Photograph
Branch: ______________________
REGISTRATION FORM
Grade:______________________
Date:_____________________
1. Personal Details
Title:_____ Surname ___________________
Other Names _________________________
Date of birth:______________________________
Address:________________________________________________________________________
_______________________________________________________________________________
Post Code:_____________________
Home Tel:__________________________________
Mobile:_______________________
Email:_____________________________________
Fax:__________________________
National Insurance No:________________________
Nationality:______________________
Driver:
Yes/No
If Yes, Expiry Date:_________________
Required Work Permit Yes/No
Explain Type of Permit:________________
Next of Kin:___________________________________________________________________
Address: _____________________________________________________________________
Tel No: ___________________________
Mobile: __________________________________
Next of Kin email: ______________________________________________________________
Relationship to next of kin: _______________________________________________________
Qualified Nurses and Social Workers Only
N&MC PIN / Registration Number: _________________________________________________
Date first entered on Register: ____________________________________________________
Which Parts of the Register: ______________________________________________________
Expiry / Renewal Date: __________________________________________________________
Providers and Professional Indemnity Insurance No.:__________________________________
2. Health Screening and Medical History – (Optional but required for NHS placements)
a) Have you completed and signed the attached Oblique Personnel Self Declaration for Fitness
to Work Questionnaire?
YES/NO
If “YES” enclosed is a copy that will be filed with this form. If “NO”, please fill one and attach
it to this form.
b) Are you immune to the following?
YES/NO
TB
evidence required
Hepatitis C (Exposure Prone)
evidence required
Rubella (German Measles)
evidence required
Hepatitis B
evidence required
Please note that the documentary proof have to be from a qualified occupational Health Practitioner or your GP. You are
required to be immune to the above if you are to work in the NHS. It is the responsibility of the applicant to obtain the Fit to
Work Certificate from the GP
To be completed by the Professional Practitioner as a Certificate
This is to cetify that based on the questionnaire, certificates/records of immunisation
produced and relevant to the position applied for, I consider the applicant fit for work.
Tick off certificates seen or pathological tests done here.
Rubella
Hepatitis C
TB
Vericella
Hepatitis B
Other (State)
_______
________
___
Names ____________________
_______
_________
Date_________
__________
Qualifications_________
Signature _________________ Other Comments __________________________
__________________________________________________________________________
3. DBS Checks
Application Ref: ___________
Date applied:____________
Date Received__________
4. Bank Details
Account Holder’s Name: ____________________________
Name of Bank:_______________________
Sort Code:___________________________
Account No:___________________
Bank Address: _______________________________________________________________
Town:____________________________________
Post Code:____________________
5. Qualifications
(Qualified nurses must provided documents showing details of their professional registration
with NMC which will be places in their file):
Qualification
Period
Institution
Course Title
Grade attained
_______________
________
__________
__________
____________
_______________
________
__________
__________
____________
_______________
________
__________
__________
____________
_______________
________
__________
__________
____________
_______________
________
__________
__________
____________
Mandatory and induction training
(Applies to all Healthcare Workers)
Date Trained / Expiry
Food Hygiene
___________________
Safeguarding
___________________
Health and Safety
___________________
Manual Handling
___________________
C & R – Handling of Violence & Aggression
___________________
Lone Worker Training
___________________
Fire Safety and Procedures
___________________
First Aid – Basic Life Support
___________________
Infection Prevention and Control including MRSA,
Clostridium Dificile
___________________
6. Work History / Experience and References – A must
(Note: This is also authority for Oblique Personnel Ltd to ask for references from your most
recent employer. Please complete your last five years history. If not worked at some time in
this period, please provide an explanation for the gaps. WE need at least two past employers to
give us a reference.)
Title
Employer
Address
Contact
Start
Finish
_______
____________
___________
_________
____
_____
_______
____________
___________
_________
____
_____
_______
____________
___________
_________
____
_____
_______
____________
___________
_________
____
_____
_______
____________
___________
_________
____
_____
_______
____________
___________
_________
____
_____
Please provide details of a work colleague who will give us your character reference.
