Care Registration Form 2 PERSONAL DETAILSTitle*:---MrMrsMissMsDrProfRevOtherOther Title:Surname*:Maiden Name:First Name(s)*:Other Name(s):Marital Status*:---SingleMarriedDivorcedWidowedGender*:---MaleFemaleDate of Birth(DD/MM/YYYY)*:National Insurance No:You can upload a passport photo of yourself below which we will use to create your Staff ID.Current Address*:Post Code*:Email Address*:Mobile Phone*:Home Phone:Do you have a driving licence?*---YesNoDo you have use of a car?*---YesNoJOB DETAILSPosition Sought:Speciality 1:Speciality 2:Current Place of Work:Work Sought:---Full TimePart TimeDaysNightsOTHER DETAILS - BANK DETAILSName of Bank/Building Society:Account Name:Personal/LTD:---PersonalLTDBranch Address:Account No:Sort Code:OTHER DETAILS - NEXT OF KINName of Next of Kin*:Relationship*:Telephone*:Email:Address: Next QUALIFICATIONSNurses NMC Number:RCN Number:Band:ODPS This does not apply to HCA’sHPC Number:MANDATORY TRAININGPlease tick if you have completed the following training within the last 12 months. Please enclose copies of your training certificatesMoving and Handling:Basic Life Support:Intermediate Life Support:Advanced Life Support:Complaints Handling:Handling Violence and Aggression:Fire Safety:COSHH:RIDDOR:Caldicott Protocols:Data Protection:Infection Control:Lone Worker Training:Food Hygiene (where required to handle food):Personal Safety (Mental Health and Learning Disabilities):Resuscitation of the Newborn (Midwifery):Interpretation of Cardiotocograph Traces (Midwifery):APPRAISALSIn order to work in the NHS you will need to be appraised annually by a Senior Practitioner of the same discipline, this person will become your “appraiser” Please give details below of the Senior Practitioner who you have made arrangements with to act as your appraiser. Please give the date of your last appraisal:Name of Appraiser:Position and Grade of Appraiser:Address:Phone Number:Post Code:E-mail: BackNext REFERENCESPlease supply us with two professional referees. One must be from your present or most recent employer and must be a senior grade to yourself and you must have worked for that person for a period of not less than three months duration. Reference 1Reference Name:Position:Work Address:Postcode:Email:Telephone:Fax:Reference 2Reference Name:Position:Work Address:Postcode:Email:Telephone:Fax:DBS DISCLOSUREPlease enclose, with your application a copy of your registration and membership cardDo you have a current DBS Disclosure (formally known as CRB)*YesNoIs DBS Clear?YesNoIssue Date:Disclosure Number:Is this certificate registered with the update service?YesNoAttach Current DBS:You will be requested to carry out a DBS at registration and annually upon employment BackNext WORK HISTORYPlease ensure you complete this section even if you have a CV. The NHS states that “Employment history should be recorded on an Application Form which is signed” Please ensure that you leave no gaps unaccounted for and it covers 10 years or up to your education. Covers 10 years work history or as far back as your educationDates to and from are shown in a DD/MM/YYYY formatDates are continual with NO gapsWhere there have been gaps in work history please state the reason for the gapsLists all relevant training undertakenCurrent or Most Recent EmploymentFrom:To:Name of Employer:Job Title:Grade:Address:Main Responsibilities:Reason for Leaving:Previous Employment 2From:To:Name of Employer:Job Title:Grade:Address:Main Responsibilities:Reason for Leaving:Previous Employment 3From:To:Name of Employer:Job Title:Grade:Address:Main Responsibilities:Reason for Leaving:Previous Employment 4From:To:Name of Employer:Job Title:Grade:Address:Main Responsibilities:Reason for Leaving:Previous Employment (Continued) If you have more employment details please list in the space provided below specifying Job Title, Job Description, Start - End Dates, Name of Employer and Reason for Leaving. You can upload your Current CV below. Attach CV: BackNext DECLARATIONSHEALTH DECLARATIONS All applicants must complete the enclosed health questionnaire to enable us to establish your fitness for work. We would ask all OVERSEAS candidates to provide a medical statement from their GP or medical department confirming your state of health. Your details will be passed to our Occupational Health Doctors to establish your fitness for work. Please sign the declaration below to allow Rainbow Creative Media /Care Providers Recruitment to release your information for inspection. I consent to Rainbow Creative Media/Care Providers Recruitment releasing my health and immunisation records for review to Rainbow Creative Media qualified Occupational Health Advisor. I understand that based on this review I may be required to undergo a medical examination to establish my fitness for work. I confirm that I will immediately inform Rainbow Creative Media /Care Providers Recruitment in confidence if I am HIV Positive, HepB positive or if I have AIDS in accordance with the Department of Health guidelines. I am aware of my obligations regarding MRSA contact and the need for screening. I agree to immediately inform Rainbow Creative Media /Care Providers Recruitment should my general condition of health change. I will inform Rainbow Creative Media /Care Providers Recruitment immediately if I discover that I am pregnant. I understand that withholding information or giving false answers may lead to dismissal. I also hereby consent to Rainbow Creative Media /Care Providers Recruitment obtaining further information regarding my health from my GP or Occupational Health Department. Please tick the box to acknwledge that you agree with the statements above.