73a, High Street,
Battle, East Sussex, TN33 0AG.
Tel: 07519985933/01424 774086
Email: [email protected]
Interview Date:
I.D Issue Date:
CRB Applied Date:
CRB No:
Trained
Nurse
APPLICATION FORM
PERSONAL DETAILS
Please complete in black biro and in block capitals
Title: MR / MRS / MISS / MS (delete as applicable)
Surname : ……………………………………………………. Maiden name : …………………….……...………………..
Forenames (in full) : ………………………………………………..………………………………….……..…………………
Month and year surname changed................... ....................
Home Address : ………………………………………………….……………………………………..….……………………
……………………………………………………………… …. Postcode : ………………..….……………………
How Long have you lived at this address………………………………………………………..…….……………………..
Home Tel. No : ………………………………………………..Work Tel. No : …………………………...………...………..
E mail Address : ………………………………………………Mobile No: ……………………………………………………
If you have lived at this address for less than five years please give previous address:
Previous address : …………………………………………………………………………………………..…………………..
……………………………………………………………………………………………………………………………………..
National Insurance Number : ……………../…………..……../……………….…/………………………/………………….
Date of Birth
Age
Passport
number
NMC pin
number
Town of birth
Expiry
Date
Expiry
Date
County of birth
Nationality
Permit No
Level of
Registration
Have you recently been resident outside the UK?
Yes: ………………..…... No: …………..……………..
Do you hold a current UK driving licence?
Yes: ………………….…. No: ………………………....
Do you have use of a car?
Yes: ……………….….. No: ...... ...……………….....
Next of kin to be notified in case of emergency Name : ……….……………………………………………………………
Address : ……………………………………………………..……………….………………………………………………….
……………………………………………………………………………………………………………………………………..
Telephone : ……………………………………………………………
Mobile : ………………………..…………………
WORK RECORD
Please give details of all your employment, to include all nursing agency membership, in reverse date order
starting with your present or last position. Please include reasons for gaps. Use additional sheets if you require
more space.
Please include training schools and dates of registration
Date
From
To
Place of
Employment
Position
Held
Reason for
Leaving
Please give relevant details and dates of any training or courses you have attended: .manual handling, CPR
,infection control, first aid etc) Please provide certificates.
……………………………………………………………………………………………………………………………………..
……………………………………………………….…………………………………………………………………………….
Dates of refresher courses or return to practice courses.
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PROFESSIONAL DETAILS
The service we give depends on accurate up to date information. Please keep us informed of all developments in
your career. To assist us in finding suitable work for you please tick all nursing specialities of which you have
significant post training experience.
A&E
Isolation
Phlebotomy
Aero medical
ITU
Practice nursing
AIDS/HIV+
Anaesthetics
Burns and
plastic
Cardio-thoracic
Learning disabilities
Liver unit
Marie Curie
Psychiatry
Radiotherapy
Recovery
Medical
Renal Dialysis
CCU
Dental nursing
Dermatology
Mental
health
Midwifery
Nanny
SCBU
Screening
Social work
District nursing
Neurology
STDs
Elderly care
NNU
Surgical
ENT
Occupational health
Terminal care
Family planning
ODA
Theatre
Genito-urinary
Oncology
Tropical disease
Gynae
Ophthalmic
Venepuncture
s
Haematology
Orthopaedi
X Ray
CCc
ICU
Paediatrics
Industry
NVQ details
Please give details of any certificates or qualifications you hold. (Including any in specialities
listed above) I
...........................................................................................................................................................
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REFEREES
Please give the names of three recent professional referees, including your present or most recent employer,
whom we may approach for a reference. (Not relatives or friends) Business addresses must be given
1. Name : .... ........... ....……......... ......... ............ ........ Qualification : ………………………………………………..
Position held : .......………........ . ..... ..... ........ . ........…Telephone : …………….…………………………….... . ......
Address: ....………......…………….…………………………………………............. ............ ......... .......... ..................
Post code : …………………………………………………….Known me for……………………………..…………years
2. Name: .... ........... .............. ......... ..........………. ........ Qualification : …………………………………………….. .
Position held : .......………........ . .......... ....….... . ........…Telephone : ……………………..………………….... . ......
Address : ....……………......…………………………………………………............. ............ ......... .......... ..................
Post code : …………………………………………………Known me for : ………………………………………….years
3. Name: .... ........... .............. ......... ..........………. ........ Qualification : …………………………………………….. .
Position held : .......………........ . .......... ....….... . ........…Telephone : ……………………..………………….... . ......
Address : ....……………......…………………………………………………............. ............ ......... .......... ..................
Post code : …………………………………………………Known me for : ………………………………………….years
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CONFIDENTIAL HEALTH QUESTIONAIRE
Name : ____________________________________________________________________
Are you suffering from, or have you ever suffered
any of the following? If Yes, please give details
including dates and any length of time you were
off work.
Heart disease
High blood pressure
Asthma, Bronchitis or Pneumonia
Persistent indigestion
Jaundice / Gall bladder / Hepatitis
Bowel problems
Kidney disease or stones
Tropical diseases
Hernia
Back / Neck / Limb problems
Rheumatism / Arthritis
Persistent headaches / Epilepsy
Stress / Anxiety / Depression
Eye disease or infection
Deafness or Ear disease
Dermatitis / Eczema / Psoriasis
Allergic conditions
Diabetes
Blood disorder e.g. anaemia
Any form of Cancer
Bladder or other genito-urinary problems
Have you ever had an accident or illness that
has required admission to hospital?
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Yes
from
No
Details
Have you ever had surgery?
