your strengths and weaknesses? What s your understanding of Confidentiality? THANK YOU FOR COMPLETING THIS FORM 6

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 W: www.vklnursing.co.uk IF YOU DO NOT ALREADY HAVE WRITTEN PROOF OF ALL OF THE IMMUNISATIONS LISTED BELOW you are required to consult your GP or practice nurse to complete this form prior to starting work placements with this Agency. It is YOUR responsibility to pay for any charges your GP may make for immunisations. It is very important that you commence your immunizations as soon as possible as it may take several months to fully complete the course. NB. YOU MUST HAVE TB AND RUBELLA SCREENING AND HAVE COMMENCED THE HEPATITUS B COURSE BEFORE YOU WILL BE CONSIDERED FOR WORK. IN ADDITION YOU MUST NOT HANDLE BLOOD AND BODY FLUIDS UNTIL YOU HAVE COMPLETED THE HEPATITIS B COURSE AND HAD A BLOOD TEST TO CHECK FOR HEPATITIS ANTIBODIES. NAME OF APPLICANT: VACCINATIONS DATE BOOSTER DATE HEPATITIS B 1 2 3 Varicella GP S OR PRACTICE NURSE NAME (BLOCK CAPITALS) AND SIGNATURE Rubella Tuberculosis Tetanus SCREENING (blood tests) Post vaccination Hepatitis B antibodies Varicella Zoster Virus Antibodies (if not had chicken pox) Rubella Antibodies DATE RESULT GP S OR PRACTICE NURSE NAME (BLOCK CAPITALS) AND SIGNATURE TB screening (heaf / mantoux / tine) Only if no BCG scar. Confirm scar seen. PLEASE SEND COMPLETED FORM WITH YOUR APPLICATION FOR EMPLOYMENT Official Surgery Stamp 7

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The following training courses are available to everyone. Compulsory Courses: On Line Training. All Courses are compulsory to those with no previous experience. A Deposit of 5.00 per on-line course is required. Tick the boxes of the courses you would like to complete. COMPLETION OF TRAINING DOES NOT GUARANTEE PLACEMENT WITH VKL. Challenging Behaviour Communicating Effectively Continence Promotion CoSHH (Control of Substances Hazardous to health) Dementia Care Deprivation of Liberties Safeguards Develop as a Worker Diversity & Equality Fire Training First Aid / Basic Life Support Food Hygiene Health & Safety Induction Awareness Infection Control Medication Administration Mental Capacity Moving & Handling Assessment Moving & Handling Theory Palliative Care Person Centered Care Principles of Care Record Keeping Risk Assessment Role of the Care Worker Safeguard of Vulnerable Adults On Line Training Tariff No of Courses 1-10 11-15 16-20 21-25 Cost per Course 9.00 8.00 7.50 7.00 Compulsory Tutor based training Manual Handling Practical.... 25.00 Minimum 6 people per course Mental Health Awareness Course. Includes Dementia, Challenging Behaviour, Parkinson Disease, Diabetes, Epilepsy and more... 35.00 Minimum 6 people per course Money to be paid before attending the course. Non-Compulsory Tutor based training Physical Intervention. (Control & Restraint) 2 day Course... 120.00 Maximum 8 candidates per course This course is recommended for those working in Mental Health or Patient Transport The above are online training course provided by Social Care TV. Where specified These are complete courses and not short versions. You can do these courses anywhere there is a computer either at home, our office or a cyber café. The certificates for the above courses will be printed out by VKL and issued after full payment is received. COMPLETION OF TRAINING DOES NOT GUARANTEE PLACEMENT WITH VKL. 9

Cost Breakdown for SCTV On-Line Training No of Courses 1-10 11-15 16-20 21-25 Cost per Course 8.00 7.00 6.00 5.00 No of Courses Cost per Course 1-10 11-20 21-20 21-25 9.00 8.00 7.50 7.00 1. 9.00 2. 18.00 3. 27.00 4. 36.00 5. 45.00 6. 54.00 7. 63.00 8. 72.00 9. 81.00 10. 90.00 11. 88.00 12. 96.00 13. 104.00 14. 112.00 15. 120.00 16. 120.00 17. 127.50 18. 135.00 19. 142.00 20. 150.00 21. 147.00 22. 154.00 23. 161.00 24. 168.00 25. 175.00 All prices correct at time of print and may be subject to change without notice. Some courses and course places are subject to availability. Call VKL on 0208 381 6254 for any more information on these courses You may pay directly into the VKL bank account using your name as a reference. HSBC BANK Sort Code: 40-12-27 Account Number: 91381415 PLEASE CALL THE OFFICE WHEN YOU HAVE DONE THIS TO CONFIRM I enclose Cheque / Proof of BACS payment (delete as appropriate) For Signature: Print Name: COMPLETION OF TRAINING DOES NOT GUARANTEE PLACEMENT WITHIN VKL. 10

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 W: www.vklnursing.co.uk Equal Opportunity Monitoring Form VKL Transport Services Ltd aims to be an equal opportunity company and selects staff solely on merit irrespective of race, sex, disability etc. In order to monitor the effectiveness of our equal opportunity policy we request all applicants to provide the information indicated below. Completing this form will help to assist the monitoring of our workforce to be representative of the local community and to target any under represented groups. Please Note: Ethnic minority questions are not about nationality, place of birth or citizenship. They are about colour and broad ethnic groups UK citizens can belong to any of the groups indicated. My sex is Male Female Ethnic Origin I would describe my ethnic origin as: British White Irish Any other white background * White and Black Caribbean Mixed White and Black African White and Asian Any other mixed background * Indian Asian or Asian Pakistani British Bangladeshi Any other Asian background * Black or Black British Chinese *Other ethnic group Caribbean African Any other Black background * Chinese Please state: Please tick one box Is there anyone who relies on you for day-to-day care and attention? YES/NO If YES, are they: a) Children b) Other family member or partner Do you consider yourself to have a disability? YES / NO My age is: (please tick appropriate box) 16 19 40 49 20 29 50 59 30 39 60 64 11

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VKL Transport Services Ltd Patient Transport, Nursing Agency Studio 2000, Unit 210 & 211 5 Elstree Way Borehamwood Hertfordshire WD6 1SF T: +44 (0)208 381 6254 F: +44 (0)208 327 0165 E: enquiries@vklnursing.co.uk W: www.vklnursing.co.uk Important Notice RE: CRB PRICING & PAYMENT THE TOTAL AMOUNT OF * 55.00 IS TO BE PAID AT TIME OF REGISTRATION WITHOUT EXCEPTION. You may pay direct into VKL Bank Account using your name as a reference. HSBC BANK - Sort Code: 40-12-27 - Account Number: 91381415 PLEASE CALL THE OFFICE WHEN YOU HAVE DONE THIS TO CONFIRM. CRBs ARE NO LONGER TRANSFERABLE BETWEEN AGENCIES YOU WILL HAVE TO APPLY FOR A VKL CRB. All Prices correct at time of print. *Prices are subject to change without notice ----------------------------------------------------------------------------------------------------------------- Public Transport directions to VKL @ Studio 2000 From Elstree & Borehamwood Railway Station BUS Take the 107 Bus going towards New Barnet/New Barnet Station Departing from Stop A Travel for 6 stops (7 mins) Walk Cross the road so you are on the same side as Cardiff Pinnacle. VKL Patient Transport Services Ltd @ Studio 2000 is the 4 th building on Elstree Way. About 2 mins (0.1 mi) 13