Name:____________________________
Position:________________________
Address:_____________________________________________
Tel:_________________________________
Post Code__________
Email:__________________________
Give details of any major medical condition of continuous medication:
__________________________________________________________________________
7.
Work Preferences
Please use this space to Oblique Personnel Ltd if you have any work preferences:
a) Shifts (state hours)______________________________
b) Location(s) ______________________________________
c) Other ___________________________________________
Please add below any other information that is relevant to your application that has not been
covered above:
____________________________________________________________________________
_____________________________________________________________________________
8. Professional Memberships
Details of Membership
Name of Body
Date Admitted
Level
__________________
___________
____________
________
__________________
___________
____________
________
__________________
___________
____________
________
Please note that it your responsibility to inform Oblique Personnel when you are no longer a
member or under investigation from the professional body.
9. Fitness to Work Certificate – (This is optional but some employers may prefer it completed)
A copy of this questionnaire has to be presented to your GP, a local NHS Trust or a qualified
occupational Health Practitioner. Ask for a fresh copy if you do not intend to take this one to the
practitioner. With your certificates of immunisation, they will be able to certify that you are fit
to work in the position you have applied for:
Surname: ___________________________
Other Names: _______________________
Gender: Male
Date of Birth: ________________________
Female
Nationality: ____________________________
Position Applied for: ___________________
Exposure levels – Please mark areas below that you believe are applicable to the position you
have applied for:
Exposure to chemicals
Yes
No
Night Work
Yes
No
Contact with client for personal care Yes
No
Working in a confined space
Yes
Driving
Yes
No
Working at heights
Yes
No
Exposure to Blood or body fluids
Yes
No
Shift rotation
Yes
No
Food Handling
Yes
No
Frequent VDU screen user
Exposure Prone Invasive Procedures
Radiation
Moving, Lifting & Handling of Client
Pharmacy
Moving, Lifting & Handling of Other objects
Substantial access to children
Yes
Please indicate if you have ever felt that you have a medical condition that may affect your
working at night.
How many days have you lost from work in the past year? ______________________
No
No
Please state the reason(s) for the loss:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
10. Medical History: Please answer ALL questions
Do you, or have you ever suffered from the following; (Where indicated “Yes”, please give
details)
Suffered any accidents that significantly affected you physically or mentally Yes/No_________
Eyesight problems not corrected by Glasses / contact lenses
Yes/No_________
Significant discomfort when using a keyboard
Yes/No_________
Diabetes, Thyroid or endoctrine problems
Yes/No_________
Cardio – Vascular problems including hypertension or blood disorder
Yes/No_________
Dysentery, Typhoid, Paratyphoid, food poisoning, salmonella
Yes/No_________
Do you think you had an illness that was made worse by your work
Yes/No_________
Fits / blackout or epilepsy
Yes/No_________
Muscular – Skeletal problems, including Arthritis or back problem
Yes/No_________
Loss of weight or fever
Yes/No_________
Have you ever had any Drug or Alcohol problems
Yes/No_________
Do you consider yourself having a disability?
Yes/No_________
Have you ever had any concern / fear that you may have a health problem? Yes/No_________
Coughs/Vomiting/diarrhoea/Rash – in the last 12 months
Yes/No_________
Have you ever had a cough for more than 3 months?
Yes/No_________
Coughed/Vomiting/diarrhoea/Rash blood or unexplained:
-
Severe gastroenteris or diarrhoea
Yes/No_________
-
Episodes of migraine?
Yes/No_________
Psychological conditions including stress at work
Yes/No_________
Treated Tuberculosis
Yes/No_________
Had an operation in the last two years
Yes/No_________
If you are under medication (please given name of drug & dosage)
Yes/No_________
Are you waiting for any medical treatment, investigation or test?
Yes/No_________
Have you ever suffered from serious / frequent headaches or
Yes/No_________
Gastrointestinal problems including Hepatitis?
Yes/No_________
Difficulties in hearing not correctable by hearing aid?