CONFIDENTIAL HEALTH QUESTIONAIRE
Yes
No
Details
Are there any medical conditions that run in the
family?
Are you currently receiving or waiting to receive
any medical treatment?
Have you ever left or been denied a job on health
grounds
Have you ever been denied a driving licence on
health grounds?
Have you ever been treated for addictive
substance dependency including alcohol?
Have you ever suffered from any work related
health condition?
Have you any disabilities affecting standing/
walking/lifting/driving/stair climbing/use of hands?
Have you experienced difficulty with reading or
written material?
Have you had a chest X-ray in the last 5 years?
Do you smoke?
How many per day?
Do you drink alcohol?
How many units per week?
(1 pint = 2 Unit; 1 short glass of wine = 1 Unit.)
Have you ever been tested or treated for MRSA?
Are you aware of any illnesses or condition which
may be adversely affected by your undertaking
night work.
Please give last date of immunisation or vaccination of:
Tuberculosis (BCG)
Diphtheria
Rubella
Date:
Skin test for TB
Date:
Date:
Date:
Have you had chickenpox?
Tetanus
Date:
Poliomyelitis
Date:
Hepatitis B injections
1st Date:
2nd Date:
3rd Date
Evidence of immunity
We strongly recommend that all members be inoculated against Hepatitis B. Please be aware that this inoculation
can cease to be effective and it is necessary to have an antibody check every 3 years.
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It is a condition that all members who wish to work in Hospitals have the above inoculation certificate.
Pregnancy at work regulations
To protect your health at work please indicate in confidence to a member of staff if you are pregnant or
breastfeeding
I declare that the above information is correct to the best of my knowledge and hereby give permission for a further
report to be requested from my GP for clarification if requested.
GP Name : ………………………………………………….. Address: ……………………………………………………….
…………………………………………………………………………………………………………………………………….
Signed: ………………………………………………………. Date: …………………………………………………………..
I declare that I am fit for work and that all the information is correct and accurate to the best of my knowledge:
Signed............................................................................ Date............................................................................
Rehabilitation of Offenders Act 1974
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 of which is exempted under the above order. Therefore it is necessary for you to disclose any criminal convictions, even
if, under the Rehabilitation Act, they would otherwise be regarded as “spent”.
Applicants are therefore not entitled to withhold information about convictions which for any other purpose are “spent” under the provisions of
the act and in the event of employment, any failure to disclose such convictions could result in dismissal. Any information will be completely
confidential and will be considered only in relation to this employment.
Have you been convicted of a criminal offence by a court of law including bind over’s and cautions (with the exception of minor motoring
offences
or offences committed as a juvenile under the age of 16 Yes 
No
If so, please give details of the conviction(s) and the date(s) :
…………………………………………….………………………………………………….
Have you ever been the subject of an investigation or enquiry by the police or a statutory agency into abuse. Yes 
No 
Or any other inappropriate behaviour. If yes please give details………………………………………………………………………………….
Are there any reasons why you would be considered unsuitable to work with children or vulnerable adults.
Yes 
No 
If yes please give details………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………….
Signed as a correct statement : ………………………….…………………………………….………Date :
…………………………………………………
Failure to declare any convictions will result in termination of Membership.
It is a condition of Membership that all applicants under go an Enhanced Criminal Record Beuro Check prior to commencing employment and
annually there after. The cost of this is born by the member.. Please sign to give your agreement to this.
Signed : ………………………………………………………………………. Date : ………………………………………………………………………….
Print Name : ……………………………………………………………………………………………………………………………………………………….
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Working Time Disclaimer
I hereby agree to opt out of the 48-hour working week limitation, as laid down in the Working Time Regulations 1998.
Signed : ……………………………………………………………………………… Date : ………………………………….
I wish to undertake night work and I have completed a health questionnaire
YES /
NO
I understand that I may end this agreement by giving two weeks notice in writing to Diversity Care Solutions Ltd
Please indicate your level of proficiency according to the scale below
1 no experience
2 previously performed but not proficient
3 competent to perform independantly
Cardiovascular
Respiratory
Skill
1,2,3
Administering intravenous therapy-via pump
via giving set
Basic ECG interpretation
Care of patient with congestive cardiac failure
CVP readings
Perform ECG
Use of cardiac monitoring equipment
Use of defibrillator
Venepuncture
Skill
1,2,3
Administering oxygen therapy
Care of patient using CPAP
Care of patient with COAD/COPD
Care of the ventilated patient
Interpret arterial blood gas result
Infection control
Gastrointestinal
Skill
1,2,3
Assessment and care of pressure sores/ulcers
Knowledge of universal precautions
Wound care
General
Skill
Syringe drivers
Palliative care
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1,2,3
Pulse oximetry
Respiratory status assessme nt skills
Suctioning-oropharangeal
-nasopharangeal
-tracheostomy
Tracheostomy care
Skill
1,2,3
Care of PEG/RIG
Administration of NG feeds
Check placement of NGT
Insertion of NGT
Care of ileostomy
Care of colostomy
Administration of suppositories
Administration of enemas
The following details are required by our accounts office before any payment can be
made.
PLEASE PRINT CLEARLY
New Member Payroll Information
Member’s Name:……………………………………………………………………………………………..…………………
Name of Bank or Building Society:…………………………………………………………………………………………...
Address:…………………………………………………………………………………………………………………………
Post Code: ………………………………………………………………………………………………………………………
.
Account in the name of:………………………………………………………………………………………………………..
Account Number:……………………………………………………………………………………………………………….
Sort Code: ………………………………………………………………………………………………………………………
Registered by the Care Quality Commission
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