*YesNo PERSONAL DECLARATIONS I hereby confirm that the information provided on my application is correct and true to the best of my knowledge and that I have not withheld any information that should be taken into account when offering me work. I understand that providing false or inaccurate information may result in the termination of any placement. I agree that I will make best endeavours to make myself aware of the Health and Safety procedures for each client I am assigned to. I confirm that I have read and understood the Terms of Engagement and the terms of the declaration and agree to be bound by them. Please tick the box to acknowledge that you agree with the statements above.*YesNoWORKING TIME REGULATIONS DECLARATIONS For the purposes of the Working Time Regulations 1998 (as amended) I, consent to work in excess of an average of 48 hours per week, averaged over 17 weeks. I understand that I may withdraw this consent by giving Rainbow Creative Media /Care Providers Recruitment not less than three months’ notice at any time. Please tick the box to acknowledge that you agree with the statements above.*YesNo OTHER DECLARATIONS In addition, I also consent to work in excess of the maximum number of hours permitted to work at night under the directive. Please note you are under no obligation to sign either declaration. Please tick the box to acknwledge that you agree with the statements above.*YesNo CONFIDENTIALITY I hereby declare that at no time will I divulge to any person, nor use for my own or any other person’s benefit, any confidential information in relation to the Client or the Company (Rainbow Creative Media /Care Providers Recruitment) or in relation to any of their employees, business affairs, transactions or finances which I may acquire during the term of my agreement with the Company (Rainbow Creative Media) under the Terms of Engagement. Please tick the box to acknwledge that you agree with the statements above.*YesNo REHABILITATION OF OFFENDERS ACT 1974 Please answer all five questions Because of the nature of the work for which you are applying, section 4(2), and further Orders made by the Secretary of State under the provision of this section of the Rehabilitation of Offenders Act (1974) (Exceptions) Order 1975 apply. Applicants are therefore required to give information about convictions which for other purposes are “spent” 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. 1. Do you have any convictions, cautions or bindovers?If yes please give details belowYesNo2. Have you ever had disciplinary action taken against you?If yes please give details belowYesNo3. Are you at present the subject of criminal charges or disciplinary action?If yes please give details belowYesNo4. Do you consent to Rainbow Creative Media requesting a police check and any appropriate references on your behalf?YesNo5. Have you been police checked in the last three years?If so, by whom?YesNo RIGHT TO WORK IN THE UKPlease complete this form, regardless of your nationality, as it is a legal requirement. If you are an overseas national or require a work permit to work in the UK please include copies of supporting documentation. Your entitlement for working in the UK is based upon what status: EU Citizen:Spouse of an EU Citizen:Work Permit:Permit Free Visa:Right of Abode in the UK:Admitted to UK as Doctor Prior to 1985:Passport Copy:Visa Copy:Home Office Letter: HEALTH AND SAFETYEach agency worker has a responsibility at the start of their first shift to become familiar with the Client’s general policies including, without limitation, those relating to Crash Call Procedures, the Hot Spot Mechanism for alerting security staff that an individual is in trouble, Fire Policy and the Violent Episode Policy. Please tick the box to acknowledge that you agree with the statements above.