Yes/No_________
Suffered from Asthma, Bronchitis or serious chest pain
Yes/No_________
Difficulties in walking, bending, lifting or any other movement?
Yes/No_________
Any impairment that may affect your ability to work or perform duties
safely?
Allergies – Please state here if any:
Yes/No_________
______________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Do you have any other relevant healthcare related information that you think is not covered
above? If yes, please state here or continue on a separate sheet of paper:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
11. Self Declaration by Applicant
1. I declare that the information provided on this questionnaire is true to the best of my
knowledge and accept that it will form the basis upon which the Qualified medical
practitioner will base the Certification as to my fitness to work for the position applied for.
2. I was made aware of the Equality Act 2010, and that I am satisfied with the details asked
from me and the way I have supplied the same in good faith.
3. I also state that I will inform Oblique Personnel of any changes that may affect my ability to
work for the position applied for.
4. I confirm that I have received a job description and specification and a contract of
Employment which enabled me to complete the above questionnaire for the part relating to
Exposure levels.
5. I understand that it is my responsibility to ensure that all information provided is based on
my truthfulness and that if I fail to notify Oblique Personnel of any changes that may occur
at any time, Oblique Personnel may at their choice cease placing me for job vacancies.
6. I confirm that I have been made aware and been issued with fact sheets on: AIDS/HIV. (HSC
1998/226) MRSA, Vericella, Clostridium Difficile, Safe guarding, Prevention of abuse of
Children and I will undertake necessary training when asked by Oblique Personnel.
7. I accept that my personal details will be safely stored and handled by Oblique Personnel in
accordance with the Data Protection Act 1998, and that the same may be made available to
Audit/ Review by relevant organisations like NHS, PASA or to any authority and where by law
necessary that affects the company’s service users.
8. I understand that a service user may require me to undergo a medical check before
commencement of an assignment.
9. I understand that I am required to declare when unfit (including when suffering from
Vomiting, Dirreheo, or rash before accepting any placement.
10. I understand where the client books me direct and bypassing Oblique Personnel, such work
may not be paid or / and Oblique Personnel takes no responsibility.
11. I also understand that all female workers must declare when they become pregnant.
12. (a) Declaration of Offenders Act 1974 – You are not allowed to withhold information
regarded as “spent” under the Act. This due to the nature of the work of the post which
may be exempt from sec.2(2).
Ay information which you give will be treated in strict confidence and in accordance with the
Data Protection Act, which Oblique Personnel adheres and complies with.
Have you ever been convicted of a criminal offence, currently suspended, on notice of
dismissal from employment or under investigation from any employer?
YES/NO
If “YES”, please provide details of all convictions and cautions, including those “spent”.
(b) By signing this application from, you also declare that to the best of your knowledge:
1. I authorise Oblique Personnel to disclose, if requested, any data to any authority or third
party e.g Police, Safeguarding Teams as permitted by law and that I will immediately inform
the company should I receive any police cautions, reprimands or convictions while under
this employment.
2. All information is my full disclosure including that which might be omitted by the CRB /
safeguarding check.
3. That Oblique Personnel has the right to withhold payment against revenue lost due to my
negligence and non coverage of placements per contract of employment.
4. I will inform the company whenever there are changes in my personal details listed in this
form.
5. To comply with the Mandatory Training, performance appraisal procedures in place from
time to time.
6. I have been made aware of my responsibilities to prevent myself from infectious
environments and among others issued with handouts covered at Clauses 4 above,
Safeguarding, MRSA, Clostridium Difficile, HSC 1998/226 on AIDS/HIV, Protection of
Children, Health & Safety and Manual Handling.
7. Issued with a contract of employment, staff handbook in which I was made aware of the
company policies and procedures contained therein and not limited to complaints,
grievances and disciplinary, general conduct, WTR, Time Sheets and payroll issues including
working time regulations etc.
8. I will inform Oblique Personnel any time I am not in good health and not fit before starting
any work placement offered.
Name_____________________________________________________; (please print)
Signature:__________________________________:
Date_______________________