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QUALIFIELD NURSE CARE/SUPPORT WORKER APPLICATION FORM

What You Need To Register All required documents must be the originals

Passport and if applicable work permit 2 x Proof of Address ( household Bill, Mobile Phone Bill) Proof of NI (National insurance card or P45) Driving Licence (both Photocard and Paper parts) Birth Certificate and/or Marriage Certificate All Training Certificates (M&H, First Aid, Food Hygiene, Skills for Care etc.) Original CRB Disclosures from any previous roles 44.00 for new CRB (Fill in Section A, B, C, only) Any immunisation records held Contacts details for Previous Employment for referencing purpose Qualifications Certificates 2 Passport-sized Photographs An up to date CV including all work, education and qualifications NMC Number & Indemnity Insurance Details (if applying for Qualified Roles ) If you want to be paid by Limited Company we need the details.

If sending by post we suggest you send all documents by recorded delivery, once received we will return the same day also by recorded delivered

NAME

ATTACH PHOTO

QUALIFIELD NURSE/HCA APPLICATION FORM

POSITION APPLIED FOR:


QUALIFIED NURSE: HCA GRADE: GRADE: SKILL/S: SKILL/S:

PERSONAL INFORMATION
Forenames: Address: Surname: Home Tel: Mobile No: Email: Date of Birth: Age: YES National Insurance Number: NO NO Any Hours

Do you hold a valid driving licence?

Do you have your own transport? YES Please circle the shifts for which are available: Nights Days

GENERAL INFORMATION
Languages Spoken: Are you covered by indemnity insurance? Are you a member of a professional union? (if so which) Parts: Banding:

Pin No:

Expiry:

NEXT OF KIN DETAILS


Name: Address: Home Telephone Number: Mobile Telephone Number: Relationship to you:
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PREVIOUS EMPLOYMENT DETAILS: (Must be full employment history with no gaps) Current/Last Employer Company Name: Company Address: Telephone Number: Dates of Employment Job Title: Reason for Leaving: Can We contact this company for a reference? Previous Employer 1 Company Name: Company Address: Telephone Number: Dates of Employment Job Title: Reason for Leaving: Can We contact this company for a reference? Previous Employer 2 Company Name: Company Address: Telephone Number: Dates of Employment Job Title: Job Description: Contact Name: Position: Yes No If no reason Job Description: Contact Name: Position: Yes No If no reason Job Description: Contact Name: Position:

Reason for Leaving: Can We contact this company for a reference? Previous Employer 3
Company Name: Company Address: Telephone Number: Dates of Employment: Job Title: Reason for Leaving: Can We contact this company for a reference? Job Description: Contact Name: Position:

Yes

No

If no reason

Yes

No

If no reason

Previous Employer 4 Company Name: Company Address: Telephone Number: Dates of Employment:
Job Title: Reason for Leaving: Can We contact this company for a reference? Job Description: Contact Name: Position:

Yes

No

If no reason

Previous Employer 5
Company Name: Company Address: Telephone Number: Dates of Employment: Job Title: Job Description: 5 Contact Name: Position:

Reason for Leaving: Can We contact this company for a reference?

Yes

No

If no reason

PREVIOUS EMPLOYMENT DETAILS CONTINUATION SHEET

Company Name: Dates: Job Details:

Company Name: Dates: Job Details:

Company Name: Dates: Job Details:

Company Name: Dates: Job Details:

Company Name: Dates: Job Details:

Have you worked for an agency before? Yes If yes Name of Agency 1:

No Dates Employed: From: To:

What rate were you Paid? If yes Name of Agency 2:

Where did you work? Names of Companies:

Dates Employed: From: To:

What rate were you Paid?

Where did you work? Names of Companies:

GENERAL EDUCATION
Educational Establishment Please provide details of educations: Dates from Date to Qualifications Gained (including Grades)

FURTHER EDUCATION
Please provide details of education gained at college or university, and any relevant courses (Including Manual Handling, introduction to care/skills for Care. Food hygiene etc) Educational Dates from Date to Qualifications Gained Establishment (including Grades)

REFERENCE DETAILS (to total 5 years)


1st Reference Name Name Of Company Address

Telephone Number 2nd Reference Name Name Of Company Address

Known me for...................Years

Telephone Number 3rd Reference Name Name Of Company

Known me for...................Years

Address

Telephone Number 4th Reference Name Name Of Company Address

Known me for...................Years

Telephone Number 5thReference Name Name Of Company Address

Known me for...................Years

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Telephone Number

Known me for...................Years

Competency Checklist Qualified Nurse/Care/Support Worker


Applicants Name: .......... Date

A CAN PERFORM UNSUPERVISED B REQUIRE SOME SUPERVISION C UNABLE TO PERFORM PERSONAL HYGIENE
Bath/Shower/Strip Wash
Use of Bath Aids Care of Eyes Care of Fingernails Care of Hair CA