*YesNo REGISTRATION FORM DECLARATIONSPlease read before signingI declare that by signing this form I am stating that I am legally entitled or allowed to work in the United Kingdom, with or without necessary permission from the Home Office or any other relevant authority. If I have secured permission to work, I have included copies of all documentation. I also acknowledge that if it is found that I am working without the relevant permission, my employment will be terminated with immediate effect and all details passed to the relevant authorities. I agree that Rainbow Creative Media /Care Providers Recruitment retains the right to hold this registration form and any other data required to process it and pass onto any authorised third party and the details held within. I also agree to use all reasonable efforts to assist to comply with the Data Protection Act 1998. In addition, I confirm that that all the information provided is true and accurate and that I have received and agree to Rainbow Creative Media / Care Providers Recruitment terms of engagement and Staff Handbook. Please tick the box to acknowledge that you agree with the statements above.*YesNo BackNext Employee Medical QuestionnaireCONFIDENTIAL The purpose of the questionnaire is to see whether you have any health problems that could affect your ability to undertake the duties of the post you have been offered or place you at any risk in the workplace. We may recommend adjustments or assistance as a result of this assessment to enable you to do the job. Our aim is to promote and maintain the health of all people at work. Before health clearance is given for employment you may be contacted by the Rainbow Creative Media and may need to be seen by an occupational health advisor or physician. PERSONAL INFORMATIONTitle:---MrMrsMissMsDrProfRevOtherDate of Birth:First Name:Surname:Home Telephone:Mobile:Work Telephone:Email:GP Address: MEDICAL HISTORYAll staff groups complete this section Do you have any illness/impairment/disability (physical or psychological) which may affect your work?*YesNoHave you ever had any illness/impairment/disability which may have been caused or made worse by your work?*YesNoAre you having, or waiting for treatment (including medication) or investigations at present?*YesNoIf your answer is yes, please provide further details of the condition, treatment and dates.Do you think you may need any adjustments or assistance to help you to do the job?*YesNoADDITIONAL INFORMATION (If you have answered yes to any questions above please provide additional information below) IMMUNISATIONSPlease indicate which off the following Immunisations you have been vaccinated against and include your vaccination reports when returning your registration.EPP and Non EPP*Hep B:TB:Varicella:Measles:Rubella:All applications who cannot provide a registered DBS or full immunisation record will be required to complete at their own cost.Rainbow Creative Media Providers will cover the cost of any Mandatory Training updates however cancellations outside of 48 hours and late attendances will be charged to the candidate. Candidates will be required to purchase uniform if required at the cost of £20 this will be deducted from your timesheet once you have started working through us.Please tick the box to acknowledge that you agree with the statements above.*YesNo TUBERCULOSISClinical diagnosis and management of tuberculosis, and measures for its prevention and control (NICE 2006) Have you lived continuously in the UK for the last 5 years?*YesNoIf you answered No above, please list all of the countries that you have lived in over the last 5 years Have you had a BCG vaccination in relation to Tuberculosis?*YesNoIf you answered yes please state whenDate:Do you have any of the followingA cough which has lasted for more than 3 weeks*YesNoUnexplained weight loss*YesNoUnexplained fever*YesNoHave you had tuberculosis (TB) or been in recent contact with open TB*YesNoADDITIONAL INFORMATION (If you have answered yes to any questions above please provide additional information below) CHICKEN POX OR SHINGLESHave you ever had chicken pox or shingles?*YesNoDate: IMMUNISATION HISTORYHave you had any of the following immunisations?* Triple vaccination as a child (Diptheria / Tetanus / Whooping cough)*YesNoDate:Polio*YesNoDate:Tetanus*YesNoDate:Hepatitis B (If Yes is ticked please give dates below)*YesNoDate:Course:1: 2: 3: Booster:1: 2: 3: PROOF OF IMMUNITY(Please send the following) VaricellaYou must provide a written statement to confirm that you have had chicken pox or shingles however we strongly advise that you provide serology test result showing varicella immunity.TuberculosisWe require an occupational health/GP certificate of a positive scar or a record of a positive skin test result (Do not Self Declare).Rubella, Measles and MumpsCertificate of “two” MMR vaccinations or proof of a positive antibody for Rubella Measles and Mumps.Hepatitis BYou must provide a copy of the most recent pathology report showing titre levels of 100lu/l or above. EXPOSURE PRONE PROCEDURESWill your role involve Exposure Prone Procedures*YesNo DECLARATIONI declare that the answers to the above questions are true and complete to the best of my knowledge and belief. I also give consent for Rainbow Creative Media to make recommendations to my employer.Full Name*:Date*: If you are have finished completing the application form, please click "Submit Registration Form" below. If you would like to make any chnages please select "Back" below.