A B C
Bed Bath Shaving mouth Care care Of feet Dressing/undressing

B C

ELIMINATION
Continence Care Catheter care Applying a Urinary Sheath use of Commodes, Bedpans Attaching a Nightbag

Stoma Care

MOBILITY
Moving & Handling Use of Hoists Use of Cert Use Wheelchairs Moving Aids

NUTRITION
Preparation of Meals Care of PEGs Feeding Dependant Clients Special Diet Requirements

BASIC CARE
Pressure Area Care Simple Dressing Procedures Assisting with Medication Basic Obs, Temp, BP, Pulse

PRACTICAL/DOMESTIC TASKS
Bed Making Washing Personal Laundry Shopping light Housework Cooking Collecting Benefits

ADMINISTRATIVE ABILITIES
Report Writing Recording Instructions

PREVIOUSEXPERIENCE IN
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Hospital Residential Home Nursing Home

Hospice Learning Disabilities Mental Health

Any other information, experience, specialised areas of work e.g. First Aid, Dementia, Spinal injury, MS etc.

Acute Area Skills Venepuncture Cannualtion Intravenous Drug Therapy Care of/Recording CVP Care of/Recording Arterial lines Arterial Blood sampling Interpretation of Electrolytes Interpretation of Blood gases Basic ECG interpretation Recording 12 lead ECG PCA Management Entonox Administration Cardiovascular Cardiac output monitoring Use of inotropes Assist/Monitor Intra-Aortic Balloon Pump Assist with cardio-Version Post Angiogram care Post coronary artery by-bass care Assist with Transcutaneous pacing Use of streptokinase Respiratory/ITU/HDU Bi-pap CPAP Care of ventilated patient Assist with Intubation Tracheotomy Care Care and removal of chest drains Care epidural infusions A&E Eye Irrigation Eye Ph measurement Bandaging and support of strains Application of POP Minor Suturing and gluing Management of Epistaxis Care in minors

No Experience

Requires support

Competent

Comments

Qualification Yes/No

Qualification Yes/No

Qualification Yes/No

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Care in majors Triage Care is resus area Paediatric experience Liase with social worker

Name

Signature

Date

WORK PREFERENCES
Full time Nursing Home Days Please specify which type/s of work you are looking for. Tick all that apply Part time NHS Private Hospital Private Nights Yes No Live In Visits

Do you have any other work commitments?

If Yes please specify:

Which areas do you which to exclude?

When are you available to commence work?

BANK DETAILS
Sort Code

__ __-__ __-__ __

Account Number Account Name:

__ __ __ __ __ __ __ __ __

Branch Address:

BSoc No:

Other Reference :

PASSORT & WORK PERMIT DETAILS


Do you have a UK Passport? Do you have a work permit? Yes Yes No No

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If yes please give the expiry date: Place of Birth Passport

/ Passport Nationality Place of issue

Restrictions

DECLARATION OF HEALTH
Please provide details of any health problems you have had with any of the following: Have you ever experienced problems with: Raised blood pressure Heart of circulatory problems Chest pain Blood Disorders Chest complaints e.g. Asthma, Bronchitis, Pleurisy. TB Chronic Indigestion Bowel Complaints Persistent abdominal pains Liver disease or jaundice Diabetes, problems with thyroid or other glands Kidney or bladder problems Epilepsy, blackouts or dizziness Mental Health problems including depression, psychiatric treatment, eating disorders or attempted suicide Are you taking any medication that may prevent you from working night shifts Have you received or receiving counselling 14 YES NO If yes please provide details

Substance misuse including alcohol Persistent or recurrent backache or injury Ear, nose or throat problems Rheumatism, arthritis or other joint problems Vision problems or eye disease Hay Fever or allergies Any other serious illnesses Any operations Admission to hospital Serious accidents/visits to A&E. If yes How many times in the past years? Other

FURTHER MEDICAL QUESTIONS


Weight: Height Are you presently taking any medication or receiving any treatment? Please provide details of the past 12 months: Do you smoke? If yes, how many a day? Please provide details of any sickness or absence within the previous 2 years? GP Name: GP Address:

IMMUNISATIONS (for Qualified Nurses, care/support workers only)


Please tick all immunisations you have had: Please Tick If you Name Please Tick Date of Immunisation have a Serology Report Showing Blood Levels Rubella Mumps Measles Tuberculosis (BCG) Varicella (Chickenpox) Hepatitis B 15 Date of Blood Test

Exposure Prone Procedure workers only: Have you been tested for the following? (Please tick all that apply) Hepatitis B Surface Antigen Hepatitis c HIV other please specify Date of Test: Date of Test: Date of Test:

DISABILITY
Do you have a disability? If yes please provide details

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